









































Volume 6 - No. 8 2018

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 6 - No. 8 2018 

Anesthesia eJournal - Online
ISSN 2333-2611

Page 37

Opioid-Free Anesthesia for an Emergency Laparoscopic Cholecystectomy in a Patient 
Taking Buprenorphine-Naloxone for Opioid Addiction: A Case Report
Thomas Baribeault, MSN, CRNA

Affiliation:
Founder of  Society for Opioid-Free Anesthesia and Chief CRNA at Lexington Surgery Center

Funding/Conflict of Interest Disclosure: 
No grants or financial support were used in this paper

Acknowledgments
Jennifer Holmes, ELS, is acknowledged for medical writing support

KEYWORDS:Opioid-Free Anesthesia, Buprenorphine-Naloxone, Pain Management, Opioid addiction, Anesthesiology

Abstract
With the growing public health problem of opioid misuse, addiction, and overdose, the number of patients presenting 
for surgery and anesthesia who may be opioid-dependent or undergoing medication-assisted treatment for opioid use 
disorder is increasing. These patients may be appropriate candidates for opioid-free anesthesia. This case report describes 
a patient being treated with buprenorphine-naloxone for opioid addiction who required an emergency laparoscopic cho-
lecystectomy. She requested that opioids not be used in her treatment plan. The patient’s pain was successfully managed 
with opioid-free anesthesia and she was discharged with no requirement for additional pain medications.

INTRODUCTION
Opioid misuse, addiction, and overdose are growing public health problems. In 2016 alone, 11.5 million persons aged 12 
or older in the United States misused prescription pain relievers.1 According to recent data from the Centers for Disease 
Control and Prevention, the rate of drug overdose deaths involving synthetic opioids other than methadone (eg, fentanyl, 
fentanyl analogs, and tramadol) doubled from 2015 to 2016 (from 3.1 to 6.2 per 100,000 persons).2 As the number of 
prescriptions written for opioid pain medication rises, so too does the number of patients presenting for surgery and 
anesthesia who may be opioid-dependent or undergoing medication-assisted treatment for opioid use disorder. 
Buprenorphine combined with naloxone (Suboxone) is used to treat opioid dependence in outpatient settings. 
Buprenorphine is a mu-opioid receptor partial agonist and a kappa-opioid receptor antagonist, and naloxone is an opioid 
receptor antagonist. By binding to the mu-opioid receptor, buprenorphine mimics the pharmacological effect of an opioid 
but to a lesser extent, thus preventing opioid withdrawal symptoms.3 However, the high receptor binding affinity and long 
half-life of buprenorphine make it difficult to treat acute pain in patients being treated for opioid addiction.4

In the present case, a patient who was being treated for opioid addiction required an emergency laparoscopic 
cholecystectomy. She requested that opioids not be used in her treatment plan. This report describes the successful delivery 
of opioid-free anesthesia to a patient being treated with buprenorphine-naloxone.

AEJ



Anesthesia eJournal          www.anesthesiaejournal.com
Volume 6 - No. 8 2018 Page 38

