Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone

I just saw a keyword from Albany NY: suboxone and epidural.  I presume this is a pregnant woman anticipating labor who is taking Suboxone.  I have had several patients deliver babies while on Suboxone;  two by C-section and one by vaginal delivery.  I also was an anesthesiologist for ten years before my opiate addiction took that away.  I miss it from time to time– it was a fun job.  The pace was perfect for my personality;  relax, relax, relax, TERROR, TERROR, relax, relax…  OK maybe it wasn’t good for me… but it was fun.  And I loved doing labor epidurals, as everyone loved me when I showed up– the women in labor, the OB nurses, the obstetrician (who could go back to bed)… even the husband, who could get some sleep as well (but only after the wife dozes off first).
As far as Suboxone, first understand that it is possible to do an epidural without using any opiate at all, and being on Suboxone doesn’t have to be a problem.  During labor for a vaginal delivery or during a C-section, either by general or by epidural (or spinal for that matter) the Suboxone is not a problem.  Yes, usually a very small amount of fentanyl is added to the infusion of and epidural and is given IV after the baby is born in a C-section.  But those steps are not critical.  In fact, my own wife hated epidural narcotics, as they always made her itch terribly, so she asked to keep them out for her last delivery.
I’ll talk about the things that are not a problem first.  It is not a problem to take Suboxone while breast feeding.  The only potential problem is that you will run into a militant breast feeding advocate who makes you feel guilty about the whole thing.  I did a literature search on the topic and found several papers for it, and one against it.  To summarize, a very small fraction of buprenorphine is excreted in breast milk;  the baby drinks the milk, and the suboxone quickly passes the mouth (skipping absorption there) and going to the stomach, duodenum, and liver.  The liver destroys almost all of the buprenorphine, as it does in adults.  For the sake of purity I do suggest using subutex at this point so that the baby is only exposed to one mosty harmless drug, instead of to two mostly harmless drugs.  In the papers I dug up there were no reports of babies becoming sedated or drugged after breast feeding from moms on Suboxone.
Now, the problems…  it can be difficult to get good pain control in a person who dosed Suboxone on the morning of surgery.  One of my patients had it all set, to stop three days in advance… but then she had an immediate section a couple hours after dosing with 8 mg (I DO tend to reduce the maintenance dose from 16 to 8 mg in people close to surgery for this very reason;  it is half as hard to get pain relief after one pill than after two.  I was called after the surgery was over and she was in the recovery room.  They had done a spinal… my first comment was that ‘an epidural would have been nice, as we could have run dilute local anesthetic through it post-op with dilute bupivicaine to treat her pain, and it would have worked well. Since they didn’t do an epidural we ended up transfering her to the ICU, where they could keep her on oxygen monitorin and dose her with huge doses of morphine– 20-30 mg at a time.  The better way would be to stop the buprenorphine three days in advance, or at LEAST cut down to a very low dose, say 2 mg per day, and nothing on the day of surgery.  Remember, agonists will ‘out-compete Suboxone at the receptor if you have enough  of it there.
Talk to your anesthesiologist before hand.  They can be hard to find, and they don’t take ownership of cases until the last minute, but try to find on and ask him or her to do your case.  Pick the one that talks opently to you, as some anesthesiologists can be odd ducks.  Don’t let the Suboxone thing get you all worked up, and keep your focus on the wonderful new member of the family.  And it really is wonderful.
This final part is the worst part.  You might be judged, and that would be a shame, but some nurse might peg you as the ‘addict mom whose baby is withdrawing’.  First, remember that ALL babies cry.  Second, remember that YOUR experience with withdrawal is nothing like the baby’s experience.  Withdrawal is not all that painful– it is suffereing that we don’t like, not pain per se.  Think about it– we feel guilty, sad, low, we feel jealous of people who are still using;  we feel mad at ourselves for not arranging things better.  The baby feels NONE OF THIS.  Not only that, your baby just squeezed through a tunnel so tight that they had to pull on his head to get him out of there.  He was gasping like mad, using fluid-filled lungs, trying to catch his breath.  So if he is crying too much, or not crying enough, or too hungry, or not hungry enough (you get the idea) give yourself a break and just ignore what people say.  Your baby is fine;  don’t treatment him like a medical specimen.  All of the data we have shows no problems with babies born to mothers on Suboxone.

