Baby’s Buprenorphine Withdrawal

This morning I responded to a woman at SuboxForum.  Her baby was taken to the NICU for ‘withdrawal’, which is better identified as neonatal abstinence syndrome.  She said that the baby is eating well, but there is concern that the baby sleep only 2 hours at a stretch.  The baby is on morphine, and mom is wondering when they both can go home.  She is kicking herself for not trying to stop buprenorphine before the delivery.  I spent a while responding, so I decided to post my response here as well, in case a mom in a similar situation stops by.

My comments:

I have written a number of posts about neonatal abstinence, and I invite you to read a post in my blog about the guilt you are feeling.

First of all, you did the right thing.  Period.  Every medical specialist, study, or text will say the same thing:  that women addicted to opioids should be maintained on a long-acting opioid until the baby is born.  Traditionally, that opioid was methadone.  But women on methadone who are pregnant often end up on very high doses of that drug– pushing their tolerance to high levels, so that virtually all their newborns have significant withdrawal.   Of course, the babies do fine in the long run— and the experience of withdrawal is not among the worst things that a baby experiences, by far.

People see a shivering newborn and somehow imagine that the baby just ‘came to be’, at that moment. In reality, a couple hours earlier the baby was in the birth canal, squeezed so tightly that shoulders are sometimes broken, probably experiencing a sensation akin to suffocation.  I say that because while oxygen is being delivered via the umbilical cord, during deliver the cord is often compressed, causing changes in oxygen and carbon dioxide that would cause the same physiologic sensations as asphyxiation. The low oxygen tension and high carbon dioxide levels stimulate the ‘preborn’ to breathe, a hopeless challenge when the baby’s face is tightly wrapped by the birth canal!

And of course before that, the baby was upside down, getting pushed, squeezed, bounced… we picture this wonderful intra-uterine environment, but in reality we have no idea what it ‘feels like’ to the fetus.  All the things we see after the birth were before birth, except perhaps the shivering.  When the baby is born, there is no ‘on switch’ that suddenly starts recording his experiences!

As buprenorphine has become more-available, the trend has been to use buprenorphine instead of methadone.  There are several advantages– the tolerance of the mother is much lower, meaning any withdrawal in the baby will likely be less severe.  According to a number of studies, about half of babies born to moms on buprenorphine show signs of neonatal abstinence syndrome, compared to almost all babies born to moms on methadone.  Studies show no benefit to tapering buprenorphine to lower doses before delivery, but I tend to think that there must be value in doing so.  I wonder if those studies truly had good control over the doses that study subjects were taking.  My patients seemed to benefit by reducing to 4- 8 mg during pregnancy– but perhaps my impressions are biased.

Another biased impression of mine is that babies have experiences largely dictated by the sensibilities of their neonatologists.  Almost all of my patients who delivered at the local, small community hospital did great, and moms and babies went home at the regular time.  If there was any withdrawal, it wasn’t noticed.   Maybe it was treated by the buprenorphine in breast milk, because all of the mothers were encouraged to breast feed.  Nursing while on buprenorphine seems to me to be the ideal way to wean a baby off the medication; the baby’s immature liver gets better and better at metabolizing medications after birth, allowing the amount of buprenorphine in the bloodstream to decrease over time.

Hospitals with neonatologists and a neonatal ICU are going to USE those things.  The regular OB nurses in those environments tend to become less-familiar and less-comfortable with anything other than ‘normal’, and watch for reasons to send babies to a higher level of care.  Every nurse on the OB unit knows that this baby’s mom is an addict.  If the baby cries along with all the other babies, the nurses will believe that ‘this’ baby is suffering from withdrawal.  And when the baby is sleeping along with all the other babies, the nurses will think ‘this’ baby is sedated from buprenorphine.
They will transfer the baby to the neonatal ICU, where the environment makes ANY baby look sick and miserable, opioid withdrawal or not.   Just look at the environment, and all of the little ways that mom’s experience changes…. instead of smiling nurses wheeling the baby into the room, congratulating mom repeatedly in front of smiling family, you have busy, serious-faced nurses and doctors bent over charts or computers.  When they take time to talk with mom, the conversations are serious, and certain to instill guilt and fear.  The baby is attached to wires or tubes, perhaps wearing oxygen, under unnatural lighting that changes skin color from healthy-looking to some type of medical specimen.

The baby will remember none of this, just as the baby won’t remember the difficult journey down the birth canal… or the circumcision!  Rest assured that all of the pain and misery will reside completely in mom, which is probably where the doctors and nurses intend for it to go.  I realize, of course, that there are good doctors and nurses out there… but I know that when you get a group of people together, the urge to look down their noses at people with addictions often becomes too powerful to avoid.

