Buprenorphine for Postoperative Pain Following General Surgery in a Buprenorphine-Maintained Patient

To The Editor: Office-based, long-term buprenorphine is a growing treatment for opioid dependence (1) . Patients with opioid dependence may require treatment for pain during their opioid therapy, and such treatment can be complicated. Recently suggested recommendations for the treatment of acute pain in a buprenorphine-maintained individual include the following four options: using concomitant short-term opioid analgesics, dividing the daily buprenorphine dose, replacing the buprenorphine with another opioid analgesic, or replacing the buprenorphine with methadone and then adding an opioid analgesic (2) . We present a case of postoperative pain control in a buprenorphine-maintained patient, using supplemental doses of sublingual buprenorphine for pain management.

Although this individual case was limited by self-report, self-titration, and lack of control, the off-label use of supplemental doses of sublingual buprenorphine for acute postoperative pain in a buprenorphine-maintained individual is a novel approach. Buprenorphine is a partial m agonist shown to have a ceiling to analgesic effects in preclinical studies. Indeed, the bell-shaped dose-response curve of buprenorphine suggests that high doses may produce diminishing analgesic effects (3 , 4) . However, this was not the case for our patient, who had adequate pain control, with total daily doses of up to 72/18 mg following surgery that typically may require 60 mg per day of oxycodone. Furthermore, because no other respiratory depressants were used, this high dose of buprenorphine could safely be used as an outpatient dose. These findings suggest that the time-limited, off-label use of supplemental doses of sublingual buprenorphine may be an effective fifth option for management of acute pain in selected buprenorphine-maintained patients.