19 thoughts on “Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone”

  1. As a practicing anesthesiologist I can only reiterate that communicating with your doctors is key. I have yet to have a patient on Suboxone or their primary doctor contact me prior to surgery. I have had to cancel cases because nothing was done with the Suboxone dose prior to surgery. This is a simple fix as long as you communicate with your anesthesiologist ahead of time. I think a lot of this has to do with a lack of knowledge in the primary care arena about Suboxone

  2. I HOPE A MOTHER WHO IS PRGNANT OR BREASTFEEDING WHILE TAKING SUBOXONE CAN READ THIS AND FIND PEACE OF MIND. DONT FRET LIKE I DID. THE STESS ALONE ALOMST KILLED ME. I WAS SNEAKING THEM FROM MY BOYFRIEND WHO THOUGT I HAD QUIT COLD TURKEY. I DIDNT TELL ANYONE AND ALMOST HAD AN ANXIETY ATTACK EVERY TIME I PUT A PEICE UNDER MY TOUNG. I FOUND THIS BLOG, THAK YOU SOOO MUCH FOR WRITING IT I WISH I WOULD HAVE FOUND THIS WHILE I WAS PREGNAT. THERE ARE NOT ALOT OF PREGNAT WOMEN WHO JUMP ON LINE AND EXCLAIM THEIR DRUG ADDICTION. I WISHE THEY DID. SO I AM. MY LITTLE GIRL HAS NO SIDE EFFECTS NO WITHDRAWL. I BREASTFED, NO DIALATED PUPLIS, NO HARD STOOLS, AND NO NAUSIA LIKE ME. SHE WAS HAPPY GAINIG WEIGHT AND OVER ALL IN GOOD HEALTH. I WORRIED ABOUT WHEN I HAD TO GO BACK TO WORK. WOULD SHE WITHDRAWL? SHE DIDNT, SHE WAS FINE, THANK THE GOOD LORD. I WANT TO SAY AGAIN TO THE WRITER OF THIS BLOGG YOU HAVE MADE ME FEEL LIKE A GOOD PERSON AGAIN. THIS IS MY SECOND TIME ON THIS BLOG. I FIRST FOUND IT THE DAY IT CAME OUT. I BROUGHT MY FRIEND WHO IS NOW GOING THROUGH THE SAME. I HOPE IT HELPS ALL THESE OTHER GOOD PEOPLE OUT THERE WHO NEED THE REASSUANCE, THAT YOU ARE DOING THE RIGHT THING, THE BEST THING FOR YOU BABY vs THE OPIATE.

  3. Please help. I am confused by the information I am finding on the internet. I am on suboxone, it will be 2 years in April ’09. I was planning on getting off suboxone this summer — as I teach & summer would be the best time to try to get off this med. The reason I am pushing to get off suboxone right now is because I want to have a baby. And of course it would be in the best interest of the baby to be off. Here is the problem —- FIRST, I may be pregnant right now. This terrifies me because I was pregnant last November & I had a miscarriage. I have one child, so I know I can be pregnant. The OBGYN said I could have miscarried for a number of reasons, it didn’t necessarily have to do with suboxone. IF I AM PREGNANT, what should I do? I suffer from chronic pain — which is what lead me to become addicted in the first place. With suboxone I was able to live a normal life, without a high. And so I am terrified to be WITHOUT the drug & terrified to be WITH the drug. Any advice from anyone, especially any woman who delivered a child while on suboxone would be a blessing. PLEASE, PLEASE, help me…I am terrified.

  4. Great blog – very interesting and helpful
    I’m a maternal fetal medicine doc who’s new to the use of buprenorphine in pregnancy instead of methadone. I’ve recently had a patient who’s in her third trimester – 34 weeks – and is on 8 mg/day of Subutex.
    I’ve read what I could find on buprenorphine, though there is little in an organized format regarding total pregnancy care.
    Can you please give your comments on the below points ??
    1. Early/mid pregnancy care – assuming that switch to methadone is not an option. Given overall smallish amount of pregnancy-related data, wise to use lowest effective dose – makes sense to decrease fetal exposure as long as mom is effectively treated, though smaller doses don’t necessarily mean lower rate of NAS (similar to methadone data).
    2. Prior to elective delivery (by induction or cesarean), wean dose to off – preferably for 24 + hours. (I’d imagine that long half-life should keep WD symptoms at a minimal).
    3. Pain control with epidural (with vaginal delivery or cesarean). Ideally anesthesia consult (and NICU) prior to delivery.
    4. Post vaginal delivery – Restart Buprenorphine – Suboxone SL. Standard NSAID/Tylenol therapy for pain control.
    5. Post cesarean delivery – Keep epidural in place for as long as possible – dilute local anesthetic. Restart Buprenorphine – Suboxone SL. NSAIDS/Tylenol as above. IV/PO narcotics as needed – though dosing may be difficult to figure out.
    6. Breastfeeding probably okay with Suboxone.
    Thanks
    Peter