Most important of all:  a couple years ago I did a talk for a large group of public health nurses, social workers, and AODA professionals about the impact of opioid dependence on pregnancy and on children born to women addicted to opioids.  I did an extensive literature search to prepare for the talk, and I was glad—and surprised— to find that there are NO known long-term effects on children from methadone or buprenorphine treatment during pregnancy.  There ARE problems in some children born to addicted moms, but when the studies are controlled for cigarette smoking, poor or absent prenatal care, use of alcohol, and other factors, the use of opioids has no long-term developmental impact.   That is VERY good news.

Newborn Buprenorphine Abstinence: Get Real!

First Posted 2/6/2014
A few weeks ago I wrote about the differing standards of care for women who deliver babies while treated with buprenorphine for opioid dependence.  Some hospitals require newborns exposed to buprenorphine to stay in the neonatal ICU for arbitrary length of time.  Intravenous infusions of opioid agonists are given to infants whose first yawns or cries are interpreted as neonatal abstinence syndrome.  Other hospitals allow women on buprenorphine to take babies home at the regular schedule, allowing a natural taper from buprenorphine by breast-feeding.
Regardless of hospital policy, many women on buprenorphine enter into the delivery process with a sense of dread, knowing they are harshly judged by doctors and nurses.  Doctors warn women that their babies will suffer from withdrawal if they don’t taper off their medication before delivery.  And members of the media decry the selfishness of women treated for addiction who become pregnant, suggesting the more responsible expectant mothers would use ‘will power’ to avoid all substances.
Even while experts recommend that women treated for addiction stay on medication treatment regimens during pregnancy, society looks negatively on women who do the right thing.   A new mom on SuboxForum recently wrote about how horrible she felt, for putting her baby through such a difficult time.  But should women compliant with recommended treatment for opioid dependence feel so guilty?
Until 30 years ago or so, newborns having major surgery often received paralytic agents with little or no anesthesia or pain medication.  Surgeons and anesthesiologists did not think babies with heart anomalies would survive anesthetics, and saw no reason to anesthetize a brain that lacked a ‘record’ function.   Now, most babies having major surgery receive anesthesia.   But in many situations, non-medicated babies are simply restrained during procedures that would be painful in adults, ranging from awake intubation to circumcision to multiple attempts at IV access (the latter is required when doctors insist on treating neonatal abstinence with morphine infusions).
I did not enjoy working on newborns in those settings back in my anesthesia days, especially after having three children.  But there will always be times when anesthesia is too dangerous or impractical, leaving no choice but to tune out the baby’s cries and focus on safety.  In these cases, do babies experience pain?  We know that babies react to stimuli that adults would find painful, and generate stress responses to those stimuli.  But the answer to the question about pain is far more complicated than a simple ‘yes’ or ‘no.’
People having conscious sedation for colonoscopy, gastroscopy, or some emergency procedures (like reduction of a displaced fracture, emergency D and C, or insertion of a chest tube) often appear awake while appropriately sedated.  Patients who will later think that they were blissfully sleeping, in reality, carry on conversations and move about as directed on the OR table.  Depending on the anesthetic used, patients may react strongly to pain.  Patients who can’t be fully anesthetized because of the risk of aspiration or airway obstruction may yell out in response to the injection of local anesthetic, even when administered enough Versed and Ketamine to guarantee full amnesia.   They moan in pain throughout the procedure, and then thank their anesthesiologist for keeping them completely ‘asleep’.  Similar experiences are the norm in every GI suite across the country.
In this common scenario, do patients experience pain?  When someone sedated beyond the point of recall complains of discomfort, did the discomfort really happen?   Did the patient feel pain and then forget it?  How do we know?  Before my endoscopy, I knew that I would experience pain going forward in time.   But afterward, when I thought back about the procedure, it was a piece of cake.  Did I suffer?  Not at all.
Similar experiences occur in newborns.  Babies are not capable of remembering those first weeks or months.  One could argue that repeated discomfort creates brain pathways that lead to a heightened stress response in later years… but if that is true, how does the brain differentiate ‘normal’ pain experiences of the newborn from ‘abnormal’ pain?  The baby’s head is squeezed hard enough during delivery to change the shape of the skull.  That has to hurt… not to mention the discomfort of being squeezed inside a uterus during the last 4 weeks before delivery.  During delivery, the baby is transferred from a 37 degree uterus, where oxygen is delivered through the umbilical cord, to a bright, cold, environment where getting oxygen requires gasping for air, with every bit of strength.  Sounds traumatic to me!  During deliveries, babies sometimes experience dislocated shoulders and major nerve damage (shoulder dystocia).  Forceps or suction cups may be used to pull the baby, by the head, from the birth canal.
Newborns have immature nerve supply to the gut, so early peristalsis– the coordinated contracting that propels digestible material downstream in the fully developed intestine– creates cramping and ‘pain’ in infants (sometimes called ‘colic’).  Limb muscles are spastic, and the spasticity would likely be painful in an adult.  Choking or coughing on breast milk is a normal part of the newborn experience.
How does ‘withdrawal’ compare?  What is the worst part of withdrawal— diarrhea?  Cramping?  Body aches?  Anxiety?  Depression?  Compared to the normal experience of a newborn, how do these symptoms rate?  Babies do not feel embarrassed or ashamed of their condition.  They don’t feel guilty or remorseful.   And after raising children through, I don’t think a baby coming off buprenorphine could be more ‘depressed’ than other babies.  Can a baby who turns purple crying his lungs out, feel any worse?  Normal infants get pretty miserable at baseline!
Like most parents I have always been willing to put my life or discomfort before that of my kids, if that were possible.  I don’t lack empathy for babies experiencing pain.  But ‘to keep it real’, writing about those ‘poor babies going through withdrawal’ is an emotional response, not an accurate understanding of the newborn experience.
Most new moms torture themselves enough with fears about their mothering skills, without the medical profession piling on.

