Capstone — Case Integration
Module 11 of 11 · 45 min
Apply all 10 modules to a complex case spanning admission, intraoperative, postop, discharge, follow-up.
Learning objectives
- •Integrate SUD recognition, MAT, perioperative analgesia, harm reduction across one patient's trajectory
- •Develop a perioperative pain plan for a buprenorphine-treated patient
- •Counsel + document appropriately at every encounter
- •Coordinate with SUD provider + primary care
Case
Mr. R is a 38-year-old male presenting for emergent appendectomy. PMHx: OUD on buprenorphine 16 mg sublingual daily for 18 months (prescribed by his addiction medicine doctor); generalized anxiety disorder on sertraline; chronic low back pain managed with PT + acetaminophen. He's nervous about surgery — last surgical experience (knee scope 5 years ago) led to relapse on oxycodone before MAT. Asks if he should hold his bup.
Pre-op decisions
Continue buprenorphine — modern guidance. Plan multimodal: regional block if anatomy permits (TAP block for appy is excellent), IV acetaminophen scheduled, ketorolac if no contraindication, dexmedetomidine infusion intraop, ketamine 0.25 mg/kg/h infusion. Engage his MAT provider by phone if possible. Counsel: 'We're keeping your bup. Pain control is our priority. We may need higher-than-typical opioid doses to break through the buprenorphine effect; that's expected and doesn't mean relapse. We'll monitor closely.' Document the plan.
Intraop + immediate postop
GETA + TAP block. Multimodal as planned. Anticipate higher fentanyl requirement. PACU: continue ketamine infusion at 0.1 mg/kg/h, scheduled IV acetaminophen 1 g q6h, ketorolac 15 mg q6h × 24h, low-dose hydromorphone PRN with strict monitoring (RR, SpO₂, sedation). Avoid benzodiazepines.
Discharge + follow-up
Resume bup at usual dose. Discharge prescription: hydromorphone 1 mg PO q4-6h PRN × 5 days (limit 20 tabs); acetaminophen + ibuprofen scheduled. Counsel + co-prescribe naloxone. Communicate with MAT provider about hospitalization + plan. Follow-up call at 48-72h to check pain + opioid use + reassure. Document everything.
What this module covered
Pharmacology (mu receptor saturation by bup), recognition (validated PMH + active MAT), MAT continuity (continue buprenorphine), behavioral support (pre-op counseling, post-op call), harm reduction (naloxone co-prescribing), prescribing safety (limited quantity, scheduled non-opioid first), motivational interviewing (respect his concern about relapse), special population implications (anxiety + SUD + chronic pain), documentation (every step), bias awareness (treat his pain as legitimate). All 10 modules apply to one patient.
References
- · All prior modules
- · SAMHSA Clinical Tools
- · ASA Practice Advisory: Perioperative Care of Patient on MAT