Written by Barbara Hoefener, FNP 3/2021
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Suboxone and Pregnancy - Notes from my training with Reference to the Mothers Study.
Pregnancy and Buprenorphine (Category C) “Mothers Study”
-Buprenorphine (& methadone) have been shown to be safe and effective in pregnancy & compatible with breastfeeding.
-Opioid maintenance therapy is recommended over detoxification.
-Buprenorphine diminishes the severity of NAS compared to methadone.
Maternal Benefits:
-70% reduction in overdose related deaths
-Decreased risk of HIV, Hepatitis B and Hepatitis C
-Increased engagement in prenatal care & recovery treatment
Fetal Benefits
-Reduces fluctuations in maternal opioid levels, thus reducing fetal stress (vs detoxification, then relapse in 78-98%. This increases fetal stress, and results in a 500% increase in the rate of still births)
-Decrease in intrauterine fetal demise
-Decrease in intrauterine growth restriction
-Decrease in preterm delivery
-Shorter NAS treatment duration in hospital and lower morphine dose if needed.
Dosing: Goal is to reach the dose just high enough to stop use and block cravings.
-Split dosing is ideal to meet the accelerated metabolic clearance of pregnancy
-Blood volume inc 45%, cardiac output inc 30-50%, GFR doubles, Drug clearance inc, and half-life dec w lower trough levels àcan lead to withdrawal symptoms à May need increase in medication. Women should report any withdrawal symptoms without fear an increase in meds will affect baby’s hospital stay or NAS treatment.
**There is NO correlation between maternal opioid maintenance therapy dose and duration or severity of NAS.**
Labor and Delivery: Labor pain is treated with Epidural only. Continue with maintenance dose without rapid taper.
Neonatal Abstinence Syndrome (NAS)= Generalized dysfunction of the autonomic NS, GI tract, and respiratory system.
-Occurs in 60-80% infants with intrauterine exposure to opioids/ maintenance therapy.
-Onset/ duration: Most infants present within 72 hours after delivery and can last up to 4 weeks. (longer >drugs)
-Treatment: Pharm: DTO, morphine, methadone.
*Non-Pharm*: Breastfeeding, skin to skin, swaddling, low stimulation environment, maternal room-in.
Breastfeeding Benefits for ALL:
-Benefits for all mother- infant pairs
-Decrease risk of SIDS, diabetes, and obesity for children
-Decreases risk of breast and ovarian cancer for women
-Improved infant cognitive development
-Improved mother-infant bonding
-Financial benefits (cost of formula isn’t cheap)
-Additional benefits for preterm infants
-50% reduction in necrotizing enterocolitis
-Better feeding tolerance and attainment of full enteral feedings
-Decreased rates of late onset sepsis.
-Improved developmental outcomes.
-Opioid use disorder/ NAS -- recommend Breastfeeding (Category L3)
-Buprenorphine has poor oral bioavailability, the amount in human breast milk is minimal.
-30% decrease development of NAS with 50% decrease in neonatal hospital stay
-Positive reinforcement for maternal recovery.
-Recommended for women with hepatitis, unless cracked or bleeding nipples. Pump/ dump until healed.
Contraindications to Breastfeeding.
-Maternal HIV infection
-Current Maternal substance use
-Recent heavy marijuana use because marijuana is lipophilic and concentrates in breast milk.
-If Bleeding, infected or cracked nipples (pump and dump until healed)- especially if hepatitis positive.
Reference: ASAM Buprenorphine Course 2019
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