Buprenorphine and surgery: continue, don’t hold
The recommendation reversed. Why holding buprenorphine before surgery rested on a misreading, and what the receptor kinetics actually show.
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For years the standard instruction was to stop buprenorphine before surgery, on the reasoning that its high receptor affinity would block the opioids needed afterward. That reasoning has been substantially overturned, and the current recommendation is close to its opposite.
Key takeaways
- Continue buprenorphine through the perioperative period. A multisociety expert panel in 2021 recommended it should not be routinely discontinued, and a Delphi-based practice advisory concluded it is rarely appropriate to reduce the dose.
- The original rationale was a misreading. The practice grew from case reports of undertreated pain, which may have reflected the difficulty of managing opioid-tolerant patients rather than any blocking effect of buprenorphine itself.
- Receptors remain available. A clinically significant proportion of mu receptors are unoccupied even at high stable doses, and full agonists can still bind them.
- Stopping carries its own risk — relapse, overdose after loss of tolerance, and a difficult reinduction.
- Analgesic ceiling and respiratory ceiling are not the same thing, and conflating them drives poor decisions in both directions.
- Poor initial pain control is not evidence of drug-seeking. It is a predictable feature of an opioid-tolerant patient having surgery.
What the recommendation now says
| Source | Position |
|---|---|
| Multisociety expert panel, 2021 | Buprenorphine should not be routinely discontinued in the perioperative setting, as adequate analgesia can be achieved1,2 |
| PAIN clinical practice advisory (modified Delphi) | Continue buprenorphine perioperatively; it is rarely appropriate to reduce the dose, irrespective of indication or formulation. If analgesia is inadequate after optimizing adjuncts, start a full mu agonist while continuing buprenorphine3 |
| SAMHSA | Updated in 2018 to recommend most patients continue buprenorphine perioperatively, because of the relapse risk with discontinuation2 |
| Systematic reviews | No evidence favoring discontinuation, particularly at doses below 16 mg daily. Discontinuation with introduction of a full agonist has been identified as a possible risk factor for OUD exacerbation2 |
A 2025 retrospective cohort in Anesthesiology of 1,881 surgical cases in 1,673 veterans on buprenorphine examined postoperative pain scores and opioid requirements with continuation versus interruption, and supported the guideline direction.4 A recent review characterized the position more bluntly: the data now overwhelmingly refute full preoperative discontinuation.5
Where the old practice came from
The reasoning was plausible and the evidence behind it was thin. Buprenorphine is a partial mu agonist with very high receptor affinity and slow dissociation, which made it seem obvious that it would displace or block the full agonists needed for postoperative pain. That belief — that adequate pain management was not achievable while a patient remained on buprenorphine — was the stated impetus for perioperative discontinuation.3
But it was built largely on case reports of undertreated pain in this population, which may have reflected the general difficulty of managing opioid-tolerant or opioid-dependent patients rather than an effect of buprenorphine.6 And it turns out that even at high stable doses, a clinically significant proportion of mu receptors remain unoccupied and available to bind full agonists.7
The kinetics that actually matter
Affinity and efficacy are different properties
Buprenorphine binds the mu receptor with very high affinity — it holds on tightly — but has only partial efficacy, producing a submaximal effect. High affinity is why it is not easily displaced. Partial efficacy is why it has a ceiling. These are separate properties and they have separate consequences.
The ceiling applies to buprenorphine, not to what you add
This is the distinction most often lost. Buprenorphine’s ceiling on respiratory depression applies to buprenorphine’s own intrinsic effect. It does not extend to co-administered full agonists. A patient on buprenorphine who receives escalating hydromorphone can still develop respiratory depression, and still requires monitoring. The ceiling is not a safety net for other drugs.
Equally, naloxone reversal of high-affinity buprenorphine is not straightforward — it may require higher doses, often given as an infusion rather than a bolus, because of the affinity that makes buprenorphine difficult to displace in the first place.
Receptor occupancy is not linear with dose
Occupancy is high at typical maintenance doses and falls off substantially at lower doses. This is the pharmacologic basis for dose-splitting strategies: at 16 mg daily, occupancy is high; reducing toward 8 mg meaningfully increases available receptors while retaining most of the treatment benefit.
Receptor half-life exceeds plasma half-life
Because buprenorphine dissociates slowly, its effect at the receptor outlasts its plasma concentration. Holding the drug on the morning of surgery does not free receptors on the timescale of that operation — which is the pharmacologic reason a same-day hold accomplishes little while carrying the full risk of an interrupted treatment.
What to actually do
The default
Continue at the usual dose. Plan multimodal analgesia deliberately rather than reactively — regional technique where possible, acetaminophen, NSAIDs where not contraindicated, ketamine and intravenous lidocaine intraoperatively where appropriate.8
Where a modification is considered
Where the dose exceeds 16 mg daily and moderate-to-severe pain is expected, some institutions split the dose to maximize buprenorphine’s own analgesic contribution, and reduce the dose on the day before and day of surgery to increase receptor availability for full agonists.9 Others recommend continuing without any reduction.2 The practice advisory position is that reduction is rarely appropriate.3
What is consistent across sources is that this should be a planned decision made with the buprenorphine prescriber, not a default applied at the pre-op desk.8
If analgesia is inadequate
Optimize the adjuncts first, then add a full mu agonist while continuing buprenorphine — not by stopping it.3 Expect to need higher full-agonist doses than in an opioid-naive patient, and monitor accordingly.