Newborn Buprenorphine Abstinence: Standard of Care

First Posted 2/1/2014
The topic of newborn abstinence syndrome from buprenorphine provokes strong emotions.  Expectant mothers anticipate harsh attitudes from doctors and nurses.  They worry that their use of buprenorphine will cause their babies to suffer from withdrawal.  They hear about the experiences of women reported to CPS after delivery, or whose babies were kept on inpatient opioid tapers for weeks.
A member of SuboxForum recently wrote that the hospital she planned to use, in downstate NY, required mothers on buprenorphine to sign a formal policy regarding the care of their newborn infants.  The policy stated that all babies of mothers on buprenorphine must go to the NICU for at least 10 days after delivery, regardless of condition. Mothers were not allowed to refuse that level of treatment for any reason.
Last week, one of my buprenorphine patients came to her appointment with her 5-day-old baby, after both she and her baby left the hospital less than 48 hours after delivery.   Her discharge struck me as premature, not because of anything to do with buprenorphine, but because new moms are frequently anemic and sleep-deprived and can use a bit of rest before taking on an infant’s schedule.
How can the ‘standard of care’ vary so greatly?  What role does insurance coverage play in decisions about opioid tapers, NICU admissions, and discharge schedules?  After having dozens of patients go through the process uneventfully without intervention by neonatologists, I wonder if newborns are always positively served by their interventions. I also question the wisdom of using opioid agonists to taper from a long-half-life, partial agonist, i.e. buprenorphine.
In blinded studies, only half of babies born to women on buprenorphine show objective signs of ‘withdrawal’, which is a misleading word for describing the experience of an infant.  I have no doubt that in the typical non-blinded nursery, neonatal abstinence symptoms are grossly over-diagnosed.  Mothers on buprenorphine describe a biased diagnostic approach to their newborns, where babies who cry are ‘too agitated’, and babies who sleep are ‘too sedated’.
In the case of babies who truly show symptoms of NAS, do the symptoms always warrant ten days in the NICU?  Is a baby distressed by mild neonatal abstinence better off in mom’s lap nursing with breast milk containing small amounts of buprenorphine, or lying alone in a plastic incubator under fluorescent lights, with multiple IV lines? Some docs and nurses in my area allow moms on buprenorphine to nurse, a policy that makes sense from an anatomical and developmental perspective.   As the baby’s liver matures, ingested buprenorphine is eventually completely destroyed through first-pass metabolism.  The process allows for a gradual, natural taper, without the misery and cost of IV infusions and monitoring systems.
Decisions about monitoring and discharge should, of course, revolve around safety.  I question whether the various approaches to buprenorphine abstinence in the newborn are based on informed, intellectual consideration, or are instead liability-motivated rules supported by ‘best guesses’ by people who don’t understand buprenorphine.  Given the 180-degree difference between the approaches of different hospital systems, somebody is clearly doing it wrong.
I’ve griped about how research studies about drug addiction are so-often focused on demographics, where the data does more to describe the past than to improve care going forward.  The best approach to babies born to mothers on buprenorphine should be near the top of the list for research funds.  The hard part of such studies will be identifying (and following) the conclusions that are derived from science, vs. those that come from concerns about litigation, where the costliest and most-intense treatments always win out.

Pregnant Taking Suboxone: Should Social Services be Involved?

