pregnant pt on methadone requesting buprenorphine

Buprenorphine Post
Posts: 22

Postby m_kaylor » Mon Aug 10, 2015 7:15 am

Methadone was the gold standard but with the new MOTHER trial it looks buprenorphine had less NAS. All studies seem to indicate that whether it is methadone or buprenorphine the key is to avoid withdrawal as it is hard on the fetus. You could make a case to try and taper down and possibly switch over to buprenorphine in the second trimester as she is on a fairly low dose of methadone but it could get kind of hairy as she is going to have to have some withdrawal to avoid precipitated withdrawal and I think you would want OB in your back pocket for monitoring as you do so. I agree with you that it might be better to leave well enough alone. If women come in pregnant and are new to MAT I will usually use buprenorphine but if she is stable on methadone and then becomes pregnant I usually encourage them to stay with what is working. I also warn them that dosing may change as pregancy progresses. Usually they need more methadone due to metabolism, fluid changes etc to avoid withdrawal.

NAS is complex and I don't think we are great at which babies will get it and which won't. It looks pretty clear that dose isn't the direct cause. It seems that COMT genetics are the major factor. What I don't know, and maybe someone here does know, is if you had a baby with NAS is there an increased chance of subsequent pregnancies leading to babies with NAS. Anyone have better information on this?


Posts: 84

Postby DrBallester » Mon Aug 10, 2015 7:15 am

Buprenorphine is an option that can have better outcomes for the baby.

40 mg methadone is a reasonable dose to transition to buprenorphine, I would not take full risk/responsibility, discuss the patient with the OB and Perinatologist, review the old records of the mother and the baby and make an informed decision with the mother.

There are several resources on the PCSS site and you could also discuss the case with a mentor.

Good luck!

Posts: 137

Postby deegee » Mon Aug 10, 2015 7:15 am

I believe the general consensus is not to transition a patient who is pregnant and stable on methadone, to buprenorphine. As you stated, the risk of a rocky transition and withdrawal symptoms are greater than that of any possible negative effects of methadone compared to buprenorphine on the newborn.
That being said, I have had patients who did the transition themselves, using buprenorphine that was purchased illegally.

Posts: 9

Postby tdbailey » Mon Aug 10, 2015 7:15 am

Methadone does remain the gold standard of MAT in pregnancy. Also as you point out, to transition she will have to have some withdrawal. Our procedure is the pt doses down to 30mg and remains at that dose for a week, then misses 1-2 days, then starts on Bup. (This is not specific to pregnant pts but is for any pt wanting to switch to Bup, most commonly they are looking to get in a Suboxone program) If she is going to insist on this, the second trimester is thought to be the least problematic for the baby-so now is the time. Also, I would make sure the OB is involved in the sense that they are aware what is going to happen and ideally you get a letter they are ok with it. However, I hope your pt is aware that being on Bup does not eliminate the possibility of NAS. (I'm not sure it even decreases the possibility all that much as it seems most of my Bup pts see NAS in their babies)

I would be curious if you know whether 2 years ago she was also on 40mg Mtd. Seems like a low dose for her baby to have had terrible withdrawal. I realize severity of NAS does not 100% correlate with maternal dose but still. Also, I guess in the 3rd trimester she may have to go up on her dose of Mtd to remain stable.

It sounds like in this case I would recommend to her not changing, particularly as I am not sure she is gaining much in terms of NAS. If she insists (rather than have her drop out of treatment) and her OB is on board I would taper her down to 30mg for the week with the understanding if she does not tolerate it we can just increase her back to a stable dose.

Posts: 198

Postby NoDrugs4u » Mon Aug 10, 2015 7:15 am

I agree with your gut sense.

Posts: 180

Postby entjwb » Mon Aug 10, 2015 7:15 am

You can use Subutex in pregnancy. I would not switch anyone from methadone to Subutex when pregnant. There is a significant risk of losing the baby. It is best to not try to wean off any opiate when pregnant. You can safely switch from Suboxone to Subutex because there is no weaning process needed. There is a significant withdrawal coming off Methadone.
The newer research is showing the infant withdrawal from Bup is by far less intensive than from Methadone.

Posts: 571

Postby kcairns » Mon Aug 10, 2015 7:15 am

McChaplin, you know that you know the answer to that very well... current guidance is that overall in such setting, more better pregnancy outcomes achieved by not makng said change,,,also no guaranteee as you know in any individual case re what nas will be on either med from one preg to next, ....if she wants switch best is ater this preg past....that being said, at dose of 40, in an individual case it is very unllikely there would be any adverse effect, and 2nd trimester best time and if she very determined, now would be better than waiting till perhpaps the pregnancy requires a larger mtd dose or get into 3rd trimester

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