Veterans Do Not Always Receive Appropriate Continuation of OUD Medications During Surgical Hospitalizations
BACKGROUND:
Medication for opioid use disorder (OUD), including buprenorphine and methadone, is considered gold standard treatment. Clinicians increasingly work with patients prescribed buprenorphine for OUD who present for surgery and require perioperative pain management. There is evolving consensus that buprenorphine should be continued during the perioperative period, but little is known about clinician and health system practice in this area, or how it may vary by patient characteristics. This retrospective cohort study sought to describe practice patterns of perioperative buprenorphine use within VA – and patient outcomes up to 12 months following surgery. Using VA administrative data and medical record review, investigators identified all VA patients prescribed buprenorphine for OUD with an inpatient surgery in 2018 (n=183; 95% male, 77% white). They examined the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, and post-surgical outcomes. Socio-demographic and clinical characteristics associated with perioperative hold also were assessed.
FINDINGS:
- The majority of VA surgical patients in this study who received buprenorphine for OUD experienced a dose hold at some point during the perioperative period despite a trend in clinical guidelines recommending buprenorphine continuation: 40% of Veterans were instructed to hold buprenorphine prior to surgery, more than 60% did not receive buprenorphine on the day of surgery, and 55% did not receive a buprenorphine dose on the day following surgery.
- Homelessness/housing insecurity and rural residence were the only two predictors explored in this study that were associated with decreased likelihood of a perioperative buprenorphine dose hold.
- Discontinuation of buprenorphine following surgery also was relatively common. One month following surgery,13% of Veterans had no active buprenorphine prescription, increasing to 25% and 33% at 6- and 12-months post-surgery, respectively.
IMPLICATIONS:
- As holding buprenorphine perioperatively does not align with emerging clinical recommendations – and carries significant risks – educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care before and after surgery.
LIMITATIONS:
- Surgeries performed on an outpatient basis were excluded.
- Data were drawn from clinical notes documenting requests for patients to abstain from taking buprenorphine prior to surgery; thus, investigators were unable to state whether patients had followed their clinicians’ recommendations to hold their buprenorphine dose.
- Findings reflect clinical practice just prior to the release of internal VA guidance on perioperative use of buprenorphine, so may not reflect current clinical practice.
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D. Dr. Wyse and Mr. Herreid-O’Neill are part of HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC).
Wyse J, Herreid-O’Neill A, Dougherty J, et al. Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: A Retrospective Cohort Study. Journal of General Internal Medicine. September 20, 2021; online ahead of print.