First Posted 11/4/2013
I recently saw a new patient who described treating her own opioid dependence with diverted Suboxone.  She sheepishly described reading everything she could find about buprenorphine and meticulously using half of her friend’s medication to avoid other opioids, without fail, for four years. She would likely be treating herself now, if she hadn’t become pregnant and  told her OB and a hospital nurse what she was doing.  Her disclosure prompted a call to CPS, leading to the assignment of a caseworker and the threat to remove her baby from her home.  CPS eventually allowed her to keep her baby providing that she stop using medication illegally—prompting her to call my office.
My first reaction was that everything worked out well, and justice had been served.  But since the visit I’ve thought about some of the inconsistencies in how HIPAA is applied, and in the general attitude toward doctor/patient confidentiality.
I’ve also given thought to how things could have worked out, had my patient count been at 100 rather than 99.  There are not many buprenorphine-certified prescribers in my area, and she very likely would have been unable to find a doctor if my practice was full.  Had that been the case, what would have happened?  Would CPS have backed off and told her to go back to doing what she had been doing?  More likely she would have been given the choice of stopping buprenorphine or going to the methadone/buprenorphine clinic an hour’s drive away.    In the latter case, how would that work, exactly, traveling an hour at 6 AM each day as the single mother of a newborn infant?
I suspect that if my practice had been full she would have stopped buprenorphine or Suboxone, and joined the ranks of either the 4% of people who remain clean after stopping buprenorphine or the 96% who relapse within a year.  Would anyone at CPS have noticed which group she became part of?
Her case is an example of how complicated the ‘diversion’ issue has become.  And perhaps I’m paranoid, but I feel the need to say that I am against diversion of buprenorphine.  I’m saying so because I know the righteous attitudes of some physicians who claim to be more careful than others.  So to avoid confusion…. diversion is bad.  I’m on THAT side.
But death is bad too.  And breaking patient confidentiality is bad.  My new patient is someone’s daughter, and I found myself wondering what I would have recommended had she been MY daughter?  What would the reader recommend for his/her daughter?  She is 22 years old.  She became addicted to opioids at 16, when her best friend shared Vicodin that she found in her mother’s medicine cabinet.  By 18 had tried to quit a number of times on her own and with the help of meetings.  She failed intensive outpatient and residential treatment, like the vast majority of patients who take those paths, before her parents asked her to move out.
She tried calling numbers on the NAABT and SAMHSA databases but found that all listed practices within an hour’s drive were full, or more often were out of the ‘Suboxone business.’  She went on methadone for a few months but had trouble making the 50 mile drive to the clinic in the middle of January—an understandable problem for people who know the area.
At some point she met someone who agreed to share a prescription of Suboxone, splitting the script if she picked up most of the cost.  Compared to a buck per mg for oxycodone, she thought she found a bargain.
I’m usually able to let go of conflict in such cases by arguing for the common good, or by pointing out the things that she should have done to avoid her current problems.  But those positions are more difficult when one imagines the hypothetical case of a son or daughter.
I was going to make a number of points, but it is getting late, the Packers lost, and I’m in the mood to just call it a night.  I was going to ask whether or not her isolated case truly threatens the ‘public good.’  I was going to ask if it is appropriate to call CPS about someone who has done all that she can to create a better environment for her baby.  I was going to ask if breaking her confidence for the good of the child would be a bit paternalistic by modern medical standards.  I was going to ask if there are different types of ‘diversion’, and if self-treatment, in the absence of any other option, should always be condemned?
But I think I’ll just leave it here, and ask people to imagine their own daughter in the situation that I described.  Would you be angry that she met someone who shared Suboxone?  I know that some will claim that there must be other options— an argument that I’ve already heard from several people claiming the doctor did the right thing to turn her in.  But if there were any options I didn’t mention, I am not aware of them.
What would you have recommended for your child?  Things worked out this time, but I have a waiting list of 90 people who are looking for a doctor who prescribes buprenorphine, and I had just discharged a patient the day before her call.  Nobody was out there making certain that after the call to CPS, she would find a reasonable option.  With that in mind, how was the call to CPS consistent with the thought of ‘first, do no harm?’
A few comments from the original post:
WisdomQ:
What is a pregnant woman taking buprenorphine supposed to do? Stop being addicted to opioid’s for 11 months?
A 2010 study (http://www.nih.gov/news/health/dec2010/nida-09.htm) found bupe to be less problematic than methadone. Perhaps the most powerful tool is to never tell the child about it unless the child starts to abuse opioid’s on their own; considering the power of suggestion.
Tic:
This patient had been diverting suboxone for four years. I doubt that she was looking for a provider for four years without any success.
Me:
I don’t know what things are like in your area, but patients in northern Wisconsin have no access to buprenorphine-certified physicians. Some are listed– but they are all people who either signed up but never actually prescribed buprenorphine, or who shut down that aspect of their practice.
I’ve been at the 100-patient limit since shortly after the limit went from 30 to 100. My waiting list has 90 patients. Note that I do no accept any insurance panels– not just for the 30% of my practice that comes for addictive disorders, but for all patients– but patients wanting buprenorphine have no choice (the other patients choose to see me because I provide much longer appointments, guarantee to start on time, provide easy access, etc). There were two other docs in the county that at least prescribed the medication; one left a year ago, leaving one person.
Even in areas where there are more doctors, many doctors arbitrarily discharge patients after one year (or Medicaid in a state may stop covering the medication after one year). Studies show 94% relapse rate in people treated with buprenorphine for a year– i.e. the medication is best considered as similar to most other medications, as a TREATMENT, not a CURE. There are also practices who abandon the people who struggle the most– a cruel way of practicing medicine that is unique to addiction. So again, I imagine there are places where a patient has been kicked out of the practice of the only provider, perhaps for taking a benzodiazepine– instead of seeing the illicit use as one more aspect of her ILLNESS that deserves better treatment. Perhaps you consider it fair to give a 17-y-o woman one chance– and if she fails, tough luck—- and if that is the case, I hope you’re not someone’s doctor.

