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.

Treatment? Or Murder?

I subscribe to Google news alerts for the phrase ‘overdose deaths.’ Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.
Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.
I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.
In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts. On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even if we tattooed the letter A across their chests, there are addicts who are in need of pain treatment. Are we to decide that every person who has become addicted to pain medication gives up the right to pain treatment? And we know that many of the patients addicted to opioids became addicted through the course of pain treatment from their physician— so I would expect that on average, patients addicted to opioids would have a higher incidence of chronic pain, and vice versa.
I do not find it reasonable to make patients with addiction histories endure pain that would be treated in other patients. Father than singling out some patients for ‘special non-treatment,’ we should prepare for the risks from opioids in ALL patients—a set of ‘universal precautions for opioid treatment,’ similar to the way we use a different set of universal precautions to avoid transmission of blood-borne infections.
There are times when doctors have to tolerate being the bad guys. Some patients have been taught, through careless prescribing, that all pain should be treated with narcotics. Those patients are not happy when told, after paying several hundred dollars, that they do not ‘need’ narcotic pain medication– and so many of their doctors have a hard time saying ‘no.’ After all, doctors studied hard to do well in school, and usually receive praise for what they do. It is much easier to write a prescription and hear ‘thank you’ than to be called an unsympathetic jerk! But doctors are paid the big bucks to tolerate such things, and to keep the long-term health of patients in mind. And for many people with chronic pain, opioids will provide a good month or two, but for the price of many years of misery.
I’ve been told by patients “I don’t care about the risks, doc– I’d rather have three good months and then die, then have twenty years in pain.” I reply, “that’s why these medications require a doctor to consider things very carefully, and a good doctor would not allow someone to make that decision.” I’m sure that some people will be angered by that attitude. But the approach is similar to how we handle many other illnesses, where we encourage patients to tolerate short-term misery for long-term benefits. Many patients would refuse chemotherapy and give up on life if not pushed to move forward. And to depressed patients, suicide can appear a reasonable option. I’m a fan of free will, but I recognize that we don’t always choose our paths through life with full insight.
Even with full knowledge of the reasons to avoid narcotics, some doctors really struggle over withholding opioids. I find it somewhat ironic that the doctors who are too ‘kind-hearted’—i.e. who want to please patients so much that they cannot deny even that which is bad for them—are the ones who end up getting into trouble. The Iowa doctor is being sued over several of the deaths, likely by relatives of the patients who pled the hardest for pain pills! Talk about good deeds not going unpunished!
But there are aspects of the case in Iowa that do not argue well for the doctor. Several of the patients who died were only seen once, but treated with narcotics for years. The DEA requires that patients are prescribed no more than 90 days of narcotic medication at one time (divided on three monthly prescriptions). I presume that patients were picking up scripts every three months, without having appointments each time. Such a practice is not strictly illegal (not that I am aware of, anyway), but the standard of care would be to evaluate patients on potent opioids every three months, or even more frequently. And one news article stated that the doctor had tens of thousands of pain patients. As a full-time practitioner with less than 1000 patients, I wonder how so many patients could be managed by one physician.
When I write about this topic I receive angry comments from some readers. Some attack me personally with comments like “I’m glad I’m not YOUR patient!” or “I hope YOU have to suffer with horrible pain some day!” I realize that this is a very hot topic, and my only intent is to educate and inform, to help people understand what is happening in the minds of physicians. Of course, the care of patients should not be determined by the need for doctors to protect their own interests. But at the same time, it is understandable that doctors are affected by headlines announcing the imprisonment of other doctors facing the same treatment decisions.
Bottom line– there are very good reasons to avoid using opioids for nonmalignant chronic pain. Just giving patients what they want, and ignoring the danger of opioids, will likely result in criminal and civil prosecution. But that reason is secondary to the most important thing– the promise all doctors make to first, do no harm. And patients should realize that their doctors may be withholding narcotics for that reason alone.