A point worth stating plainly. Poor initial response to opioid analgesia in a patient on buprenorphine is a predictable pharmacologic finding, not evidence of drug-seeking. Interpreting it that way is a documented failure mode in this population, and it has consequences for both the pain and the therapeutic relationship.
Discharge and reinduction
Patients should ideally be discharged on buprenorphine, though not necessarily at the preoperative dose; depending on analgesic requirement, discharge on a full agonist may be appropriate.3 Where the drug was held or tapered, reinitiation should be arranged before discharge or as soon as feasible — and that coordination should be scheduled before the surgery rather than left to the patient to manage.9 Low-dose induction allows reinitiation without requiring the patient to experience withdrawal.9
Two distinctions to establish preoperatively
- Why is the patient on buprenorphine? The practice advisory specifies distinguishing chronic pain use from opioid use disorder, because long-term treatment retention and harm reduction dominate the calculus when OUD is the primary diagnosis.3
- Which formulation? Sublingual and injectable preparations are approved for OUD; buccal and transdermal are approved for chronic pain.2 Extended-release injectable formulations cannot be held in any meaningful sense — the decision is already made by the time the patient arrives.
Frequently asked questions
Do I have to stop Suboxone before surgery?
Current guidance says no. A multisociety expert panel in 2021 recommended that buprenorphine should not be routinely discontinued perioperatively,1,2 and a Delphi-based practice advisory concluded that it is rarely appropriate to reduce the dose at all.3 SAMHSA updated its guidance in 2018 to recommend most patients continue, because of the relapse risk when it is stopped.2
Will buprenorphine block my pain medication after surgery?
Not completely. A clinically significant proportion of mu opioid receptors remain unoccupied even at high stable buprenorphine doses, and full agonist opioids can still bind them.7 Higher doses of full agonist are typically required than in an opioid-naive patient, but adequate analgesia is achievable while buprenorphine is maintained.3,5
Why did the advice change?
The original practice grew out of case reports of undertreated pain, which may have reflected the general difficulty of managing opioid-tolerant patients rather than a blocking effect of buprenorphine itself.6 Once studies looked directly, maintaining buprenorphine was not associated with worse pain control, and the risks of stopping — relapse, overdose, difficult reinduction — became clearer.2,5
What if the dose is 16 mg or higher?
Practice varies. Some institutions split the dose to maximize buprenorphine’s own analgesic effect and reduce it on the day before and day of surgery when moderate-to-severe pain is expected.9 Others continue without reduction.2 The Delphi practice advisory holds that reduction is rarely appropriate.3 This should be decided in advance with the prescriber.
Does buprenorphine’s ceiling effect make added opioids safe?
No, and this is a common and dangerous misreading. The ceiling applies to buprenorphine’s own intrinsic effect, not to co-administered full agonists. A patient receiving escalating full-agonist opioid alongside buprenorphine can still develop respiratory depression and requires monitoring.
What happens if buprenorphine is stopped for surgery?
Discontinuation in a patient on stable treatment is associated with relapse risk, overdose risk from lost tolerance, and a difficult transition back. Discontinuation with introduction of a full agonist has been identified as a possible risk factor for exacerbation of opioid use disorder.2 If it is held, reinitiation should be arranged before discharge and scheduled before the surgery rather than left to the patient.9
References
- Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021;46(10):840–859.
- Perioperative management of patients on buprenorphine for opioid use disorder. ASRA News, February 2023. Summarizes the 2021 multisociety panel, the 2018 SAMHSA update, and systematic reviews finding no evidence favoring discontinuation, especially below 16 mg daily.
- Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth. 2019. PMC6676043.
- Hitt JM, et al. Perioperative continuation of buprenorphine in surgical patients with opioid use disorder. Anesthesiology. 2025. Retrospective cohort, 1,881 surgical cases in 1,673 patients.
- Perioperative management of patients on buprenorphine. Curr Pain Headache Rep. 2026. doi:10.1007/s11916-025-01432-w
- Perioperative buprenorphine management and postoperative pain outcomes: a retrospective study with evidence-based recommendations. Med Sci (Basel). 2024. Describes the origin of the discontinuation practice in case reports of undertreated pain.
- Perioperative pain management guidance for patients on chronic buprenorphine. US Department of Veterans Affairs, February 2022. Notes that a clinically significant proportion of receptors remain available even at high stable doses, and that this finding drove the change in expert consensus.
- Guidelines for the perioperative management of buprenorphine. US Department of Veterans Affairs, February 2022. Multimodal strategy including regional catheters, ketamine, lidocaine, gabapentinoids, acetaminophen and NSAIDs.
- Wyse JJ, et al. Perioperative management of buprenorphine/naloxone in a large, national health care system: a retrospective cohort study. J Gen Intern Med. 2021. doi:10.1007/s11606-021-07118-4. Describes dose-splitting above 16 mg, care coordination for reinitiation, and low-dose induction.
- Further reading. Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To stop or not, that is the question: acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017;126(6):1180–1186.
- Further reading. Quaye A, Potter K, Roth S, Acampora G, Mao J, Zhang Y. Perioperative continuation of buprenorphine at low-moderate doses was associated with lower postoperative pain scores and decreased outpatient opioid dispensing compared with buprenorphine discontinuation. Pain Med. 2020;21(9):1955–1960.
Disclaimer. Reference information for licensed clinicians and students. Not a medical device, and not a substitute for clinical judgment. Decisions about buprenorphine should involve the prescriber. Verify against your institutional protocol and current package inserts.
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