Does Suboxone Cause SIDS?

Originally posted 1/13/2013
In a recent Google search about Suboxone and pregnancy, one of the top links included the frightening statement that Suboxone and buprenorphine have been linked to SIDS or sudden infant death syndrome, commonly called ‘crib death.’
The statement was from a health forum where a woman wrote about taking Suboxone during pregnancy.  She wrote that her child went through opioid withdrawal after delivery, recovered, and then died two months later from SIDS.  She then claims that her doctors told her that Suboxone was a possible reason for her child’s death.
Suboxone and SIDS?
I don’t know if the woman’s story is true. If it is, I hope my comments do not cause her pain, and I’m sorry for her loss.  But someone should comment on the information, given the number of young women on Suboxone who become pregnant and frantically search the internet for reassurance that their baby will be OK.  I know that pregnant women in my practice lose a great deal of sleep because of guilt over taking buprenorphine.  I am not a SIDS specialist, obstetrician, or pediatrician, and I do not actively follow the SIDS literature.  But I have done some reading to prepare for this post, and I’ll do my best to address the issue.
While the causes of SIDS are not completely understood, a number of factors have been associated with sudden infant death, including maternal age and socioeconomic status (higher rates in infants of poorer, younger mothers), maternal smoking, air pollution, low birth weight, season of birth (higher in infants born in the winter), too high or too low room temperature, male sex, history of premature birth, and bottle feeding (instead of breastfeeding).
One of the biggest risk factors is the easiest to correct: sleeping position. The incidence of SIDS is thought to be about twice as high for babies who are placed prone (face-down).  Since 1992, when 4895 deaths were attributed to SIDS in the US, a public relations campaign to encourage parents to place infants on their backs may have reduced the incidence of SIDS by 50%.  I write ‘may have’ because some experts attribute the decrease to changes in how infant deaths are coded and reported, rather than to a true decrease in cases.
SIDS is a leading cause of death among healthy US infants.  But the actual risk is very low, estimated at about one death from SIDS per 2000 infants.  Deaths from prematurity or from congenital disorders are far more common than SIDS.
When I started this post, I planned to write that the link about buprenorphine causing SIDS was nonsense.  And it may be nonsense.  Realize that it is very difficult to determine the risk factors for things that rarely occur. Only relatively common factors like smoking or prematurity are identified as risks for SIDS in controlled studies.  Unless the connection is very strong (and it isn’t), there are not enough pregnant women on buprenorphine to cause a detectable rise in deaths from SIDS, even in the largest studies.
So what about the link in search engines about SiDS and Suboxone?  From what I can tell, the connection between buprenorphine, Suboxone and SIDS comes from a 2007 study in Finland that prospectively followed 67 women who had babies while prescribed buprenorphine.  In that study, 2 of the 67 infants were reported to have died from SIDS, an incidence of 3%.  A number that high is certainly frightening. But at the same time, an effect that strong would be evident in the larger SIDS studies—- especially those including thousands of women.
A closer look at the Finnish study reveals that the two infants who were thought to have died from SIDS were born to women who were not compliant with the buprenorphine program, i.e. who were using other opioids including heroin.  The associations between SIDS and other risk factors—risk factors that are common among active drug users, such as smoking, low socioeconomic status, low birth weight, and prematurity— confound the results of the study.  Are women struggling with active opioid dependence as likely to know that infants should be placed on their backs? Some SIDS researchers have questioned the numbers from the Finnish study, The forensic uncertainties often associated with SIDS, the significant risk of death associated with co-sleeping, and the challenge of monitoring women who are actively using opioids further confound the Finnish study.
One possible cause of death in SIDS is the accumulation of carbon dioxide in soft blankets or clothing, close to the mouth and nose of a baby sleeping prone (face down).  That cause of death suggests danger for an infant who is for some reason administered opioids, since opioids reduce respiratory response to carbon dioxide.  Opioids are secreted in breast milk, including buprenorphine.  The infants of mothers on Suboxone/Subutex would be tolerant to any buprenorphine in breast milk, since the exposure would be less, if anything, than the exposure during pregnancy.  But mothers who are noncompliant, i.e. intermittently dosing with high-potency opioid agonists, could in theory expose their infants to levels of opioids higher than the infants’ opioid tolerance.  I did not find any reported associations between opioid use, SIDS, and breast feeding.
My take on the data is that the safest situation for any infant is to develop in the womb of a woman who is not drinking alcohol, smoking cigarettes, taking prescription medications, or using illicit opioids.  Out of all of these things, being compliant with a stable dose of buprenorphine or Suboxone likely carries the least amount of risk.  If there was certainty that pregnant women could remain free from opioids after stopping buprenorphine maintenance, then stopping buprenorphine during pregnancy would be a good idea.
But unfortunately, far more women PLAN to remain opioid-free after Suboxone, than actually remain opioid-free.  The intermittent use of illicit opioids, and the malnutrition, cigarette smoking, poor sleep, poverty, needle-sharing, and other risky behaviors that come with opioid dependence create the worst-case-scenario, making the stable use of Suboxone or buprenorphine far safer in comparison to ‘planned abstinence.’
As with everything, there is the world we want, and the world we live in.  I encourage women addicted to opioids to do all in their power to maintain compliance in a Suboxone/buprenorphine program.  I also encourage these women to look forward to a life of doing the ‘next right thing’ for their children— and cutting themselves some slack over taking buprenorphine.  Efforts to stop Suboxone would be better used to avoid alcohol, tobacco, and illicit substances, and to maintain appropriate prenatal care.

