EXPERT ANALYSIS FROM PREMIER, INC.
Buprenorphine is the treatment of choice for opioid addiction during pregnancy, according to Dr. Marjorie Meyer, of the department of maternal fetal medicine at the University of Vermont in Burlington.
As an in-office prescription, buprenorphine is easier to access than methadone, and a large, randomized trial that pitted methadone against buprenorphine found that women treated with buprenorphine have fewer delivery complications ( N. Engl. J. Med. 2010;363:2320-31 ). Their babies are also born heavier and at greater gestational age than those born to mothers on methadone, and require less morphine for neonatal abstinence syndrome and recover from it sooner, Dr. Meyer said during a webinar sponsored by Premier Inc., a health care performance improvement alliance of about 3,400 U.S. hospitals and 110,000 other providers.
The evidence from the trial – the most rigorous to date comparing the two options – all favors buprenorphine, she said.
“The concerning thing about this study was that a third of women dropped out during buprenorphine induction; the way they induced I think might precipitate a little bit of withdrawal,” she said. If that’s avoided, “you can get the dropout rate down.”
In general, treatment for addicted mothers “improves pregnancy outcomes, and should be offered,” but traditional detox is not optimal therapy , Dr. Meyer said. It can help prevent neonatal abstinence, but the dropout rate is high, perhaps about 50%. Even if women stick with the program, “what you have is a very sick mother who is unable to parent,” she said.
There are still many questions about what physicians can do for pain when women on methadone or buprenorphine go into labor. Full-agonist opioid or regional analgesia are good options, but not nalbuphine and butorphanol, Dr. Meyer said. As partial opioid agonists, they can throw women into withdrawal.
“One thing that is very reassuring is that spinals and epidurals actually work just as well,” she said.
There’s no need to increase pain control after vaginal delivery in women on buprenorphine or methadone maintenance. Routine postpartum orders with p.r.n. opioids for 24 hours should be effective, Dr. Meyer said.
After cesarean delivery, however, these women need more opioids for the first few days, generally about 50%-70% more.
“We tend to go ahead and give them higher doses of p.o. dilaudid and it seems to work very well” dosed at 4-6 mg every 4-6 hours. Treatment doesn’t need to last longer than in other women, only about a week. Transversus abdominis plane (TAP) blocks have also very effective, Dr. Meyer said.
If women receive nalbuphine and butorphanol by mistake at some point during labor and delivery, Dr. Meyer said she’s seen IV morphine work well for rescue.
Patients on maintenance therapy often ask if there’s something they can do to help prevent their baby from going into withdrawal. “The obvious answer is ‘yes, stop smoking,’” she said.
The vast majority of opioid abusers smoke cigarettes, and smoking has been shown to be “a very important contributor to neonatal abstinence syndrome,” she said. “I use this [fact] as a tool to really encourage smoking cessation, or even smoking reduction.”
Dr. Meyer reported having no relevant financial disclosures.