Hydrocodone (Vicodin) Addiction and Buprenorphine

I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high. Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases. In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.
Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former). For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing. That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.
Tolerance is sometimes used as part of the equation when determining the severity of one’s addiction. But looking at tolerance alone can be misleading. Tolerance is a consequence of heavy use of opioids, and also a cause of heavy use of opioids. Tolerance usually goes up over time, so having a high tolerance probably correlates with length of addiction in some—- but not all— cases. Tolerance is also strongly related to drug availability. A person with a severe addiction, who only has access to codeine, will likely have a lower tolerance than a person with a more mild addiction, who has free access to fentanyl, oxycodone, and heroin.
I think it is more appropriate to measure the ‘severity of addiction’ by the degree of mental obsession that the patient has for opioids. Tolerance is one piece of information in determining that obsession, but tolerance alone can be misleading.
To get a sense of the obsession for opioids, I look at many factors. Has the person committed crimes to obtain the substance? Violent crimes? What has the person given up for his addiction? Has he been through treatment? How many times? How long did he stay clean after treatment? Have his parents or spouse thrown him out of the house, and if so, does he still use? Did he choose opioids over his career? Over his kids?
Answers to these questions provide a broad understanding about the addicted person’s relationship with the substance—an understanding that is necessary when considering the likely success or failure of one treatment or another. It is also important to consider the person’s place in the addictive cycle—i.e. early, likely in denial, cocky, with limited insight– or late, after many losses, more desperate—and perhaps more accepting of treatment.
I am a fan of buprenorphine as a long-term treatment for opioid dependence, as readers of this column know. I consider opioid dependence to be a chronic, potentially-fatal illness that deserves chronic, life-sustaining treatment— and buprenorphine, in my experience, is a very effective treatment in motivated patients. But tolerance becomes a factor, when considering buprenorphine for THIS patient.
Buprenorphine has a ‘cap’ or ‘ceiling effect’ that allows the medication to trick the brain out of craving opioids. In short, as the blood or brain concentration of buprenorphine drops between doses, the opioid effect remains constant, as long as the concentration is above the ceiling level. In order to achieve the anti-craving effects of buprenorphine, the dose must be high enough to create ‘ceiling level’ effects. If buprenorphine is prescribed in lower amounts—say microgram doses— the effect is identical to the effects of an agonist, since the dose/response curve is linear at lower levels.
Buprenorphine is a very potent opioid, and the effects of the medication are quite strong at the ceiling level. Comparisons to other opioids will vary in different individuals, but in general, a person on an appropriate dosage of buprenorphine develops a tolerance equivalent to that of a person taking 40 mg of methadone per day, or approximately 60-100 mg of oxycodone per day.
A person taking even a dozen Vicodin per day has a much lower tolerance to opioids. Such a person who starts buprenorphine treatment will obtain a very significant opioid effect from the drug— unless the dose of buprenorphine is raised very slowly over a number of days. And in that case, the person’s tolerance level would be pushed much higher.
So if our current patient starts buprenorphine, he will have a much higher opioid tolerance if/when the buprenorphine is eventually discontinued. I receive emails now and then from patients who are angry at their doctor for starting buprenorphine, feeling trapped by the considerable threat of withdrawal from stopping the drug. But at the same time, taking hydrocodone and acetaminophen in high amounts creates the risk of liver damage from the acetaminophen, as well as the considerable risks from opioid dependence.
And so the dilemma. Should buprenorphine be considered in such a case?

Jerk Counselor

Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention. This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’
I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness. I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions. In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do? Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

Some Jerks advocate punishing patients who struggle.
This Jerk Counselor

We all know that certain professions attract certain types of people. Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt. When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people. It’s the power trip, I suppose.
This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment. He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way. One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room. But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.
Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position. In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room. We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.
The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power. Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids. Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.
This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety. He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.
In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious: when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts. On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.
I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric. I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach. I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right. But most of us leave that world behind when we commit to helping people suffering from illness.
What’s This Jerk’s excuse? Is it that he just doesn’t get it? Or are there other motives at play? With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.
Or is it the power trip– that people with difficult addictions are an affront to therapists? I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die. I suppose This Jerk would say ‘not my problem! I did MY job!’
Readers may suspect that this topic irritates me—and they’re right. Maybe I’ve seen more death, up close, than the typical counselor. I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery. I have spent hours with the parents of young patients who died from overdose. I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child. Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.
I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior. People like This Jerk hold power over an individual with an addiction history, but there is power in numbers. It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle. It is not appropriate to humiliate a patient in front of others. If you see that behavior, collect witnesses, and bring it to someone’s attention. Maybe that ‘someone’ will write a blog post about it!
Doctors in particular should treat patients with ALL diseases—including addiction—with respect. It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite. I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.
Would THAT make sense— even to This Jerk?

