A man in his 40s with a history of opioid use disorder (OUD) in remission taking buprenorphine/naloxone, 16mg/4mg, presented to the hospital with a fifth distal phalanx fracture and was scheduled for surgery. He was told to stop taking buprenorphine/naloxone starting 2 days prior to surgery and was discharged hours after surgery with a prescription for oxycodone.
The patient presented for follow-up at the surgery clinic 4 days later reporting continued pain. He had finished the oxycodone and was instructed to restart buprenorphine/naloxone treatment. However, the surgeon was unable to write a prescription because buprenorphine (including the buprenorphine/naloxone formulation) can only be prescribed in the outpatient setting for treatment of OUD by physicians, nurse practitioners, and physician assistants who have completed a buprenorphine waiver training and received a special “X” number issued by the Drug Enforcement Agency. The patient’s primary care physician (PCP), who holds a buprenorphine waiver and had prescribed him buprenorphine/naloxone for years, was not contacted. Without a clear plan for how to restart buprenorphine/naloxone treatment, and concerned that withdrawal was imminent, the patient experienced OUD relapse. Two months later he presented to the hospital with chest pain after snorting heroin. The patient was reconnected with his PCP, who prescribed buprenorphine/naloxone and explained that, in accordance with recent guidelines, her practice was generally not to stop buprenorphine/naloxone treatment prior to surgery, but rather to transition patients to every-8-hour dosing.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Cooper R, Vanjani R, Trimbur MC. Acute Pain Management in Patients Treated With Buprenorphine: A Teachable Moment. JAMA Intern Med. Published online July 29, 2019179(10):1415–1416. doi:10.1001/jamainternmed.2019.3103
Customize your JAMA Network experience by selecting one or more topics from the list below.
Create a personal account or sign in to: