Transcript MULTI-TRAUMA IN A 22 Year

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
Australian patients on methadone-maintenance therapy
(MMT) or buprenorphine-maintenance therapy (BMT) :
1998: 24,657
2009: 43,445
AIHW 2009
Buprenorphine
Opioid Pharmacology
•
Partial mu-agonist & kappa-antagonist
•
Full mu-agonist at analgesic doses
•
Anti-hyperalgesic properties
•
High opioid receptor affinity
•
Slow offset kinetics
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?
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)
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.
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
Results
Total patients = 51
BMT = 22
BUP
cont = 11
BUP
ceased = 11
MMT = 29
METH
cont = 22
METH
ceased = 7
Results
BUP
cont.
Age (yrs)
BUP
ceased
40.2  0.4 38.9  10.8
METH
cont.
METH
ceased
39.0  7.2
38.8  7.9
Alcohol
27%
18%
14%
14%
Cannabis
9%
9%
23%
14%
BZD
18%
36%
50%
29%
st
1
24hr PCA Requirements
250
0
METH
(ALL)
METH
METH
(CONT) (CEASED)
BUP
(ALL)
245 ± 109 mg
155 ± 135 mg
50
196 ± 128 mg
100
281 ± 129 mg
150
211 ± 130 mg
200
180 ± 139 mg
Morphine equivalents (mg)
300
BUP
BUP
(CONT) (CEASED)
st
1
24hr PCA Requirements
250
0
METH
(ALL)
METH
METH
(CONT) (CEASED)
BUP
(ALL)
245 ± 109 mg
155 ± 135 mg
50
196 ± 128 mg
100
281 ± 129 mg
150
211 ± 130 mg
200
180 ± 139 mg
Morphine equivalents (mg)
300
BUP
BUP
(CONT) (CEASED)
Results
BUP
cont.
BUP
ceased
METH
cont.
METH
ceased
Pain – rest
4.1  1.9
4.7  2.2
4.6 2.0
5.4  2.2
Pain – movt.
6.6  1.7
6.9  2.6
7.5 1.7
8.1  2.5
N & V (Req. Rx)
36.4%
27.3%
22.7%
32.9%
Sedn Score = 2*
18.2%
27.3%
18.2%
28.6%
* Overall incidence sedn score of 2 in all RAH APS patients = 1.68%
Results
BUP
cont.
BUP
ceased
METH
cont.
METH
ceased
Pain – rest
4.1  1.9
4.7  2.2
4.6 2.0
5.4  2.2
Pain – movt.
6.6  1.7
6.9  2.6
7.5 1.7
8.1  2.5
N & V (Req. Rx)
36.4%
27.3%
22.7%
32.9%
Sedn Score = 2*
18.2%
27.3%
18.2%
28.6%
* Overall incidence sedn score of 2 in all RAH APS patients = 1.68%
Results
BUP
cont.
BUP
ceased
METH
cont.
METH
ceased
Paracetamol
100%
100%
100%
100%
Ketamine
27%
100%
54%
71%
Days PCA
2.2  1.4
4.6  3.0 2.7  1.6 6.0  2.8
Days APS
3.0  1.7
5.9  3.9 4.0  2.5 8.7  3.4
Opioid-tolerant Patients
Royal Adelaide Hospital 1998 (n = 214, PCA)
Opioid-tolerant
1st 24 h PCA Morphine
171 mg
Pain Score - Rest (median)
6
Pain Score - Movt. (median)
8
Sedation score 2 or 3
14%
Opioid-naive vs. Opioid-Tolerant
Rapp et. al. 1995 (n = 149, PCA)
Opioid-naive
Opioid-tolerant
47  32 mg
136  69 mg
Pain Score - Rest
3
5
Pain Score - Movt.
7
8
19%
50.3%
1st 24 h PCA Morphine
Sedation score 2 or 3
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
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
Conclusions
Cessation of BMT & MMT
•
Higher opioid requirements
•
Longer duration of PCA therapy
•
Requirement for more intensive APS management
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.