Suboxone Withdrawal in Newborns

One of the top search terms for Suboxone relates to pregnancy, and fear that the baby will experience withdrawal; official name ‘neonatal abstinence syndrome.’  I wrote this post a couple years ago, and I think it is worth reposting. Since the first time around, several studies have shown that withdrawal symptoms occur in about half of babies born to mothers on buprenorphine. The symptoms, when they do occur, tend to be milder than the symptoms in babies born to mothers on methadone or other opioid agonists.
Headlines grasp for attention with words like ‘addicted babies.’ Realize that there are many differences between physiological dependence and addiction to substances. For example, people who take Effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockers, in that discontinuation results in rebound hypertension, but there is no craving for propranolol when it is stopped abruptly.
We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.
It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs, depression, and very severe shame and guilt. The normal newborn already has such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction!
Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about THAT discomfort—at least not from the baby’s perspective! I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal! Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s (!), babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose!
My points are twofold, and are not intended to encourage more births of physiogically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right. Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.
Addendum:  Another of my posts, including a response to a mother’s comments and several references, can be found here.

Buprenorphine and Pregnancy

I recently heard from a person who had been told by her physician that she ‘must get off Suboxone before even thinking about getting pregnant.’  I’ve mentioned a number of times that I’ve had about 15 patients go through pregnancy and delivery on buprenorphine, and all have done well.  I encourage people thinking about pregnancy to search this blog for articles related to that topic, as there are a number of posts including some that have recent articles from the scientific literature about buprenorphine and pregnancy.
I’m writing now because I noticed that my newsfeed that carries the most recent scientific reports about buprenorphine has a number of articles about pregnancy.  You will find the newsfeed in a couple places–  at the bottom of www.addictionremission.com , my portal page to all of my sites about addiction, and also at www.bupenews.com , a site that has the feed as a centerpiece.
JJ

