Toolkit: Medication-Assisted Recovery/Treatment For Opioid Use Disorder (OUD)

Community: Perioperative
Medication: Buprenorphine

Outpatient Preoperative Planning

Watch an experienced IL provider describe the outpatient preoperative planning protocols and patient materials that are used where she works.

Find insights from providers on how to set up effective communication systems with surgeons, anesthesiologists, and hospitalists.

For patients on maintenance Extended-Release Bup (Sublocade), Naltrexone (Vivitrol), or Methadone, download brief guidelines that are based on CA Bridge recommendations.

Outpatient Preoperative Planning


MAR Provider / Patient

Educate patient on the importance of maintaining bup to (a) experience best pain control during surgery and (b) avoid having to reinitiate bup after surgery.

Explain how pain will be managed during surgery (full agonist opioids such as hydromorphone or fentanyl with regional anesthesia if possible) and after surgery (multimodal approach).

Document recommendations and plan in notes.


MAR Provider / Surgeon / Hospitalist / Anesthesiologist

If possible, contact surgeon, anesthesiologist, and/or hospitalist to advocate for the following perioperative plan:

  1. 1-2 days before surgery, taper patient down from home bup dose to 8-12 mg daily.
  2. On surgery day, give full 8-12 mg dose once, use regional anesthesia if possible, and add full agonist opioids as needed.
  3. Once post-surgical pain is controlled via a multimodal approach, taper off opioids and resume home bup dose.

Inpatient Post-Operative Pain Management

Watch an experienced IL provider describe the inpatient post-operative pain management protocols and patient materials that are used where he works.

Inpatient Post-Operative Pain Management

Intervene and Monitor

Hospitalist / Patient / Pain Expert

Give full 8-12 mg bup daily dose before surgery and manage breakthrough pain after surgery by increasing along spectrum of multimodal approach available in order set (e.g., Heat/Ice Acetaminophen/Gabapentin/NSAIDs Hydromorphone/Fentanyl Ketamine).

Consult with Pain Expert if available.

With full agonists opioids, patients on bup require higher total doses. Consider allowing patients to frequently administer these medications in small doses via PCAs. Monitor CO2 levels to detect respiratory depression.

Before discharge, trial the outpatient medication regimen to assure proper pain management in a controlled setting.


Hospitalist / MAR Provider

At discharge, coordinate outpatient care with the MAR Provider, ensuring patient has enough medication until follow-up.

Outpatient Postoperative Follow-Up

Watch an experienced IL provider describe the outpatient postoperative follow-up protocols and patient materials that are used where he works.

Outpatient Postoperative Follow-Up

Review Surgical Course and Assess Pain

MAR Provider / Patient

Discuss progress or concerns since surgery and review patient’s medical record.

Determine if bup was maintained during surgery and assess pain.

Bup maintained and pain controlled
Taper full agonist opioids slowly (i.e., aggressive removal can lead to return to use), maximize non-opioid therapies, and return to home bup dose.

Bup maintained and pain uncontrolled
Ensure underlying cause of pain is secondary to post-surgical trauma (e.g., not a surgical site infection). Then, via shared decision making with patient, either (a) continue 8-12 mg daily bup dose and increase dose/frequency of full agonist opioids or (b) taper off full agonist opioids and  temporarily increase the bup daily dose to 24 to 32* mg, dosing every 6 or 8 hours. Via close follow-up, ensure pain becomes controlled. Then taper full agonist opioids (if still taking) and return to home bup dose.

*While 32 mg dose is not FDA approved, it is accepted as standard of care.

Bup NOT maintained
Address patient’s pain if uncontrolled by increasing dose/frequency of full agonist opioids. Later once pain is controlled and full agonist opioids have been reduced, use a low dose schedule (e.g., Bernese Method or Yale Case Series) over a 5- to 7-day period to slowly reinitiate patient to bup without precipitating withdrawal. Once patient is at a therapeutic dose of bup (e.g., at least 12 mg daily) on schedule’s last day, taper or stop full agonist opioids.

In all cases, ensure patient has appropriate follow-ups with surgeon scheduled, ancillary services arranged (e.g., physical therapy), and any required labs or imaging ordered.