The Other Opioid Dependence Medication

Today I met with representatives from Alkermes who were promoting Vivitrol, a long-acting mu opioid antagonist that is indicated for treatment of alcoholism and opioid dependence.

Naltrexone
Naltrexone

I admit to some pre-existing bias against the medication. I’m not certain, to be honest, whether that bias was based upon sound clinical reasoning, or whether it was based on personal, negative reactions to naltrexone in my past. Or maybe, as a recovering opioid addict, I have negative feelings about anything that blocks mu receptors!
Vivitrol consists of naltrexone in a long-acting matrix that is injected into the gluteal muscle each month. The medication is expensive, costing about $1000 per dose (!) That cost is usually covered by insurance, and like with Suboxone, Wisconsin Medicaid picks up the tab save for a $3 copay. Alkermes, the company that makes Vivitrol, also has a number of discounts available to reduce or even eliminate any copays required by insurance companies.
I’ll leave the indication of Vivitrol for alcoholism for another post. The indication for opioid dependence came more recently, and appears more obvious, given the actions of naltrexone at the mu opioid receptor.
In short, naltrexone blocks the site where opioids—drugs like oxycodone, heroin, and methadone—have the majority of their actions. Blockade of that site prevents opioids from having any clinical effect. There is some dose, of course, where an agonist would regain actions— an important feature in the case of surgery or injury. But even in those high doses, the euphoric effects of addictive opioids would be muted. People on Vivitrol, essentially, are prevented from getting high from opioids.
Back in my using days, I took naltrexone, thinking that doing so would help me get ‘clean.’ I didn’t wait long enough, however, and so I became very sick with precipitated w/d. The makers of Vivitrol recommend waiting at least a week, after stopping opioids, before getting an injection of Vivitrol. I suspect that a week is not long enough to prevent w/d, but I realize that it would be very difficult to expect patients to last longer, without using anything. I would expect that any precipitated w/d could be reduced through use of comfort medications, at least for a day or two until the symptoms are mostly gone. This requirement, though, to be clean for a week or more is one of my problems with the medication.
As an aside, I was also prescribed naltrexone (oral tabs) at the end of my three months in residential treatment, and I took the medication for another three months. I had no withdrawal or other side effects to naltrexone at that time.
Another issue was the concern that naltrexone has been connected to hepatic toxicity. We discussed that issue today, including the studies that led to that connection—which are not compelling. The discussion allayed most of my concerns about liver problems from Vivitrol.
Finally, I have always recommended buprenorphine over naltrexone because of the anti-craving effects of buprenorphine that result from the ‘ceiling effect’ of the medication. I worried that naltrexone, by blocking the actions of endorphins, would actually increase cravings. But that is not what the data shows. In the studies with Vivitrol, cravings for opioids were dramatically reduced by the medication. The mechanism of that effect is not entirely clear; some of the anti-craving effect may be psychological, as addicts stop wanting something when they know there is no way to get it. But there may be other complicated neurochemical effects at presynaptic opioid receptors that are not fully understood.
The bottom line is the result of treatment; the very sick opioid addicts treated in the studies used by Vivitrol to gain FDA approval showed a profound reduction in opioid-positive urines, over a span of 6 months.
I suspect that I will continue to favor buprenorphine. I do not buy into the ‘need’ some people describe to ‘get of buprenorphine as fast as possible.’ Buprenorphine is a very effective, safe, long-term treatment for inducing remission of opioid dependence. But because of the cap, I am glad that another option is available to treat this potentially-fatal condition. And I admit to perhaps being too quick to judge Vivitrol, which appears to be a safe alternative—particularly for people who have a lower opioid tolerance that do not want to push it higher, or for people who have been free of opioids for a week or two.
I would invite local people who are on my buprenorphine waiting list to consider Vivitrol as an option.