The article discusses factors to be considered when one becomes pregnant while taking Suboxone, a treatment for opiate addiction, the differences between Suboxone vs Subutex in pregnancy and babies born on suboxone.
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Subutex VS Suboxone
First, let’s clarify the differences between Subutex and Suboxone:
SUBOXONE Film contains buprenorphine and naloxone
- Buprenorphine is the primary active ingredient in SUBOXONE Film. Known as a partial agonist, it can attach to the same receptors as other opioids and reduce their effects by blocking them from the same receptors.
- Naloxone is included to help prevent misuse. If you are dependent on a full opioid agonist and attempt to inject SUBOXONE Film, the naloxone is likely to cause withdrawal signs and symptoms.
SUBUTEX does not contain naloxone
- Is preferred for use only during induction. Following induction, SUBOXONE sublingual film or SUBOXONE sublingual tablet is preferred due to the presence of naloxone when clinical use includes unsupervised administration. The use of SUBUTEX for unsupervised administration should be limited to those patients who cannot tolerate SUBOXONE sublingual film or SUBOXONE sublingual tablet; for example, those patients who have been shown to be hypersensitive to naloxone.
As far as Suboxone, anesthesiologist Jeffrey T Junig MD Ph.D. says
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 an 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.
Suboxone While Breastfeeding
Dr. Junig further states,
It is not a problem to take Suboxone while breastfeeding. The only potential problem is that you will run into a militant breastfeeding 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 mostly 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 breastfeeding from moms on Suboxone.
Also, note that Insight (An initiative of Queensland Health) states in their PDF “Clinical Guidelines for the use of Buprenorphine in Pregnancy, ” that use of buprenorphine post-partum, Buprenorphine maintenance should continue as long as clinically indicated postpartum with a regular clinical review to monitor the progress of all pregnant women. Rapid dose reduction should be avoided due to the risk of relapse. Consideration should be given to establishing breastfeeding and coping with demanding parenting issues. Monitoring should continue to occur with the patients’ obstetric and pediatric team.
Breast milk contains similar amounts of buprenorphine to maternal serum levels. However, due to significant first-pass metabolism, buprenorphine has reduced oral bioavailability. Infants will be exposed to proportionally less of the total active amount available. If a management decision is made to continue breastfeeding while the mother is on
buprenorphine, neonates, and infants should be regularly reviewed to monitor their development. Monitoring is most practically done by measuring weight gain. Other indices (e.g. progressive developmental assessment) can be used in addition. Monitoring would include:
- weight gain as an index of feeding and performance;
- routine medical assessment
Ideally, a comprehensive developmental assessment of all babies exposed to buprenorphine through breast milk should occur at 2 years.
Pain Control During Labor
According to Dr. Junig, it can be difficult to get good pain control in a person who dosed Suboxone on the morning of surgery. He remembers one specific patient
one of my patients had it all set, to stop three days in advance… but then she had an immediate C section a couple hours after dosing with 8 mg 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 bupivacaine to treat her pain, and it would have worked well. Since they didn’t do an epidural we ended up transferring her to the ICU, where they could keep her on oxygen monitoring 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 beforehand.
They can be hard to find, and they don’t take ownership of cases until the last minute, but try to find one and ask him or her to do your case. Pick the one that talks openly 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 suffering 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 treat him like a medical specimen. All of the data we have shows no problems with babies born to mothers on Suboxone.
These guidelines discuss the clinical management of pregnant and breastfeeding women. They do not aim to discuss medico-legal situations of the management of opioid-dependent women using buprenorphine in pregnancy.
“Suboxone And Epidural Anesthesia; Pregnancy, Delivery, And …” N.p., n.d. Web. 31 Jan. 2019 <http://suboxonetalkzone.com/suboxone-and-epidural-anesthesia-pregnancy-delivery->
“What is SUBOXONE Film?” <https://www.suboxone.com/treatment/suboxone-film>.
Pregnancy and Buprenorphine: Clinical Guidelines – TurningPoint (2003) <https://insight.qld.edu.au/shop/clinical-guidelines-for-the-use-of-buprenorphine-during-pregnancy>