  5. I know this is an old post, but I really feel like I should add my experience in case other pregnant women find this site. Im 28 years old and just had my 3rd baby 11 days ago. I was on suboxone during the entire pregnancy and stressed really bad that soemthing would be wrong with my daughter due to my sub use. I havent had a drug since March 2008 and have been on subs since that date. It has worked wonders for me. Just the fact that I havent had a relapse in all this time is HUGE for me. So anyway….due to personal reasons I didnt tell the doctors I was on subs. I planned on getting off of it on my own before my due date. After several attempts to do so, I gave in and took my last dose the morning before my scheduled csection. My daughter was born weighing 7lbs. 3 oz. and was withdrawal free!! I have watched her very carefully and havent seen a single sign of anything. She is just as healthy and alert as my first 2 kids that were born drug free. I spent 9 months stressing like crazy for something that I shouldnt have. Im not recommending that anyone do it the way I did. Its always best to work with your doctor in a situation like this. But that wasnt an option for me. The only complaint that I had was finding pain relief after the surgery. The nurses and drs didnt know so when I said I was still in pain they looked at me like I was crazy. But that part is over and I am back on my subs. I still have 14 of the 20 percs that they sent me home with. Imagine that….an addict with pills in the house. Never thought I could do it. But I love suboxone. I dont want to be high. I want to live a normal life like I have been for the past 3 years. So any pregnant women that find this….try not to stress. It will all work out.

    1. I’d like to talk to you about this. I’m in the same boat. Due to personal reasons….i don’t feel like I can tell my doctor. I’m almost 5 months pregnant. Not gaining weight very well. I’m actually skinnier than the day I found out I was pregnant. I’m on 2 mg or less a day. Have been for about 4 years. I’m trying to ween off …but I’m scared for my child. I do not want my child on methadone right out of the womb. I do not want my child to feel any of the living hell that sub detox brings. And I realize I’m at such a small dose. I buy them from friends. I don’t think the doctors have any knowledge of my use. I’m begging anyone in my situation ,or that has been in my situation to please let me know. I live in north idaho. And cps is a huge worry here. I’m already bipolar. I’m already off my lithium. I also receive disability. I really am in a horrible place if the government decides I’m not being a great mother. But I am. I swear I’m doing everything within my power to make this world easier on my baby than it was on me. Please let me know. Can I do this alone? Will my child be tested and torn from me?

  6. THANKS…to whomever wrote this article it gave me great relief and now i can enjoy the rest of my pregnancy which is a little over 4 months w.o feeling like i am drugging my baby..i have used suboxen for a little over 2 yrs which i switched to subutex when i found out i was pregnant and instead of 32mg i currently only take 8mg a day which makes me feel a little better but like i said the thoughts of negativity still run thru my mind daily…i plan to tamper myself down to at least 1mg-2mg a day up untill the last week and then it will be piece by piece until my scheduled c-section. i have searched the web for positive answers because well i need some relief and because i just want to know what to do and this article was very informational and helpful so THANKS….

    1. Please read this post also: http://suboxonetalkzone.com/withdrawal-in-newborns-lay-off-the-guilt-trip/
      You are doing the right thing; there is SO much ignorance out there! There have been a number of follow-up studies on babies born to mothers who were on methadone during pregnancy; those babies had much higher tolerance to opioids than babies of mothers on buprenorphine. But even in those cases, there were no differences compared to normal kids.
      Congratulations– and good luck!