Case Summary
A 29-year-old woman (height, 67”; weight, 61 kg; PS2) presented 
to the emergency department with acute cholecystitis. She had a 
history of thyroid cancer that had been treated by thyroidectomy, 
current tobacco abuse, social alcohol use, and a history of opioid 
abuse currently being treated with buprenorphine-naloxone 
(Suboxone; Indivior). Preoperative vital signs included a blood 
pressure of 116/74, heart rate of 82, respiratory rate of 18, 
oxygen saturation of 95% on room air, and temperature of 100.6 
degrees Fahrenheit. During the anesthesia interview, the patient 
discussed her concerns both with relapse as a result of receiving 
opioids for pain and with having uncontrolled pain after surgery 
because of her buprenorphine-naloxone treatment. Because of 
the emergent nature of the case, there was no time to involve 
the buprenorphine-naloxone provider in the discussion or to 
delay surgery until the buprenorphine-naloxone had worn off. 
The patient and anesthetist discussed a plan of care including 
multimodal therapy, reasonable expectations after surgery, 
and acceptable pain levels. The patient gave verbal consent to 
publication of the case. No approval was sought from an ethics 
committee because of the emergent nature of the case; the writing 
of the report did not change the care the patient received.
The patient was taken to the operating room and general 
anesthesia was induced with 150 mg propofol, 100 mg lidocaine, 
50 mg ketamine, and 100 mcg clonidine. Intubation was 
facilitated with 50 mg rocuronium, which also provided the 
necessary muscle relaxation for laparoscopic surgery. During 
induction, a second Certified Registered Nurse Anesthetist 
(CRNA) performed bilateral subcostal transversus abdominis 
plane (TAP) blocks with 30 mL 0.25% bupivacaine and 5 mg 
preservative-free dexamethasone per side shortly after intubation.
The case proceeded uneventfully and lasted 132 minutes during 
which general anesthesia was maintained with desflurane 4% 
to 5%. The patient required 50 mg ephedrine in divided doses 
throughout the case to maintain mean arterial pressure (MAP) 
> 70. The heart rate varied between 60 and 80 beats/min, 
respiratory rate was set at 15 breaths/min on the ventilator, and
oxygen saturation was 98% to 100%. The temperature was 100.6
degrees Fahrenheit and decreased to 99.0 degrees Fahrenheit
by the time the procedure was over. Two additional 10-mg
boluses of rocuronium were required for muscle relaxation. The
patient received 8 mg dexamethasone before incision and 4 mg
ondansetron on emergence for nausea prophylaxis. The patient
was also given 1 g acetaminophen (Ofirmev; Mallinckrodt) and
30 mg ketorolac intravenously on emergence for postoperative
pain. In addition, 3 mg neostigmine and 0.4 mg glycopyrrolate
was given for muscle relaxant reversal.
At the conclusion of the case, the patient was extubated and
taken to the post-anesthesia care unit (PACU). On admission
to the PACU, she was drowsy but awake and alert and fully
oriented to person, place, date, and time with stable vital signs. 
She had mild pain but at an acceptable level (visual analogue
scale <4/10) and did not wish to try and reduce her pain through
opioid medications. After a suitable period of recovery, she was
discharged with no requirement for additional pain medications.
Discussion
In this case, the anesthetist addressed the patient’s anxiety about 
pain and relapse by providing opioid-free anesthesia. Fear of 

postsurgical pain and the ubiquitous prescribing of opioids for 
the treatment of acute pain can be strong triggers for relapse in 
patients being treated for addiction.4 Patients should be reassured 
that a history of addiction will not be a barrier to the adequate 
treatment of postoperative pain.5 Patients can also be encouraged 
to intensify their involvement in a recovery program after surgery 
to help to prevent stress-mediated relapse.5

The availability of buprenorphine and buprenorphine-naloxone 
has expanded opportunities for outpatient treatment of 
opioid addiction. However, treatment of these patients in the 
perioperative setting is challenging. Although consensus on the 
perioperative management of patients taking buprenorphine 
is lacking, regional and systemic opioid-sparing treatments 
should be used whenever possible.4 Therapeutic options include 
alternative routes of administration of local anesthetic agents, 
infusion of ketamine, and regional anesthesia.6 Nonopioid 
analgesics can be used initially for postoperative pain with or 
without continuous regional local anesthesia or selective nerve 
blocks.5 In this case, the patient received multimodal therapy 
including regional anesthesia and nonopioid analgesics for 
postoperative pain.
The Guidelines for the Management of Postoperative Pain of 
the American Pain Society, the American Society of Regional 
Anesthesia and Pain Medicine, and the American Society of 
Anesthesiologists’ Committee on Regional Anesthesia, Executive 
Committee, and Administrative Council recommend that 
clinicians offer multimodal anesthesia to treat postoperative 
pain in both children and adults.7 The rationale for multimodal 
anesthesia is that by administering different analgesic medications 
that target different mechanisms of action in the nervous system, 
better pain management can be achieved by blocking receptors 
both centrally and peripherally. The results of randomized 
trials have shown that multimodal anesthesia is associated with 
improved pain relief and decreased opioid consumption.7

