Maternal Buprenorphine Maintenance and Lactation

Jansson, Lauren M.; Spencer, Nancy; McConnell, Krystle; Vélez, Martha L.; Tuten, Michelle; Harrow, Cheryl; Jones, Hendrée E.; Swortwood, Madeleine J.; Barnes, Allan J.; Scheidweiler, Karl B.; Huestis, Marilyn A.

doi:10.1177/0890334416663198

Cited by 33 publications

(16 citation statements)

References 22 publications

(27 reference statements)

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“…This relation was present at 32 weeks and beyond, and suggests a lingering and perhaps cumulative medication effect at higher doses (i.e., ≥ 13 mg). This finding resonates with a recent report utilizing the same sample that found that maternal buprenorphine dose and concentrations of buprenorphine in plasma of recently post-partum women are correlated, 22 a relationship not found with methadone. 23 …”

Section: Commentsupporting

confidence: 88%

Maternal buprenorphine treatment and fetal neurobehavioral development

Jansson

Vélez

McConnell

et al. 2017

American Journal of Obstetrics and Gynecology

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Background Gestational opioid use/misuse is escalating in the United States, however, little is understood about the fetal effects of medications used to treat maternal opioid use disorders. Objective The purpose of this study was to determine the effect of maternal buprenorphine administration on longitudinal fetal neurobehavioral development. Study Design Forty-nine buprenorphine-maintained women attending a substance use disorder treatment facility with generally uncomplicated pregnancies underwent fetal monitoring for 60 minutes at times of trough and peak maternal buprenorphine levels. Data were collected at 24, 28, 32, and 36 weeks gestation. Fetal neurobehavioral indicators (i.e., heart rate, motor activity and their integration (fetal movement-fetal heart rate coupling)) were collected via an actocardiograph, digitized and quantified. Longitudinal data analysis relied on hierarchical linear modeling. Results Fetal heart rate, heart rate variability and heart rate accelerations were significantly reduced at peak versus trough maternal buprenorphine levels. Effects were significant either by or after 28 weeks of gestation, and tended to intensify with advancing gestation. Fetal motor activity and fetal movement-fetal heart rate coupling were depressed from peak to trough at 36 weeks of gestation. Polysubstance-exposure did not significantly affect fetal neurobehavioral parameters, with the exception that fetuses of heavier smokers moved significantly less than those of lighter smokers at 36 weeks. By the end of gestation, higher maternal buprenorphine dose was related to depression of baseline fetal cardiac measures at trough. Conclusions Maternal buprenorphine administration has acute suppressive effects on fetal heart rate and movement, and the magnitude of these effects increases as gestation progresses. Higher dose (≥ 13 mg) appears to exert greater depressive effects on measures of fetal heart rate and variability. These findings should be balanced against comparisons to gestational methadone effects, relatively good outcomes of buprenorphine-exposed infants, and recognition of the benefits of medication assisted treatment for pregnant women with opioid use disorders in optimizing pregnancy outcomes.

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Section: Commentsupporting

confidence: 88%

Maternal buprenorphine treatment and fetal neurobehavioral development

Jansson

Vélez

McConnell

et al. 2017

American Journal of Obstetrics and Gynecology

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“…During maternal buprenorphine (sublingual)‐assisted therapy for opioid addiction at a mean dose of 9.3 mg/day, milk levels were 3.7 ng/mL on average, resulting in an estimated infant dose of 0.55 μg/(kg·day) (Table 1) . Other reports also indicate a similar range of milk levels and infant doses . The RID of buprenorphine based on the reported average milk levels is less than 1% to 2% of the maternal sublingual dose adjusted by the body weight .…”

Section: Opioid Use In Breastfeedingmentioning

confidence: 93%

“…49 Other reports also indicate a similar range of milk levels and infant doses. [94][95][96] The RID of buprenorphine based on the reported average milk levels is less than 1% to 2% of the maternal sublingual dose adjusted by the body weight. 49,94 Compared to infant sublingual doses for opioid withdrawal (ie, 15-60 μg/[kg·day]), 84,97 the infant exposure levels to buprenorphine in milk in those reports are also in the range of <1% to 4% of the low end of the therapeutic infant dose.…”

