As I’ve mentioned, I was at a ’summit’ about buprenorphine in Washington DC earlier this week. I didn’t hear anything earth-shaking at the meeting, but will share a couple things that I learned there over the next few posts. The meeting itself was disappointing in that the speakers consisted largely of those with the right connections, rather than those who are working in the trenches with addicts. One particularly frustrating moment was listening to a guy from Columbia University drone on about his thoughts about buprenorphine withdrawal, after hearing that his practice has all of 30 addicts in treatment. Out here in the sticks of Wisconsin, I’ve treated over 450 people with buprenorphine over the past 4 years, and I know many other doctors who have treated similar numbers– but shucks, comin’ from Wisconsin, I guess we ain’t got the same cerdentials to know wat we’r talkin ’bout!
One night I was reviewing messages in my hotel room and I received an e-mail from a person saying that Social Services took her baby away from her at the hospital because she had delivered on buprenorphine. The baby was essentially being held hostage by the hospital under Social Services orders, and was being treated, against her wishes, with opiates to avoid opiate withdrawal. I had a patient a year or two ago who had a similar experience, where her baby was placed on a morphine drip against her wishes, after she delivered while on buprenorphine. These stories really make me angry– even angrier than I get over snobbish east-coast academics. The literature contains case reports and even studies about buprenorphine in neonates, so why would a doctor do something so foolish, as treat withdrawal from a partial agonist using a full agonist? The literature already suggests that neonatal abstinence syndrome is milder after buprenorphine than after methadone, and there are articles that have been out for several years describing the use of buprenorphine during pregnancy. So how can a neonatologist act as if the mother is doing something abusive?
One of the more interesting speakers at the buprenophine summit had preliminary data from a study of NAS (neonatal abstinence syndrome) in babies born to mothers on methadone vs. those on buprenorphine. The NAS scores that looked at infant behavior were not significantly different from one another, but the doses of PRN opiates used to treat NAS (morphine in this study) were ten-fold greater in the methadone group than in the buprenorphine group. The lesson from the study is that much lower doses of morphine are needed to block withdrawal from buprenorphine than from methadone, in neonates from mothers on the substances.
My own opinion takes things a bit further. The studies found that the NAS scores were similar in both groups. The study was blinded, i.e. the nurses who scored the amount of withdrawal did not know which substance the mother was taking. But the nurses DID know that the mothers were taking one or the other– and from experience, it is clear that mothers known to be opiate addicts are viewed with scorn from the nursing staff in the average delivery suite. I often receive messages from mothers describing varied forms of ‘tsk tsk’ every time their baby burps, even as the other babies in the nursery scream all night long. So I take the NAS scores with a big helping of salt. I suspect that once identified as an ‘addict’s baby’, the nuances of the baby’s NAS were masked by a general attitude of disdain toward the mother, and blurred by sympathy for the newborn for having been born into such a dire situation.
As this and other reports find their way to publication, one can only hope that OB teams and neonatologists will READ the publications, and realize that buprenorphine treatment does not require a report to child safety services, and does not automatically call for a week of intravenous morphine for the newborn!
Thank you for posting this information. Addiction is an epidemic in our country and pregnant women are living in fear of having their babies removed from them even when they are trying their very best to do the right thing by stopping drug use and turning to something like subutex or suboxone. The problem I see is a complete lack of support or help for these mothers. They are terrified to talk to their doctors about this because their doctors may likely report them to family services. I believe all OBs should be licensed and EDUCATED in the use of subutex for women who become pregnant and have the desire to do the right thing for their unborn baby. As it is, women oftentimes feel no other choice but to buy these meds off the street, often paying terribly high prices to get them. The meds need to be affordable and available and moms need to be monitored by their doctors without judgmental attitudes, which just causes someone who already is struggling with self-hatred and guilt to feel that much worse about themselves. Recovery works when people feel supported and cared for; not judged and condemned. Babies will be born healthier and moms will stay in recovery when these things happen. Right now.............we're NOWHERE close.