Considerations for management of procedural sedation in methadone and buprenorphine maintenance patients:
See Perioperative Management for acute pain management in opioid tolerant patients – they will require more analgesics than the opioid naive. Titrate to effect.
Specific considerations for methadone maintenance patients:
- Benzodiazepines significantly increase the chance of respiratory depression.
- Use benzodiazepines with care, if at all, especially in the benzodiazepine naive.
- Start with less benzodiazepine and make sure the patient is under constant observation. Slowly titrate to effect.
- Consider using more opioids instead of opioids and benzodiazepines.
- Propofol may be a better option assuming the right monitoring is available.
- In the case of respiratory depression, use flumazenil before naloxone. If using naloxone titrate to effect rather than bolus.
Specific considerations for buprenorphine maintenance patients:
- Benzodiazepines are less dangerous because of the respiratory ”ceiling effect” of buprenorphine.
- Benzodiazepines are not contraindicated.
- In the case of respiratory depression, use flumazenil before naloxone.