Section: Opioid Dependence Treatmentmentioning

confidence: 99%

Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications

Itô

2018

The Journal of Clinical Pharma

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Safety of maternal drug therapy during breastfeeding may be assessed from estimated levels of drug exposure of the infant through milk. Pharmacokinetic (PK) principles predict that the lower the clearance is, the higher the infant dose via milk will be. Drugs with low clearance (<1 mL/[kg·min]) are likely to cause an infant exposure level greater than 10% of the weight‐adjusted maternal dose even if the milk‐to‐plasma concentration ratio is 1. Most drugs cause relatively low‐level exposure below 10% of the weight‐adjusted maternal dose, but opioids require caution because of their potential for severe adverse effects. Furthermore, substantial individual variations of drug clearance exist in both mother and infant, potentially causing drug accumulation over time in some infants even if an estimated dose of the drug through milk is small. Such PK differences among individuals are known not only for codeine and tramadol through pharmacogenetic variants of CYP2D6 but also for non‐CYP2D6 substrate opioids including oxycodone, indicating difficulties of eliminating PK uncertainty by simply replacing an opioid with another. Overall, opioid use for pain management during labor and delivery and subsequent short‐term use for 2‐3 days are compatible with breastfeeding. In contrast, newly initiated and prolonged maternal opioid therapy must follow a close monitoring program of the opioid‐naive infants. Until more safety data become available, treatment duration of newly initiated opioids in the postpartum period should be limited to 2‐3 days in unsupervised outpatient settings. Opioid addiction treatment with methadone and buprenorphine during pregnancy may continue into breastfeeding, but infant conditions must be monitored.

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“…Another population that may achieve great benefit from MI for breastfeeding enhancement is the growing number of women receiving medication-assisted treatment of opioid use disorders (Substance Abuse and Mental Health Services Administration, 2013). Breastfeeding is recommended for women receiving medication-assisted treatment because it may reduce the occurrence of or complications related to neonatal abstinence syndrome (Graves, Turner, Nader, & Sinha, 2016;Jansson et al, 2016;Tsai & Doan, 2016), but breastfeeding rates are lower among women receiving medicationassisted treatment than the general population (Tsai & Doan, 2016).…”

Section: Future Directionsmentioning

confidence: 99%

“…Women attending these groups have maintained varying lengths of sobriety from substances. Women in this program taking buprenorphine (suboxone) as prescribed and who denied use of other substances were eligible for the present study, as buprenorphine is considered safe during breastfeeding(Graves, Turner, Nader, & Sinha, 2016;Jansson et al, 2016;Tsai & Doan, 2016). Further, breastfeeding is encouraged among women receiving medication-assisted treatment for opioid use disorders to reduce symptoms of neonatal abstinence syndrome(Graves et al, 2016).…”

mentioning

confidence: 99%

Prenatal Lactation-Focused Motivational Interviewing for Enhancing Breastfeeding Initiation, Exclusivity, and Duration: Feasibility and Preliminary Outcomes

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Breastfeeding promotes health and well-being for both mother and infant. A variety of environmental and individual factors, including psychological ones, affect infant feeding practices. The purpose of this study was to determine the feasibility and effectiveness of a single-session Motivational Interviewing (MI) intervention delivered during the third trimester of pregnancy for enhancing breastfeeding outcomes. The Theory of Planned Behavior provided a theoretical framework for the intervention and outcome measures. The sample consisted of predominantly rural participants living in the North Central Appalachian region. Women were recruited through social media, local clinics, and word of mouth. Participants (N = 81) completed one in-person session during the third trimester of pregnancy and one follow-up phone call at one month postpartum. All participants were randomly assigned to either the MI intervention or a psychoeducation intervention focused on infant developmental milestones. Prepost intervention outcome measures included infant feeding intentions, perceived behavioral control of breastfeeding, perceived importance of breastfeeding, infant feeding knowledge, breastfeeding attitudes and subjective norms, and knowledge of infant development. At one month postpartum, participants completed a phone interview which assessed breastfeeding initiation and current breastfeeding status. Directly following the intervention, there was a significant effect of the MI intervention on increasing breastfeeding attitudes among primiparous women only (p < .05). In addition, at one month postpartum, women in the MI group were more likely to report any current breastfeeding than women in the psychoeducation group, χ² (1, N = 79) = 4.30, p = 0.040, Φ = .233. There were no significant between-group differences on intentions, perceived behavioral control, perceived importance, subjective norms, infant feeding knowledge, knowledge of infant development, likelihood of exclusive breastfeeding at one month postpartum, total proportion of feedings that were breast milk at one month postpartum, or plans for continued breastfeeding at one month postpartum. Results of this study support the feasibility of a single-session, prenatal MI intervention. Preliminary findings demonstrate MI's effectiveness in increasing the likelihood of any breastfeeding at one month postpartum, and in enhancing breastfeeding attitudes among primiparous women. Future work in this area may benefit from implementing electronic communication to reinforce messages of MI interventions. From a public health perspective, future work in this area should target populations facing breastfeeding inequities and disparities. This trial was registered on clinicaltrials.gov NCT03033459 This project would not have been possible without the 81 women who invited me into their hearts and (quite literally) their homes to participate in this project. It was a joy and privilege to know each of them. I owe countless thanks to my mentor and dissertation chair, Dr. Dan McNeil, whom...

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Maternal Buprenorphine Maintenance and Lactation

Cited by 33 publications

References 22 publications

Maternal buprenorphine treatment and fetal neurobehavioral development

Maternal buprenorphine treatment and fetal neurobehavioral development

Opioids in Breast Milk: Pharmacokinetic Principles and Clinical Implications

Prenatal Lactation-Focused Motivational Interviewing for Enhancing Breastfeeding Initiation, Exclusivity, and Duration: Feasibility and Preliminary Outcomes

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