Leg edema from Suboxone

A reader’s question:
I have been on Suboxone for 2 years. My addiction was Oxycontin.  I had knee replacement surgery and was successfully able to take pain meds and then get off them and go back to Suboxone. My medical Doc and I noticed that when I restart the Suboxone, I get 2-3 plus pitting edema in my legs, severe enough to require diuretics– and they don’t even work very wel. When I have stopped Suboxone in preparation for surgery, I immediately lose 15 lbs and the edema goes away. My Suboxone Doc says that there are no side efffects. I am 53 and have heart disease, and I know that this extra fluid is not good for my heart. My kidneys are normal. Have you heard other comments of this nature? Is it dose related?  This is a serious situation for me.
Reply:
I have had two or three patients with similar complaints.  To put things into perspective, though, over 5 years I have treated over 400 people with Suboxone or buprenorphine.  One person in particular had very bad edema, that caused a great deal of pain in his legs– so much that he stopped the Suboxone and went back on opioid agonists.  In his case, though, the edema did not lessen on agonists and he still struggles with edema a couple years later.  I don’t know if he had edema before I met him and started Suboxone;  he claimed that the edema was a new development, but I have learned that people sometimes notice things related to their health status that differs from the perspective of an independent observer.  This is why, by the way, I don’t fully jump into agreeing with people who report tooth decay ‘that starts after starting Suboxone.’  I had a patient with that complaint, and to look into things we got a copy of his dental records;  they showed that the decay was well underway years before he took Suboxone, at least according to dental notes and x-rays.  But in his mind, it all started after the Suboxone.  The mind sometimes plays tricks on us.
When I worked as a psychiatrist in the WI prison system, women in the maximum security prison reported leg edema from many different medications.  I never knew what to make of it, to be honest.  Most of the time the medications complained about were easy to replace;  if someone felt that the Seroquel caused edema, we could change it to Risperdal.  If someone complained about Risperdal causing leg edema, we could change it to Seroquel.  It reminded me of the old Dr Seuss story about the Star-Bellied Sneetches.  I strongly recommend the story for those who haven’t read it…
I like to think in terms of mechanisms, and I don’t have a good theoretical mechanism for leg edema from buprenorphine or from naloxone.  The collection of edema in the legs usually comes from an imbalance of the natural forces that should be in equilibrium;  gravity or ‘hydrostatic pressure’ causes fluid to leak out of blood vessels into the interstitial spaces, salts in the plasma and interstitium create ‘osmotic pressure’ that becomes balanced, with a neutral overall effect on fluid movement; and proteins in the plasma cause ‘oncotic pressure’ that draws fluid back into the blood vessels.  Veins in the legs are emptied by the effects of muscles that squeeze them during walking or exercise; one-way valves prevent the blood from moving backward or standing in place during this activity.  Taking all of this into account, edema is favored during immobility, when the legs are ‘dependent’ (not elevated), when protein levels are low from malnutrition or liver failure, or when the valves in leg veins have become damaged by standing too much in life.
Preventing edema involves keeping legs elevated as much as possible, reducing salt intake, wearing support stockings, and sometimes taking diuretics or ‘water pills’ to eliminate extra fluid at the kidneys.    Opioids do have effects on a number of hormones;  there are large protein molecules that are cut into smaller pieces that include endorphin and enkephalins, the brain’s ‘natural opioids’.  Other parts of those same large molecules have effects on fluid balance, among other things– the inter-relationships are complex and not entirely predictable.
I am posting this in case others have noticed similar effects, or in case a good endocrinologist or nephrologist has a pet theory.  Anyone?

Buprenorphine safer than methadone for neonates born to opioid addicts

A presentation at a recent meeting of ACOG, the American College of Obstetricians and Gynecologists, compared the use of buprenorphine or methadone for treating opioid addiction during pregnancy.  I hear from pregnant women often, who write out of frustration that their OBs have never heard of buprenorphine or Suboxone and asking what they should do to educate their physicians.  Let’s hope that studies like this one help get the word out.  If you search this blog you’ll find a number of my posts about pregnancy, opioid dependence and buprenorphine.  Some of the posts include articles about neonatal abstinence, breast feeding while taking buprenorphine, and comparisons between buprenorphine and methadone.  I also recommend, of course, the forum, where you will find many other women who have already wrestled with this issue.

Buprenorphine Favoured Over Methadone for Opiate Addiction in Pregnancy By Fred Gebhart   SAN FRANCISCO — May 19, 2010 — A recent study in Maine among women addicted to opiates has found that buprenorphine is safer for neonates than traditional treatment with methadone.

The research was presented in an oral paper on May 18 at the American College of Obstetricians and Gynecologists’ (ACOG) 58th Annual Clinical Meeting. The paper won ACOG’s Donald F. Richardson Memorial Prize.
“It has been shown that patients on methadone are more stable in terms of their physical and mental health and are more likely to receive standard prenatal care, but methadone has clear effects on the child,” noted lead author Michael Czerkes, MD, Maine Medical Center, Portland, Maine. “Buprenorphine is an attractive alternative, but there are few data on the effects on neonatal outcomes. Since our patient population uses both agents, we decided to find out.”

