Buprenorphine substitution therapy in pregnancy
- Vincenzo Berghella, MD
Vincenzo Berghella, MD
- Director, Maternal-Fetal Medicine
- Professor, Obstetrics and Gynecology
- Thomas Jefferson University
- Neil S Seligman, MD
Neil S Seligman, MD
- Assistant Professor
- Department of Obstetrics & Gynecology
- Division of Maternal-Fetal Medicine
- University of Rochester Medical Center
- Brian J Cleary, PhD
Brian J Cleary, PhD
- Chief Pharmacist, Rotunda Hospital
- Honorary Clinical Associate Professor, School of Pharmacy
- Royal College of Surgeons in Ireland
- Section Editors
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
- Andrew J Saxon, MD
Andrew J Saxon, MD
- Section Editor — Substance Use Disorders
- Professor and Director, Addiction Psychiatry Residency Program, Department of Psychiatry & Behavioral Sciences
- University of Washington
Illicit opioid use during pregnancy is associated with substantial maternal, fetal, and neonatal risks. (See "Overview of substance misuse in pregnant women", section on 'Opiates'.) Some of these risks are related to repeated opioid exposure and withdrawal, while others are related to factors associated with substance abuse (eg, smoking, poor nutrition, needle sharing). The rationale for opioid-substitution therapy during pregnancy is to reduce these risks by preventing complications associated with illicit opioid use and narcotic withdrawal, facilitating prenatal care and drug treatment, reducing drug-related criminal activity, and helping the patient avoid the myriad of other risks associated with the drug culture [1,2].
Comprehensive opioid-substitution therapy that includes prenatal care reduces the risk of obstetric and neonatal complications [1,2]. While methadone remains the standard choice for opioid agonist therapy during pregnancy, there is increasing interest in the use of buprenorphine because neonatal withdrawal appears to be less frequent and less severe .
This topic will discuss the use of buprenorphine for opioid substitution during pregnancy. General issues related to prevalence, screening, complications, and care of the pregnant opioid user and methadone maintenance therapy in pregnancy are reviewed separately. (See "Overview of substance misuse in pregnant women", section on 'Opiates' and "Methadone substitution treatment of opioid use disorder during pregnancy".)
CANDIDATES FOR OPIOID-SUBSTITUTION THERAPY
Pregnant women with substance dependence (table 1) are candidates for opioid-substitution therapy, regardless of the duration of dependence if a return to dependence is likely during pregnancy. (See "Substance use disorder: Principles for recognition and assessment in general medical care" and "Pharmacotherapy for opioid use disorder".)
Candidates for treatment should be referred to a local physician and/or substance use disorders treatment program that specializes in opioid substitution therapy. Treatment programs that are oriented to abstinence only and do not utilize or understand opioid substitution therapy should be avoided. In addition, prenatal care should be arranged.
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- CANDIDATES FOR OPIOID-SUBSTITUTION THERAPY
- BUPRENORPHINE OR METHADONE?
- Comparative outcome data
- - Neonatal abstinence syndrome
- - Other neonatal outcomes
- - Maternal treatment retention
- Switching from methadone therapy
- Switching to methadone therapy
- Safety, side effects, drug interactions
- - Risk of congenital anomalies
- Initiation of buprenorphine and subsequent management
- - Patients with hepatic or renal insufficiency
- Missed doses
- Buprenorphine versus buprenorphine plus naloxone
- PREGNANCY MANAGEMENT
- Antenatal fetal surveillance
- - Effect on fetal heart rate
- Management of pain during labor, delivery, and postpartum
- - Labor and delivery
- - Postpartum
- Management of buprenorphine postpartum
- SUMMARY AND RECOMMENDATIONS