quick sheet

Chronic opioid use & OUD (incl. buprenorphine/MAT)

Continue the baseline, build the multimodal floor, and never 'save' analgesia for later.

Top concerns

1.Continue baseline opioids (including methadone) perioperatively — withdrawal plus uncontrolled pain is the failure mode
2.Buprenorphine: modern consensus is CONTINUE it through surgery — add multimodal + potent full agonists on top for breakthrough (dose-reduction, not cessation, for the biggest surgeries per team plan)
3.Naltrexone is the opposite problem: oral held ~72h, depot up to ~30 days blocks agonists — plan alternative analgesia and timing
4.Expect tolerance + opioid-induced hyperalgesia: regional blocks, ketamine, dexmedetomidine, lidocaine, and scheduled non-opioids are the backbone
5.Patients in recovery deserve an explicit conversation: analgesia plan, exposure minimization, support person, discharge plan
6.Communicate the plan forward — PACU and the ward inherit your decisions

AVOIDStopping buprenorphine preop— Outdated practice — destabilizes OUD and worsens pain control (ASRA/multi-society guidance).
PREFERKetamine / dexmedetomidine / regional— The multimodal core when opioid dose-response is shifted.
AVOIDAgonist-antagonists (nalbuphine, butorphanol)— Precipitate withdrawal in opioid-dependent patients.

No unique airway issues from opioid history itself; consider comorbid OSA in chronic-use phenotypes

Home dose ≠ analgesia — it's just the new zero. Build on top of it.
Write the buprenorphine plan in the chart preop; the night shift shouldn't improvise it.

Continue the baseline, build the multimodal floor, and never 'save' analgesia for later.

1.Continue baseline opioids (including methadone) perioperatively — withdrawal plus uncontrolled pain is the failure mode
2.Buprenorphine: modern consensus is CONTINUE it through surgery — add multimodal + potent full agonists on top for breakthrough (dose-reduction, not cessation, for the biggest surgeries per team plan)
3.Naltrexone is the opposite problem: oral held ~72h, depot up to ~30 days blocks agonists — plan alternative analgesia and timing
4.Expect tolerance + opioid-induced hyperalgesia: regional blocks, ketamine, dexmedetomidine, lidocaine, and scheduled non-opioids are the backbone
5.Patients in recovery deserve an explicit conversation: analgesia plan, exposure minimization, support person, discharge plan
6.Communicate the plan forward — PACU and the ward inherit your decisions

AVOIDStopping buprenorphine preop— Outdated practice — destabilizes OUD and worsens pain control (ASRA/multi-society guidance).
PREFERKetamine / dexmedetomidine / regional— The multimodal core when opioid dose-response is shifted.
AVOIDAgonist-antagonists (nalbuphine, butorphanol)— Precipitate withdrawal in opioid-dependent patients.

No unique airway issues from opioid history itself; consider comorbid OSA in chronic-use phenotypes

Home dose ≠ analgesia — it's just the new zero. Build on top of it.
Write the buprenorphine plan in the chart preop; the night shift shouldn't improvise it.