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

On Suboxone, Confused, Wanting to be Pregnant

A person added a comment asking a question related to pregnancy. I have moved her comment/question up here:
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.
My Thoughts:
There certainly is a great deal of confusing information out there– it is concern about that mess that fuels my blogging.  Something to notice about the information– there is something about having an addictive disorder that causes people with no training to consider themselves ‘experts’.  The phenomenon is somewhat unique to addiction;  you don’t people with heart disease or prostate cancer arguing with physicians over which treatment is best– at least not in a way where the person with no medical education is putting out advice counter to the medical experts, and people are trying to decide which one to choose!  Then again, you don’t see patients with heart disease who are managed medically get their undies in a bundle over the fact that some other patients are being managed surgically!  Only with addiction do we have both of those things– 1.  An intense nosiness of some people about the treatment choices of others;  and 2. People with no training in addiction treatment, no years spent learning about how the mind works;  no education or research into mechanisms of tolerance at the receptor level…  who based on their own (often limited) sobriety feel confident enough about their knowledge to make recommendations to others.  Intrusiveness and ignorance–  THAT’S a dangerous combination if there ever was one!
Anyone see The Apprentice tonight?  Wow– Trump doesn’t like drunk drivers very much, does he?  I was in a bookstore the other day and I browsed through one of his books– he has a bunch of them, but they are all pretty much the same– this one called ‘Think big and KICK ASS!’ I’ll confess to something… one of the reasons I looked though it is because of the comments that I sometimes receive on this blog.  A person wrote the other day something I considered helpful– he wrote that I seemed to take another person’s comments about Suboxone personally.  One thing I have learned as a psychiatrist:  a person cannot figure himself out, no matter how smart or insightful or deep he may be.  If you want to understand yourself– REALLY understand yourself– you need to listen to others, and to accept what others are saying.  At least when you hear it more than once, anyway.  The writer was correct;  I do take the comments personally… and that bothers me.  If anyone is an expert with Suboxone and opiate dependence, it should be me– (geez, I get a bit uncomfortable saying that).  After the person’s comments about taking things ‘personally’ I realized that it is tough to be an expert;  people always take shots at the person who takes a stand, whether the stand is based on facts, morality, idealism… if you are going to ‘put it out there’, people are going to try to cut it off.  Gosh, this is running on forever….  OK– I read Trump’s book because I wondered how he ‘feels’ about all of the stones thrown his way.  No, I am no Trump!  But reading his book I realized that the awkward, lonely feeling of being an ‘expert’ happens to other people as well, and the way Trump recommends dealing with them is to just talk LOUDER, assert your expertise more STRONGLY, and GET EVEN– ALWAYS!
I would never be able to pull all of that off… but I will try to let things roll off my back a bit more.  I’m not sure whether it is good advice to keep boasting about one’s expertise;  it works for Trump, but he has become a bit of a caricature of himself.  Plus there can only be one ‘Trump’!
Sorry about going on a bit.. So, why is it that addicts tend to act like ‘experts’?  I think a big reason is that addicts are playing doctor all the time, when they are using!  No addict ever reads the instructions on a bottle of pain pills– sometimes I will tell a patient to ‘take the pills as they are prescribed– as written on the bottle’ and the person acts as if the concept has never occurred to him!  This brings us to a point about ‘getting better’ on Suboxone, or in Recovery without Suboxone:  you must stop treating yourself as your own physician.  Even doctors must stop playing doctor on themselves.  This is a boundary critical to sobriety;  once a person starts to treat himself, he is on a slippery slope that leads back to using– eventually if not right away.  But back to the point of the original question:  as to the confusing mass of information and the contradicting comments across the web, I strongy recommend that you screen out the medical comments made by people who are not trained in medicine.  That’s not to say that a person’s experiences are not useful;  but often the experiences are translated into comments that are simply silly.  Whenever you read anything about ‘endorphins coming back to normal’ or needing ‘amino acids to remake neurotransmitters’, you are reading nonsense.  I have a PhD in Neurochemistry, and I can tell you with complete certainty that WE HAVE NO IDEA what ‘endorphin levels’ do during addiction, especially at the synapse, where all of the action occurs.  Yes, I could come up with a neat story about what they ‘might’ do… but when I do that, I will try to say ‘this is all just made up on my part’.  Unfortunately the people who know the least seem to make up the most complicated, detailed stories– and act the most certain about them!
I will take on the pregnancy issue in my next post, since I wasted the night with this other stuff.  I don’t want to simply repeat myself though, so please search the blog for ‘pregnancy’, as there are a few posts already.  One of the posts includes several articles about having babies while taking Suboxone.  A couple quick points:  the least safe thing is to be on nothing, and relapse once or several times, exposing the baby to several drugs and possibly to hypoxia or toxins.  The safest thing is to be in solid recovery, off all medications.  Somewhere in the middle like buprenorphine and methadone.  I have seen no published evidence (or anecdotal evidence) for miscarriage caused by buprenorphine or naloxone.  I have had six patients who were on Suboxone throughout their entire pregnancies;  the only sigificant problems were related to fear on the part of uneducated doctors– by that I mean doctors who should have/could have read up on buprenorphine ahead of time, and didn’t,  and so they treated the newborns as if they had been born to mothers on methadone– despite evidence that the NAS (neonatal abstinence syndrome) is much more mild with buprenorphine.
Finally, in the right sidebar you will see a list of news stories about Suboxone, including one relating to pregnancy;  I might write about the article at some point as an example of a very bad ‘study’ in a throw-away journal.  There is no randomization, no control group– a subset of 15 babies are described, out of a patient population of 150… with no description of why they chose THOSE babies.  There are also many confounding factors– for example, the fact that many of the babies were in special education later in life– we know nothing about their addict-mothers, their upbringing, their nutritional status, whether they were physically abused, etc.  One can always find data to support a certain position– particularly if there is no need to explain where the data comes from!
I do recommend that women trying to become pregnant or who are pregnant change from Suboxone to Subutex;  we don’t know of danger from the naloxone, but it is always good practice to expose the baby to as few drugs as possible, and since Suboxone and Subutex work in an identical fashion there is no reason to stay on Suboxone.
More later…
SD/SuboxoneTalkZone.com

