- 50 years of documented benefits of methadone during pregnancy
- Induction is relatively simple
- Adequate doses are needed to prevent withdrawal and other opioid use
- Indicators of fetal well-being are less compromised with split-dosing
- Individualized post-partum dose reviews are needed
- Breastfeeding is compatible with methadone
Buprenorphine - A derivative of the opioid alkaloid thebaine
- Schedule III opioid
- μ-opioid receptor partial agonist
- primarily antagonistic actions on κ-opioid and δ-opioid receptors
- Half-life estimated to fall in the range of 24-60 hours
- Reviews in Jones et al., Drugs, 2012, and Addiction, 2012
Buprenorphine mono product - Buprenorphine mono product
- Buprenorphine + naloxone
- 2 mg and 8 mg sublingual tablets
- 2 mg/0.5 mg and 8 mg/2 mg sublingual film strips
- Buprenorphine: Formulations
- Reviews in Jones et al., Drugs, 2012, and Addiction, 2012
Patient must already be in withdrawal or buprenorphine may precipitate withdrawal. - Patient must already be in withdrawal or buprenorphine may precipitate withdrawal.
- Patients dependent on short-acting opioids (e.g., heroin, most prescription narcotics) will not take as long to enter withdrawal as patients dependent on long-acting opioids (e.g., methadone).
- Induction typically then takes place over a 3-day period, beginning with either 2 mg or 4 mg, with a maximum dose of:
- 8 mg – 12 mg on Day 1
- 12 mg – 16 mg on Day 2
- 16 mg up to 32 mg on Day 3
- Since 1995, over 40 published reports of prenatal exposure to buprenorphine maintenance.
- Approximately 750 babies prenatally exposed to buprenorphine (number of cases per report ranged from 1 to 159; Median=14).
- Dose range 0.4 to 32 mg
- 88% reported concomitant drug use
- Buprenorphine and Pregnancy
- Reviews in Jones et al., Drugs, 2012, and Addiction, 2012
Research with buprenorphine not as extensive as with methadone. - Research with buprenorphine not as extensive as with methadone.
- Well-tolerated and generally safe.
- In contrast to the research with methadone, little research has compared buprenorphine to an untreated control group.
- Rather, buprenorphine has been compared in both retrospective and prospective studies to methadone.
- Majority of research would suggest that maternal outcomes are not in any way different than for methadone.
- Reviews in Jones et al., Drugs, 2012, and Addiction, 2012
- Buprenorphine: Fetal Outcomes
- Salisbury et al., Addiction, 2012
Incidence rate for NAS is estimated to be 50% – about the same as for methadone - 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
- Objectives:
- 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.
- Buprenorphine: Breastfeeding
- Image Credit: “Mother Is Breast Feeding For Her Baby” by Jomphong
Share with your friends: |
