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A Comparison of Postoperative Opioid Requirements and Effectiveness in

A Comparison of Postoperative Opioid Requirements and Effectiveness in Methadone-maintained and Buprenorphine-maintained Patients. Dr. R. A. Russell Department of Anaesthesia, Pain Medicine & Hyperbaric Medicine Royal Adelaide Hospital. Opioid Substitution Therapy.

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A Comparison of Postoperative Opioid Requirements and Effectiveness in

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  1. A Comparison of Postoperative Opioid Requirements and Effectiveness in Methadone-maintained and Buprenorphine-maintained Patients Dr. R. A. RussellDepartment of Anaesthesia, Pain Medicine & Hyperbaric MedicineRoyal Adelaide Hospital

  2. Opioid Substitution Therapy • Australian patients on methadone-maintenance therapy (MMT) or buprenorphine-maintenance therapy (BMT) : • 1998: 24,657 • 2009: 43,445 AIHW 2009

  3. Buprenorphine • Opioid Pharmacology • Partial mu-agonist & kappa-antagonist • Full mu-agonist at analgesic doses • Anti-hyperalgesic properties • High opioid receptor affinity • Slow offset kinetics

  4. Buprenorphine • Opioid Pharmacology • Partial mu-agonist & kappa-antagonist • Full mu-agonist at analgesic doses • Anti-hyperalgesic properties • High opioid receptor affinity • Slow offset kinetics • Partial opioid blockade ? • To cease or not to cease perioperatively?

  5. BMT Clinical Guidelines • Acute Pain Management: Scientific Evidence • ‘…There appears to be little problem if buprenorphine is continued and acute pain managed with the combination of a short acting pure opioid agonist as well as other multimodal analgesic strategies...’ NHMRC Acute Pain Management: Scientific Evidence 3e (2010)

  6. BMT Clinical Guidelines • ASRA E-News – January, 2011 • For patients undergoing elective surgery with moderate-severe post-operative pain: • Discontinue BMT 3-7 days prior to surgery. • Transition to other opioids (e.g. methadone) and non-opioid pain medications.

  7. Study Overview • Method • Audit of APS data (2005-2010) • Inclusion Criteria • MMT & BMT patients • PCA (IV) post-operatively • Exclusion Criteria • Regional analgesia with PCA • Collaborators • Dr Kris Usher & A/Prof Pam Macintyre

  8. Results

  9. Results

  10. 1st 24hr PCA Requirements Morphine equivalents (mg) 281 ± 129 mg 211 ± 130 mg 196 ± 128 mg 180 ± 139 mg 245 ± 109 mg 155 ± 135 mg METH (ALL) METH (CONT) METH (CEASED) BUP (ALL) BUP (CONT) BUP (CEASED)

  11. 1st 24hr PCA Requirements Morphine equivalents (mg) 281 ± 129 mg 211 ± 130 mg 196 ± 128 mg 180 ± 139 mg 245 ± 109 mg 155 ± 135 mg METH (ALL) METH (CONT) METH (CEASED) BUP (ALL) BUP (CONT) BUP (CEASED)

  12. Results * Overall incidence sedn score of 2 in all RAH APS patients = 1.68%

  13. Results * Overall incidence sedn score of 2 in all RAH APS patients = 1.68%

  14. Results

  15. Opioid-tolerant Patients Royal Adelaide Hospital 1998 (n = 214, PCA)

  16. Opioid-naive vs. Opioid-Tolerant Rapp et. al. 1995 (n = 149, PCA)

  17. Conclusions • Patients maintained on methadone & buprenorphine substitution therapy: • High 1st 24 hour PCA opioid requirements • Large inter-patient variability • Higher pain scores • Increased incidence of sedation

  18. Conclusions • Patients maintained on methadone & buprenorphine substitution therapy: • High 1st 24 hour PCA opioid requirements • Large inter-patient variability • Higher pain scores • Increased incidence of sedation PCA doses and pain scores are higher if BMT and MMT are ceased perioperatively

  19. Conclusions • Cessation of BMT & MMT • Higher opioid requirements • Longer duration of PCA therapy • Requirement for more intensive APS management

  20. Conclusions • Cessation of BMT & MMT • Higher opioid requirements • Longer duration of PCA therapy • Requirement for more intensive APS management Buprenorphine can be continued perioperatively without adversely effecting pain relief using pure agonist opioids.

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