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.

Suboxone vs Subutex

I noticed that in the stats area I can see the search terms used by those who found my blog;  I think I will answer some of the ‘questions’ in the search terms now and then.  One person searched for ‘do suboxone and subutex feel the same’?  The answer is that yes, they feel the same for most people.  Some specifics:
The active ingredient in both Suboxone and Subutex is buprenorphine.  Buprenorphine is a ‘partial agonist’ that has a self-limiting effect on opiate receptors.  There is a common misperception that the naloxone in Suboxone is responsible for the ceiling effect or for precipitating withdrawal during inductions;  neither is true.  The naloxone is in there supposedly to prevent injection of dissolved Suboxone, as the naloxone is inactive orally (for the most part) but is active if injected.  I say ‘for the most part’ because there are some situations where the naloxone may make a difference.  I don’t have any data to support what I am about to say– and I don’t know if any data exists.  But I think that my ideas are sound, using some basic knowledge of how the body works.  Some background:  Naloxone is not absorbed well through mucous membranes and buprenorphine IS absorbed well; the naloxone therefore is swallowed, and some is absorbed by the small intestine.  From there it enters the portal vein and goes to the liver.  Some medications are efficiently destroyed by the liver; this is called ‘first pass metabolism’.
Times when I change patients to Subutex: 
-During pregnancy.  Even though little naloxone gets into the circulation, and even less crosses the placenta, and even less survives going through the fetal liver, there is a general principle to expose the fetus to as few drugs as possible.  Suboxone has two, Subutex has one, so Subutex wins.
-After gastric bypass.  In some gastric bypass procedures the distal small intestine is pulled up and attached to the stomach;  I would assume in such cases that the naloxone would then pass from the stomach to the ileum instead of the duodenum, and it would get absorbed by capillaries that do not empty into the portal system.  The result would be that the naloxone would bypass the liver and bypass ‘first pass metabolism’, potentially causing a touch of withdrawal.  So I give the patient Subutex.
-Some people get headaches after taking Suboxone and not after taking Subutex.  Are the headaches from the naloxone?  I don’t know.  Subutex costs considerably more, and some insurers therefore will not cover it… so it may depend on how bad the headaches are as far as making the switch.
-Same thing for the taste– Subutex supposedly doesn’t have the ‘fruity’ flavoring, and some people like it better.  It costs 50% more– is it 50% better tasting? 
Keeping it short tonight… Son back from college and so I want to talk to him a bit.  Hey– I have a radio show about psychiatry… if you want to check it out you can click on it from the Fond du Lac Psychiatry web site.  Thanks for checking it out.
Fond du Lac Psychiatry