Methadone versus buprenorphine for the treatment of opioid abuse in pregnancy: science and stigma

Abstract

The past decade has seen an increase in rates of opioid abuse during pregnancy. This clinical challenge has been met with debate regarding whether or not illicit and prescription opioid-dependent individuals require different treatment approaches; whether detoxification is preferable to maintenance; and the efficacy of methadone versus buprenorphine as treatment options during pregnancy. The clinical recommendations resulting from these discussions are frequently influenced by the comparative stigma attached to heroin abuse and methadone maintenance versus prescription opioid abuse and maintenance treatment with buprenorphine. While some studies have suggested that a subset of individuals who abuse prescription opioids may have different characteristics than heroin users, there is currently no evidence to suggest that buprenorphine is better suited to treatment of prescription opioid abuse than methadone. Similarly, despite its perennial popularity, there is no evidence to recommend detoxification as an efficacious approach to treatment of opioid dependence during pregnancy. While increased access to treatment is important, particularly in rural areas, there are multiple medical and psychosocial reasons to recommend comprehensive substance abuse treatment for pregnant women suffering from substance use disorders rather than office-based provision of maintenance medication. Both methadone and buprenorphine are important treatment options for opioid abuse during pregnancy. Methadone may still remain the preferred treatment choice for some women who require higher doses for stabilization, have a higher risk of treatment discontinuation, or who have had unsuccessful treatment attempts with buprenorphine. As treatment providers, we should advocate to expand available treatment options for pregnant women in all States.

Methadone or buprenorphine? The choice of substitution therapy in pregnant opioid dependent women

“…There are also first reports of possible transferring from methadone to buprenorphine during pregnancy [63], though this is not the practice in standard substitution therapy. Methadone continues to be the preferred choice of treatment in women, requiring higher opioid doses to maintain homeostasis of the body and implying a greater risk of treatment interruption or for those for whom treatment with buprenorphine failed [64].…”

Causal Analysis in Evaluating Complex Health Interventions: Identifying the Optimal Treatment for Opioid Abuse in Pregnancy

“…Since 1998, methadone has been the pharmacologic standard for treating opioid use disorder(OUD) in pregnancy . In 2002, the Food and Drug Administration approved buprenorphine for the treatment of OUD . As a partial agonist, it has a better safety profile and is associated with lower rates of NAS among opioid‐exposed infants .…”

“…Furthermore, since buprenorphine can be provided by prescription in an office‐based setting, it allows pregnant women to overcome barriers to treatment in addition to avoiding the stigma implied by daily visits to a methadone clinic. Buprenorphine is not, however, appropriate for all women, particularly those with significant tolerance, as its ceiling effect may preclude stabilization …”

“…7 In 2002, the Food and Drug Administration approved buprenorphine for the treatment of OUD. 8 As a partial agonist, it has a better safety profile and is associated with lower rates of NAS among opioid-exposed infants. 9 Furthermore, since buprenorphine can be provided by prescription in an office-based setting, it allows pregnant women to overcome barriers to treatment in addition to avoiding the stigma implied by daily visits to a methadone clinic.…”

“…Buprenorphine is not, however, appropriate for all women, particularly those with significant tolerance, as its ceiling effect may preclude stabilization. 8 An issue unique to the management of OUD in pregnancy is the need to balance risks and benefits to the mother and her infant. In this issue of the journal, Lemon and colleagues examine the role of preterm birth as a potential mediator of the association between medication-assisted treatment (MAT) and NAS.…”