Incidence rate for NAS is estimated to be 50% – about the same as for methadone
NAS onset approximately 48 hours
Peaking within approximately 72-96 hours
Exceptions to this onset history have been the few neonates with NAS onset of 8-10 days postnatal age
such a protracted withdrawal syndrome may to be due to withdrawal from concomitant drug exposure (e.g., benzodiazepines) rather than a direct effect of buprenorphine withdrawal
Correlation between buprenorphine dose and NAS severity has been inconsistent
Time of first dose of NAS treatment medication has been shown to be later with buprenorphine than methadone ( 71 hours vs 34 hours, respectively)
Reviews in Jones et al., Drugs, 2012, and Addiction, 2012; Gaalema et al., Drug Alc Depend, 2013
Medications that are full agonist opioids can effectively treat pain in patients stabilized on either methadone or buprenorphine.
These results are consistent with data from non-pregnant surgery patients.
The importance of uninterrupted methadone or buprenorphine treatment in these patients is critical.
Each patient needs a pain management plan before delivery.
Buprenorphine: Pain Management
the need for medication dose adjustments in participants stabilized on buprenorphine or methadone 3 weeks before and 4 weeks after delivery
the need for methadone dose adjustments during the first 7 days in participants transferred from buprenorphine to methadone at 5 weeks postpartum
Participants: Received a stable dose of methadone (N = 10) or buprenorphine (N = 8) before and 4 weeks after delivery. Buprenorphine-maintained participants were transferred to methadone at 5 weeks postpartum.
There were no significant differences pre-delivery and/or post-delivery between the buprenorphine and methadone conditions in the mean ratings of dose adequacy, "liking," "hooked," and "craving" of heroin or cocaine.
Patient response to the conversion from buprenorphine to methadone seems variable. Buprenorphine-maintained participants required dose changes postpartum only after they transferred to methadone. Regardless of type of medication, postpartum patients should be monitored for signs of overmedication.
Buprenorphine: Postpartum Dosing
Jones et al., J Addict Med, 2008
Buprenorphine is found in breast milk 2 hours post-maternal dosing
Concentration of buprenorphine in breast milk is low
Amount of buprenorphine or norbuprenorphine the infant receives via breast milk is only 1%
Most recent guidelines: “the amounts of buprenorphine in human milk are small and unlikely to have negative effects on the developing infant”
“The advantages of breast feeding prevail despite the risks of an infant opiate intoxication caused by methadone or buprenorphine.”
Akinson et al., 1990; Marquet et al., 1997; Johnson, et al., 2001; Grimm et al., 2005; Lindemalm et al., 2009; Jansson et al., 2009; Müller et al., 2011; Reece-Stremtan, Marinelli and The Academy of Breastfeeding Medicine. Breastfeeding Medicine, 2015.
Image Credit: “Mother Is Breast Feeding For Her Baby” by Jomphong