The key objection to methadone from the infant’s perspective is the appearance of neonatal abstinence syndrome (NAS), a combination of symptoms that include dysfunction of the autonomic nervous system, gastrointestinal tract, and respiratory system. NAS has a number of short-term consequences, including prolonged hospital stays, prolonged monitoring, and an increased need for intravenous medications. Methadone is also inconvenient for the mother, requiring daily clinic visits, and it is subject to diversion because it is a euphoric agent.

Limited data on buprenorphine suggest that it may carry less risk for perinatal morbidity, but trials have been small and somewhat contradictory. Buprenorphine can be dispensed in 30-day packaging, which eases the burden on the mother, and is less subject to diversion because it significantly less euphoric than methadone.

Researchers at the Maine Medical Center conducted a retrospective chart review of women addicted to opioids who were using either buprenorphine or methadone and who delivered their babies at the institution between 2004 and 2008. There were 101 methadone patients and 68 buprenorphine patients available for analysis. There were no significant maternal differences between the 2 groups.

The differences between offspring of mothers in the 2 groups were dramatic, said Dr. Czerkes. The mean NAS score for buprenorphine infants was 10.69 compared with 12.5 for methadone infants (P = .0012). While the difference was statistically significant, Dr. Czerkes cautioned that it might not be clinically significant.

Other outcomes were both statistically and clinically significant. Buprenorphine infants spent a mean of 8.4 days in the hospital compared with 15.7 days for methadone infants (P < .0001) and only 48.5% of buprenorphine infants required treatment compared with 73.3% of methadone infants (P < .001).

Among buprenorphine infants who needed treatment, withdrawal symptoms appeared by day 3 or did not appear at all. Withdrawal symptoms in methadone infants appeared anywhere between days 2 and 6. “That may be a clinically significant finding,” said Dr. Czerkes. “If you don’t see withdrawal in these babies by day 3, they may not have withdrawal at all.”
Overall, he concluded, buprenorphine appears to be safer for neonates than methadone. Researchers are recruiting patients for a larger randomized controlled trial.

[Presentation title: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes]

Pregnant and taking buprenorphine a.k.a. Subutex or Suboxone

As I’ve mentioned, I was at a ‘summit’ about buprenorphine in Washington DC earlier this week.  I didn’t hear anything earth-shaking at the meeting, but will share a couple things that I learned there over the next few posts. 
One night I was reviewing messages in my hotel room and I received an e-mail from a person saying that Social Services took her baby away from her at the hospital because she had delivered on buprenorphine.  The baby was essentially being held hostage by the hospital under Social Services orders, and was being treated, against her wishes, with opiates to avoid opiate withdrawal.  I had a patient a year or two ago who had a similar experience, where her baby was placed on a morphine drip against her wishes, after she delivered while on buprenorphine.  These stories really make me angry.  The literature contains case reports and even studies about buprenorphine in neonates, so why would a doctor do something so foolish, as treat withdrawal from a partial agonist using a full agonist?  The literature already suggests that neonatal abstinence syndrome is milder after buprenorphine than after methadone, and there are articles that have been out for several years describing the use of buprenorphine during pregnancy.  So how can a neonatologist act as if the mother is doing something abusive?
One of the more interesting speakers at the buprenophine summit had preliminary data from a study of NAS (neonatal abstinence syndrome) in babies born to mothers on methadone vs. those on buprenorphine.  The NAS scores that looked at infant behavior were not significantly different from one another, but the doses of PRN opiates used to treat NAS (morphine in this study) were ten-fold greater in the methadone group than in the buprenorphine group.  The lesson from the study is that much lower doses of morphine are needed to block withdrawal from buprenorphine than from methadone, in neonates from mothers on the substances. 
My own opinion takes things a bit further.  The studies found that the NAS scores were similar in both groups. The study was blinded, i.e. the nurses who scored the amount of withdrawal did not know which substance the mother was taking.  But the nurses DID know that the mothers were taking one or the other–  and from experience, it is clear that mothers known to be opiate addicts are viewed with scorn from the nursing staff in the average delivery suite.  I often receive messages from mothers describing varied forms of ‘tsk tsk’ every time their baby burps, even as the other babies in the nursery scream all night long.  So I take the NAS scores with a big helping of salt.  I suspect that once identified as an ‘addict’s baby’, the nuances of the baby’s NAS were masked by a general attitude of disdain toward the mother, and blurred by sympathy for the newborn for having been born into such a dire situation.
As this and other reports find their way to publication, one can only hope that OB teams and neonatologists will READ the publications, and realize that buprenorphine treatment does not require a report to child safety services, and does not automatically call for a week of intravenous morphine for the newborn!