Buprenorphine for the Treatment of Perinatal Opioid Dependence: Pharmacology and Implications for Antepartum, Intrapartum, and Postpartum Care
Daisy Goodman
Abstract:Opioid dependence during pregnancy is associated with significant health risks for both the mother and her fetus. Opioid maintenance therapy with methadone (Dolophine) is the current standard of care, reduces medical and social risks associated with illicit drug use, and decreases rates of prematurity and low birth weight. However, treatment with methadone is frequently associated with neonatal abstinence syndrome. Buprenorphine is an alternative to methadone that preliminary data indicates is equivalent in sa… Show more
“…Roper and Cox summarized prenatal considerations for women with OUD in a review that highlighted the importance of pharmacotherapy treatment programs to avoid the risk of relapse and adverse effects on the fetus . Buprenorphine is generally preferred over methadone given its equivalent safety and efficacy as well as the increased ease by which the medication can be obtained . Women receiving methadone need to attend a methadone clinic daily to obtain the medication in person, whereas women receiving buprenorphine can receive a prescription to pick up multiple doses of the medication at their local pharmacy.…”
Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at-risk women through the evidence-based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors. Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.
“…Roper and Cox summarized prenatal considerations for women with OUD in a review that highlighted the importance of pharmacotherapy treatment programs to avoid the risk of relapse and adverse effects on the fetus . Buprenorphine is generally preferred over methadone given its equivalent safety and efficacy as well as the increased ease by which the medication can be obtained . Women receiving methadone need to attend a methadone clinic daily to obtain the medication in person, whereas women receiving buprenorphine can receive a prescription to pick up multiple doses of the medication at their local pharmacy.…”
Opioid misuse is a problem that is complex and widespread. Opioid misuse rates are rising across all US demographics, including among pregnant women. The opioid epidemic brings a unique set of challenges for maternity health care providers, ranging from ethical considerations to the complex health needs and risks for both woman and fetus. This article addresses care for pregnant women during the antepartum, intrapartum, and postpartum periods through the lens of the opioid epidemic, including screening and counseling, an interprofessional approach to prenatal care, legal considerations, and considerations for care during labor and birth and postpartum. Providers can be trained to identify at-risk women through the evidence-based process of Screening, Brief Intervention, and Referral to Treatment (SBIRT) and connect them with the appropriate care to optimize outcomes. Women at moderate risk of opioid use disorder can be engaged in a brief conversation with their provider to discuss risks and enhance motivation for healthy behaviors. Women with risky opioid use can be given a warm referral to pharmacologic treatment programs, ideally comprehensive prenatal treatment programs where available (a warm referral is a term used when a provider, with the patient's permission, contacts another provider or another service him or herself rather than providing a phone number and referral number). Evidence regarding care for the pregnant woman with opioid use disorder and practical clinical recommendations are provided.
“…2,3,5 Standard treatment strategies for opioid addiction during pregnancy and for NAS include opioid substitution (methadone or buprenorphine) during pregnancy and opioid replacement (morphine, methadone, buprenorphine) with the addition of clonidine 6 or phenobarbital 7 as adjunctive therapies for infants who need pharmacological treatment for NAS. A comprehensive review has been recently published focusing on these standard therapies, 8,9 hence, these standard therapies are not further discussed in this review. Instead, we focus on novel therapeutic approaches and strategies for the treatment of addiction and how these strategies may be used during pregnancy and/or for the treatment of NAS.…”
Summary
The non-medical use of prescription drugs, in general, and opioids, in particular, is a national epidemic, resulting in enormous addiction rates, healthcare expenditures, and overdose deaths. Prescription opioids are overly prescribed, illegally trafficked, and frequently abused, all of which have created a new opioid addiction pathway, adding to the number of opioid-dependent newborns requiring treatment for neonatal abstinence syndrome (NAS), and contributing to challenges in effective care in maternal and fetal/neonatal (M-F/N) medicine. The standard of care for illicit or prescription opioid dependence during pregnancy is opioid agonist (methadone or buprenorphine) substitution therapy, which are also frequently abused. The next generation of pharmacotherapies for the treatment of illicit or prescription opioid addiction in the M-F/N interactional dyad must take into consideration the interplay between genetic, epigenetic, and environmental factors. Addiction to illicit drugs during pregnancy presents unique challenges to effectively treat the mother, and the developing fetus and infant after delivery. New pharmacotherapies should be safe to the developing fetus, effective in treating the physical and psychological consequences of addiction in the mother, and reduce the incidence and severity of NAS in the infant after birth. More pharmacotherapeutic options should be available to the physician such that a more individualized rather than a one-drug/strategy-fits-all approach can be used. A myriad of new and exciting pharmacotherapeutic strategies for the treatment of opioid dependence and addiction are on the horizon. This review focuses on such three strategies: (i) pharmacotherapeutic targeting of the serotoninergic system; (ii) mixed opioid immunotherapeutics (vaccines); (iii) pharmacogenomics as a therapeutic strategy to insure personalized care. We review and discuss how these strategies may offer additional treatment modalities for the treatment of M-F/N during pregnancy and the treatment of the infant after birth.
“…Abuse of drugs such as heroin, morphine, oxycodone and other narcotic analgesics during pregnancy has significant implications for maternal and newborn health (Goodman, ). According to a 2013 report from the Substance Abuse and Mental Health Services Administration (SAMHSA),which looked at data collected from 2011 to 2012, 5.9 percent of pregnant women ages 15 to 44 used illicit substances, an increase from 4.5 percent in 2009 (SAMHSA, ).…”
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confidence: 99%
“…In addition, opiate dependence without treatment during pregnancy can lead to maternal episodic withdrawal, concurrent multiple substance use, poor antenatal nutrition and neonatal abstinence syndrome (NAS). Conversely, complete acute opiate withdrawal is not advised during pregnancy, as it may lead to maternal hypertension, maternal tachycardia (Johnston, Mandell, & Meyer, ), risk of preterm birth, placental abruption, meconium aspiration, poor fetal heart patterns and intrauterine fetal demise (Goodman, ). In addition to the maternal‐fetal complications from drug addiction, intravenous drug use increases a woman's risk of cellulitis, endocarditis, chorioamnionitis, HIV and sexually transmitted infections (Keegan et al., ).…”
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