The multimodal anesthesia plan in this case included ketamine, 
clonidine, ketorolac, acetaminophen, and regional anesthesia. 
Nonopioid analgesic agents were given on emergence. 
Postoperative pain guidelines recommend the consideration 
of ketamine as a component of multimodal analgesia.7 When 
included in a multimodal regimen, clonidine has been shown to 
be effective for reducing acute postoperative pain and progression 
to chronic pain.8 In this case, acetaminophen and ketorolac were 
given intravenously on emergence. The classes of nonopioid 
analgesics that can be considered in this population for acute 
pain include acetaminophen, nonsteroidal anti-inflammatory 
drugs, N-methyl-D-aspartate (NMDA) receptor antagonists, 
alpha-2 agonists, gabapentinoids, and selective serotonin reuptake 
inhibitors.4

The patient in this case, a woman aged less than 20 years, 
undergoing general anesthesia, and possibly needing 
postoperative opioids, had characteristics that placed her at higher 
risk for postoperative nausea and vomiting (PONV). In addition 
to reducing postoperative opioid use, multimodal therapies can 
significantly reduce the incidence of PONV.8 Patients undergoing 
bariatric surgery are also at high risk for PONV. In a small 
prospective, randomized study of patients undergoing elective 
bariatric surgery, Ziemann-Gimmel et al reported that opioid-
free anesthesia with dexmedetomidine significantly reduced the 
risk of developing PONV.9



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 8 2018 Page 39

Opioid-free anesthesia is a relatively new trend in anesthesia 
administration. As the United States continues to address the 
opioid epidemic, anesthesiologists will encounter patients who 
may be appropriate candidates for opioid-free anesthesia. In 
another case in which opioid-free anesthesia was successfully 
provided, a female soldier on active duty underwent a cervical 
ganglionectomy 7 days after ultra-rapid opioid detoxification 
under general anesthesia.10 The patient was eager to return to duty 
and requested that opioid use be avoided. In that case, a balanced 

anesthetic including dexmedetomidine, ketamine, and a volatile 
anesthetic was used. In both that case and the present case, the 
patients wanted to prevent relapse by avoiding opioids during 
surgery. In both cases, the combination of an NMDA receptor 
antagonist such as ketamine with an alpha-2 agonist, such as 
dexmedetomidine or clonidine, seemed to be especially effective 
for controlling hemodynamics intraoperatively and reducing 
postoperative pain. The benefits of opioid-free anesthesia are 
summarized in Table 1.

Table 1. The Benefits of Opioid-Free Anesthesia
• Providing superior postoperative pain control by protecting the patient from surgical and opioid-induced 

hyperalgesia
• Minimizing respiratory depression in patients with impaired respiratory function, such as patients with 

chronic obstructive pulmonary disease, sleep apnea, and obesity
• Treating patients with chronic pain conditions, patients receiving chronic opioid therapy, patients with 

addiction, or patients in recovery and treatment for opioid use disorder (eg, with methadone or buprenor-
phine-naloxone)

• Minimizing postoperative cognitive dysfunction
• Minimizing other side effects of opioids such as nausea, pruritus, immune suppression, urinary retention, 

and constipation 

The growing opioid crisis has implications for practitioners in the fields of surgery and anesthesia. Substance abuse should be addressed 
early and frankly by providers, and patients should be reassured that their pain can be effectively controlled and their risk for relapse 
minimized. Opioid-free anesthesia should be considered as a means of achieving these goals.



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 8 2018 Page 40

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