    2. Hi first off congratulations on your pregnancy and hope all goes well with your delivery! I just wanted to let you know I saw your post when looking up information on subutext and pregnancy. I am 32 weeks pregnant and have to have a c section as well. I am currently on 4 to 6mg of subutext a day so I know how you feel. There isn’t much information on the subject and I personally know no one going through this so I just wanted to let you know you’re not alone and if you wanted to talk and share what’s going on or just some support, you got a friend in me. I understand what you’re going through. Take care!

    3. I see this post is a few months old but I was wondering how your little one was. I am 27 weeks along and have been on 8mg of subutex since I found out I was pregnant in January. My psychiatrist has never had a pregnant suboxone patient before and isn’t sure how a lot of this will go or how my subutex maintenance will affect my delivery, my baby, or breastfeeding. I don’t anticipate needing a C-section (I hope not!) and am hoping to use as few interventions as possible. I was curious how everything went for you if you wouldn’t mind sharing.

      1. Hopefully she will notice your comment. But otherwise, I’ll say that I’ve had many pregnant buprenorphine patients over the years. Labor epidurals are not significantly impacted by buprenorphine, and neither are the odds for having a c-section. Likewise, there have been studies of babies born to mothers on methadone that showed no differences in development or other indices going out several years. In other words, babies born to mothers on opioids show no health problems, including mental health, as they grow up– at least out to age 5 or so. It is difficult to do longer studies for a number of reasons, but all data suggests that treatment of mothers using medication-assisted treatments has no impact on their babies or children.
        I have a couple posts about breastfeeding, so use the search function to find those as well.

        1. Hello there! You posted at the perfect time we just got home from the hospital today. I was taking between 1 to 3 mg a day for 4 years and also pregnant with her and even upped my dose to sometimes 8mg a day for about 2 months but was able to taper back to 2mg 1 week before she was born and the day before I had her I took .5mg. I had no complications with the c section and the pain medicine I’m not sure if it worked or not as I’m still in pain but I did get surgery so that’s expected. As far as she goes she was in the hospital 5 days to watch her because that’s protocol for me being on the medicine. They watched and scored her and sometimes she was high but nothing was consistent thankfully! Just normal newborn stuff. Also thankfully the hospital let me keep my room since I breast feed and stay with her since I only stayed 4 days. I stressed myself out praying and praying she wouldn’t withdrawal but every baby and experience is different. I currently have not taken the medicine since the day before her delivery. I feel I can ween off completely with the pain meds I recieved and I’m hoping and praying I don’t need it anymore! I am breastfeeding and so I don’t know how that will go with taken the subutext since I haven’t taken it as of yet! But I hope this helps in some way. I know how you feel trust me I do so if you need anything else let me know I’ll be happy to share!!

          1. Sara, please feel free to use the forum as well (www.suboxforum.com). Most people in your shoes would experience some withdrawal symptoms over the next few weeks, but I’ve had a few patients who had almost no withdrawal. Hopefully your symptoms will be mild as well.

  7. I am glad I found this site. I see mommytobe333 is in the same boat I am just about. So congratulations to you and good luck, I pray everything goes well for you and your baby. I myself have been searching for information on suboxone and pregnancy. I currently am 32 weeks and I am 30 years old. I was on 1mg to 3mg of subutex a day until I had to increase to 4mg to 6mg a day. I also take xanax as needed. I plan on weaning down as much as I can until I have my c section. I pray and pray for my daughter to be protected from the bad things that go in my body. I just want her to be healthy and not feel sick after she’s born. Her father doesn’t know about my subutex because we are not together, never were, and I feel he’d look at me and judge me because of ignorance. I don’t feel I owe him any explination due to we aren’t together but I do want him to know on account his daughter might be in the hospital longer. I’m really just worried about her and her health. I feel really guilty I take this medicine and hate myself for even letting it get this far. But I will keep everyone in my prayers who are going through the same thing. I will definitely want to share my experience when she is born. I know it’s very stressful and guilt weighs heavy during this time. Especially of the unknown. We just search for an answer we want to hear yet we have to experience it for ourself due to everyone being different. God bless and take care to everyone who is reading this. Glad to see this post is continuing years later. Helped me speak for the first time about this!

