Considerations for management of procedural sedation in methadone and buprenorphine maintenance patients:

Follow the above principles 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 patient is  under constant observation. Slowly titrate to effect.
• consider using more opioids instead of opioids and benzodiazepines
• propofol is 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