Reply to

Abstract

Editor, We appreciate Dr Huxtable's and Dr Macintyre's interest1 in our review article about the perioperative management of pain in patients who abuse opioids.2 We have attentively read the letter to the editor by Huxtable et al.3 describing an extremely interesting alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy (BOST) programmes.4 Currently, about 15 000 Austrian addicts are in a substitution treatment. Methadone is used in about 20 to 25% of them and buprenorphine in about 10 to 21%. Other substances, such as codeine, are used by only about 1% of these patients.5 The result of the described retrospective cohort study is undoubtedly interesting4 and seems to be a comfortable alternative in the management of acute pain in patients who are in BOST programmes to achieve adequate perioperative analgesia. However, the management of acute perioperative pain in a patient, as reported in the BOST article, depends mainly on local medical treatment regimens. In Austria, buprenorphine is replaced with methadone or a pure μ-opioid agonist throughout the perioperative period for elective major surgery to ensure adequate intraoperative and postoperative pain relief,2,6,7 because of buprenorphine′s well known pharmacological, especially potential μ-antagonistic, characteristics. We remain of the view that addicted patients have to be recognised as a high-risk group in the perioperative period, especially in major surgery, because of their higher perioperative risk for organic and psychological complications. These patients have to be monitored carefully to avoid adverse effects. Therefore, we highly recommend a continuous and careful opioid dose titration to avoid unnecessary complications.2 Acknowledgements relating to this article Assistance with the study: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.