Episode 332: Buprenorphine with Tom Hickey

In this episode of the ACRAC Podcast, host Jed Wolpaw welcomes Dr. Tom Hickey, a board-certified anesthesiologist and addiction medicine specialist, to discuss the growing role of buprenorphine in perioperative and acute pain management. Hickey shares his personal journey into addiction medicine, sparked by a case cancellation due to a patient’s buprenorphine use, which highlighted the outdated fear and misunderstanding surrounding the drug. He provides a comprehensive overview of buprenorphine’s pharmacology—its high lipophilicity, strong mu-receptor affinity, long duration of action, and biased agonist profile—which contributes to its safety and efficacy. The discussion emphasizes buprenorphine’s significant advantages over traditional opioids, including a ceiling effect on respiratory depression, lower abuse potential, and utility as both a pain reliever and a reversal agent. Hickey debunks common myths, such as the idea that buprenorphine provides only partial analgesia or that it cannot be combined with other opioids, and advocates for its use in multimodal pain strategies across surgical, ICU, and emergency settings. He also highlights future research opportunities, including long-term outcomes and its potential in trauma and critical care. The episode concludes with book recommendations from Hickey: Peter Heller’s 'Dog Stars' and Michael Pollan’s 'A World Appears'. The episode underscores a paradigm shift in how anesthesiologists and pain specialists should view buprenorphine—not as a risky or limited medication, but as a versatile, safe, and underutilized tool in modern pain management. Key takeaways include the importance of continuing buprenorphine in patients already on it, the safety of combining it with other opioids, the potential for long-term opioid sparing, and the need to overcome historical fears through education. Hickey’s insights challenge entrenched practices and advocate for evidence-based, harm-reduction approaches in anesthesia and critical care. The overall tone is optimistic and forward-looking, emphasizing that buprenorphine is not just a treatment for opioid use disorder but a powerful analgesic with broad clinical applications.