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Pain Management after Cesarean Delivery in a Patient Dependent on Buprenorphine (Subutex)
Abstract Number: S-45
Abstract Type: Case Report/Case Series
The American College of Obstetrics and Gynecology (ACOG) committee recently released their opinion regarding opioid abuse, dependence, and addiction in pregnancy and recommended buprenorphine as an alternative to methadone to decrease risks associated with the use of illicit opioid dependency during pregnancy(1). Buprenorphine (Subutex™) is a partial μ-opioid agonist and at high doses a weak κ-antagonist that is taken as a sublingual tablet. Managing labor and post-cesarean pain in women taking buprenorphine is challenging, because of its long duration of action and its association with patients having a history of opioid abuse and addiction.
We report the case of a 28-yo G6P1 at 36 weeks gestation transferred to our institution for cervical shortening, vaginal bleeding and pelvic pressure. The patient had a history of 4 years of buprenorphine 8mg TID and alprazolam 1mg BID use in the setting of anxiety disorder, opiate and benzodiazepine dependence, several 2nd trimester losses, and a cesarean delivery at 40 weeks for 2nd stage arrest. Providers diagnosed intrauterine fetal demise, for which the patient strongly desired a repeat cesarean delivery.
She had weaned off alprazolam a month prior to admission, and planned to restart the medication after delivery. She was continued on her home dose of buprenorphine 8mg TID and lorazepam 1-2mg PRN anxiety. The patient requested a general anesthetic, which was induced with IV lidocaine, propofol, succinylcholine, midazolam 2mg, and fentanyl (total 2250mcg). A ketamine infusion was started intraoperatively at 8mg/h and continued postoperatively for 24h. Ketorolac 30mg IV was administered at the end of the case.
Postoperative pain regimen included a fentanyl IV PCA (50mcg bolus q6min, no 4 hour maximum), acetaminophen 1g PO q6h, and ibuprofen 600mg PO q6h. PCA use of fentanyl was 4500mcg during the 1st 24h and 2600mcg during the following 24h. On POD2 the PCA was discontinued and buprenorphine was restarted. She received 3-6 mg IV lorazepam per day. Prior to surgery, the patient’s VAS pain score was 5/10, and ranged from 6-8/10 during the 1st 24h, 6-7/10 during the following 24h, and 2-5/10 after 48h. The patient met goals for symptom relief and was satisfied with her pain control.
Multimodal analgesia including neuraxial analgesia and regional techniques such as a TAP block would have been optimal(2). Ideally, patients are rotated off buprenorphine to a pure μ-opioid agonist before surgery to facilitate perioperative pain management. However, the nature of labor and delivery doesn’t always allow time to do so. This case emphasizes the challenges obstetric anesthesiologists face when managing such obstetric cases.
1. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012 May; 119(5):1070-6.
2. SOAP 2013 Summer Newsletter. Education Committee: Post Cesarean Pain Management in the Buprenorphine (Subutex) Dependent Patient