    1. I spent some time deciding whether to publish this post, after reading ‘I feel really guilty I take this medication and hate myself for even letting it get this far.’ My concern is that someone trying to learn the truth about buprenorphine will read that comment, and buy into the idea that taking the medication is something to feel ‘really guilty’ about.
      I’m always impressed by the attitudes of people on buprenorphine. People will use illicit pain pills or heroin for years, and feel no ‘guilt’. Then they get on a medication that does not make them ‘high’, that prevents cravings for opioids, and that allows them to stop shooting up heroin… and they feel guilty for THAT? Likewise, people never seem to notice how trapped they are by heroin, cocaine, or even cigarettes, even as those substance destroy their health and their bank accounts. But on buprenorphine medications, which are usually covered by insurance and have absolutely no health risk, people feel ‘trapped’.
      The contrast in perception comes from how human minds deal with fear, using repression and other defense mechanisms. When a fear is too great to think about, we repress the thought. If a habit appears impossible to give up, we rationalize or use humor to avoid recognizing the full extent of our problems. But on buprenorphine, life gets better, and people are able to take on reality. But instead of accepting the true, shameful reality of their use of illegal substances, they ‘displace’ that shame onto something and someone else. After all, what’s harder to accept– that I have a high opioid tolerance because I made one wrong choice after another until I was using heroin? Or that I am stuck on Suboxone because a doctor put me on it?
      I’m a psychiatrist, by the way. That’s probably why I write about this stuff.
      It often brings reality into the equation when people on Suboxone are reminded that they can always go back to where they were, before they started buprenorphine. If they go back to using illicit substances, they are suddenly free from Suboxone again! Of course, nobody should do that. I’m just trying to make a point.
      A couple comments for the person who posted above. First, despite all of the nonsense you’ll read on the internet, it is easier to stop buprenorphine than other opioids. The question has been studied and answered. So buprenorphine is a step in the right direction. Of course if you STARTED your opioid addiction by taking buprenorphine– a rare situation, but one that does happen– then you should make sure you never take it further, by using opioid agonists. Nobody tapers off heroin.
      Babies born to moms on buprenorphine have a 50% chance of showing signs of neonatal abstinence syndrome (NAS). The NAS from buprenorphine is much less severe than the NAS caused by methadone or heroin. Your baby will not remember staying in the hospital an extra week or two. If you want to handle the situation in a great way, there is a path for that, as follows: Instead of fretting each day about when your baby will come home, recognize that your baby is in a safe place. Recognize that there are no long-term problems from this situation. Recognize that some moms have it far, far worse; some are coping with new babies who have serious genetic abnormalities, heart defects, physical deformities, cerebral palsy, or other life-threatening conditions.
      Trust the doctors and nurses to handle the situation correctly. If the baby is in the hospital, use that time to get your home ready for your baby, and get some rest. In a few weeks, you will CRAVE that chance to rest.
      Finally, use my forum, http://www.suboxforum.com . There are many people there in the same position, and thousands of moms have used the forum over the past 10 years. You can read their stories by using http://www.suboxsearch.com and searching the forum for posts about pregnancy or NAS.

  8. Hello everyone. I am 37 weeks pregnant and on my third child. I was addicted to heroin for a long time and switched to suboxone my doctor recently switched me to subtext idk if its all in my mind or what but I feel like I need more subtext then I did suboxone. Anyways, I was wondering if you do suboxone and go into labor will the suboxone block out your pain medication you get at the hospital?

    1. Whether you take Suboxone or generic buprenorphine, what we used to call ‘Subutex’, the blocking of opioid agonists is from buprenorphine. Naloxone is only active when injected IV, and is in Suboxone to prevent IV use of that medication. Naloxone is NOT absorbed in significant amounts when Suboxone is taken properly. And even if it WAS absorbed, naloxone is metabolized very quickly– within 20 minutes.
      I suspect that the reason you feel need for more buprenorphine is because of differences in absorption of buprenorphine in different medications. Suboxone film allows about 30% of the buprenorphine to be absorbed. Plain buprenorphine comes in different sizes, and some probably have different rates of absorption than others. For example, if you take a small pill that gets diluted in a large amount of saliva, you will likely absorb a lower amount of the buprenorphine. Absorption is increased by having a dry mouth, by holding the medication in the mouth longer, or by holding the pill between the tongue and cheek as it dissolves. It might be that you were getting better absorption of buprenorphine when you took Suboxone, compared to what you are taking now.

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