unusual pregnancy conundrum

Buprenorphine Post
jtalbert57
Posts: 4

Postby jtalbert57 » Fri Oct 23, 2015 5:00 am

Medical conditions that make methadone contraindicated would certainly be one of the exceptions that would justify the switch to buprenorphine. I would encourage her to accept buprenorphine as the relapse rates are very high during pregnancy and postpartum in patients who taper off meds before they are solidly in recovery with a strong support system. The second trimester is the best time to transition. Fetal monitoring would not be necessary, especially before 24 weeks so the induction could be done as an outpatient. I would probably use the same protocol that you use for non-pregnant patients. Split dosing often seems to work better and don't be surprised if you find that you need a little higher dose than your average non-pregnant patient. You may need to increase the dose in the third trimester but I rarely have gone above 16-24 mg. I do monitor all of the patients with frequent urine screens for bup with quantitative if I have any questions about diversion. Again, neonatal abstinence syndrome does not appear to be dose related.

kcairns
Posts: 571

Postby kcairns » Fri Oct 23, 2015 5:00 am

i have no option but to do the one I posted above w the implanted pacer -defib...in such case any advice would be appreciated, tia ie thanks in advance

jtalbert57
Posts: 4

Postby jtalbert57 » Fri Oct 23, 2015 5:00 am

I generally do not recommend switching patients who are stable on methadone to buprenorphine during pregnancy. There is no clear benefit in terms of fetal outcomes and it is best to avoid withdrawal during pregnancy.

MChaplin
Posts: 183

Postby MChaplin » Fri Oct 23, 2015 5:00 am

jtalbert57- thanks for your expertise- do you ever transfer pregnant patients from methadone to buprenorphine? I have had two patients ask, but I said no on the grounds that I was concerned about the wdrl period required to safely start bup. would appreciate your insight.

kcairns
Posts: 571

Postby kcairns » Fri Oct 23, 2015 5:00 am

many thanks, JTAlbert , your knowledge and experience are of great importance

jtalbert57
Posts: 4

Postby jtalbert57 » Fri Oct 23, 2015 5:00 am

I am an Ob who has been prescribing bup to pregnant and post partum patients for the past 2 years. I would definitely recommend methadone or bup to Ob patients who are at high risk of relapse (e.g. having cravings). Either is better than heroin. We seem to be seeing less withdrawal in split dose bup. compared to methadone but the data is still limited. Regardless, withdrawal in the baby is not dose related for either methadone or bup so she should be given the lowest dose that relieves her symptoms as you would in a non pregnant patient. Dosing often needs to be increased gradually during pregnancy due to physiologic changes of pregnancy. Fetal monitoring is not indicated if bup induction is before 24 weeks gestation.

kcairns
Posts: 571

Postby kcairns » Fri Oct 23, 2015 5:00 am

thanks both, so far she is still ok on only 25 of mtd and I will carry her so until early 2nd trimester...ob wants her to taper off all but they always do, she feels she would not be able to be safe from relapse if tapered off, HE Jones , Mother etc, describes in her series a number of moms committed to taper off all and they did well but they were committed to be off, rather than doubtful like my pt, seems to me like a slow taper off would have fetus in a somewhat long period of wdrl/distress as opposed to being off mtd for 24 h and coming in office to stay a whole morning for bup induction not leaving until no more wdrl, will also talk w ob re difference between just outpt slow taper and admittance , prob best to ob floor for taper under observation for mom and fetal monitoring, thnx, ken

drpasser
Posts: 1404

Postby drpasser » Fri Oct 23, 2015 5:00 am

Bupe is safer than methadone in terms of cardiac dysrhythmias.

:-)

MChaplin
Posts: 183

Postby MChaplin » Fri Oct 23, 2015 5:00 am

ken- beyond scary- what did you do? Is there any family support? Per previous thread, it doesn't make good clinical sense to switch from methadone to bup while pregnant esp knowing she didn't do well with it anyway....but continuing methadone knowing that she may need defib which one would think would be dangerous to the fetus....ugh. almost seems like her best option would be a slow detox under medical supervision followed by residential treatment. good luck!

kcairns
Posts: 571

Postby kcairns » Fri Oct 23, 2015 5:00 am

conundrum variant --14 wk preg,, hx on bup in past but stopped as it made her jumpy , relapsed on oxy etc then when found self pregnant put self on street mtd and came to otp for mtd maintenance....any other med hx? ." no - just my pacer/defib d/t ebsteins anomoly and congential prolonged qt".."O"...help (including minutia) !! please?


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