Buprenorphine treatment of opioid‐dependent pregnant women: a comprehensive review

Abstract

Aims This paper reviews the published literature regarding outcomes following maternal treatment with buprenorphine in five areas: maternal efficacy, fetal effects, neonatal effects, effects on breast milk, and longer-term developmental effects. Methods Within each outcome area, findings are summarized first for the 3 randomized controlled trials and then for the 44 non-randomized studies (i.e., prospective studies, case reports and series, and retrospective chart reviews), only 28 of which involve independent samples. Results Results indicate that maternal treatment with buprenorphine has comparable efficacy to methadone, although difficulties may exist with current buprenorphine induction methods. The available fetal data suggest buprenorphine results in less physiologic suppression of fetal heart rate and movements than methadone. Regarding neonatal effects, perhaps the single definitive conclusion is that prenatal buprenorphine treatment results in a clinically significant less severe neonatal abstinence syndrome (NAS) than treatment with methadone. The limited research suggests that, like methadone, buprenorphine is compatible with breastfeeding. Data available thus far suggest that there are no deleterious effects of in utero buprenorphine exposure on infant development. Conclusions Buprenorphine produces a less severe neonatal abstinence syndrome than methadone, but there is still a role for methadone in the treatment of opioid dependence during pregnancy.

Life after Addiction—Post-Operative Pain Management in an Obstetrical Patient on Long-Term Buprenorphine Therapy

“…As the rates of addiction and subsequent recovery increase in reproductive-age females, obstetricians can expect to encounter increasing numbers of patients who will require screening and treatment, with particular attention to pain management becoming a necessity. While methadone has long been the standard maintenance medication for opiate addiction in pregnancy, use of buprenorphine has increased [7]. The increasing frequency with which buprenorphine has been chosen as a maintenance medication is likely due to a combination of factors, including patients' ease of use in the form of tablets and films that can be prescribed with several doses at a time rather than a single dose dispensed, and increased access through private offices rather than through addiction centers [7].…”

“…The increasing frequency with which buprenorphine has been chosen as a maintenance medication is likely due to a combination of factors, including patients' ease of use in the form of tablets and films that can be prescribed with several doses at a time rather than a single dose dispensed, and increased access through private offices rather than through addiction centers [7]. In addition, buprenorphine acts as a partial mu-opioid agonist and kappa-antagonist with lower intrinsic affinity than methadone against the mu-opioid receptor, thus reducing peak effect and creating a plateau-this makes the risk for overdose death lower with buprenorphine than methadone [7]. Buprenorphine has a longer duration of action than does methadone, making it an attractive choice for patients requiring several doses daily [7].…”

“…In addition, buprenorphine acts as a partial mu-opioid agonist and kappa-antagonist with lower intrinsic affinity than methadone against the mu-opioid receptor, thus reducing peak effect and creating a plateau-this makes the risk for overdose death lower with buprenorphine than methadone [7]. Buprenorphine has a longer duration of action than does methadone, making it an attractive choice for patients requiring several doses daily [7]. With the MOTHER study by Jones et al demonstrating potential reductions in the severity of NAS in infants born to mothers maintained on buprenorphine, a strong possibility exists that women already maintained on buprenorphine prior to pregnancy will continue to remain on the drug during pregnancy rather than being converted to methadone [7] [10].…”

“…In obstetrical patients, maintenance on methadone is considered the standard of care. However, recent evidence suggests maintenance on buprenorphine in pregnancy may decrease the severity of NAS [7]. Buprenorphine maintenance presents a unique challenge in pain treatment secondary to the high affinity of buprenorphine for the mu opioid receptor, presenting competition for binding sites with opiate painkillers [8].…”

Neonatal Abstinence Syndrome

“…[32][33][34][35][36][37] Buprenorphine, a semisynthetic partial m-opioid receptor agonist and a complete k-opioid receptor antagonist, has been found to be equally safe and efficacious and has become an effective alternative to methadone for opioid dependency during pregnancy. [38][39][40] Multiple studies demonstrated that buprenorphine maintenance treatment in pregnancy is either comparable or superior to methadone treatment with regard to NAS; however, these studies were observational, retrospective, or small (Supplemental Table 5). [41][42][43][44][45][46][47][48] A larger prospective randomized study favored buprenorphine over methadone with regard to the doses and durations of morphine treatment and lengths of hospital stays, but not the incidence nor the severity of NAS.…”