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.

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!