Opioid maintenance therapy

Emerging evidence supports the use of buprenorphine for opioid-assisted treatment during pregnancy. Generally, women who have a high risk for relapse and who have long-standing addictions to IV opiates should be referred for methadone maintenance therapy. However, women abusing oral or intranasal opioids have shown success with buprenorphine treatment.9 This medication must also be prescribed and dispensed by a specifically trained and federally waivered physician. Due to the social stigma that substance abuse entails, many women like the privacy that buprenorphine provides because it is dispensed at the physician’s office and can be combined with routine prenatal appointments and substance-abuse counseling.9 The usual dose of buprenorphine (8-16 mg daily) has been shown to be as effective as methadone (60 mg) in preventing relapse, but it is not nearly as effective as high-dose methadone (120 mg) (Table 2). Buprenorphine acts on the mu receptor and can accelerate withdrawal symptoms in opiate addicts by evicting opiates such as morphine and methadone. Patients have a typical opioid effect from buprenorphine, but it is limited by the ceiling of 24 to 32 mg, which makes lethal overdose from respiratory depression unlikely.9

TABLE 2. Medications and dosages for treatment of opioid dependence

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Drug name Constituents Supplemental variations
Methadone Methadone hydrochloride, 10-30mg Oral tablets
Suboxone Buprenorphine, 8 mg/naloxone, 2 mg
Buprenorphine, 2 mg/naloxone, 0.5 mg
Sublingual tablets & film
Subutex Buprenorphine, 8 mg and 2 mg Sublingual tablets
Buprenorphine Generic as above Sublingual tablets
Probuphine Buprenorphine, 80 mg Implant, 6-month duration
Adapted from Alto and O’Connor.9

Physician-only waivers are fundamental for prescribing all forms of buprenorphine and methadone maintenance in the treatment of addiction. Providers should be familiar with federal and state regulations for prescribing these medications. Any addiction treatment provider, whether for buprenorphine or methadone, falls under the confidentially law 42 CFR Part 2. This law has patient information release forms with specific language regarding substance abuse that should be used during all communication.3

Care and coordination

Management of opioid use in pregnancy should be a coordinated interdisciplinary team approach to include a provider who is familiar with substance abuse treatment, a pain management and maintenance treatment center, a pediatrician to treat the neonate, and nurses who are familiar with this type of treatment. For the obstetric provider, it is not necessary to refer these patients to a maternal fetal medicine specialist. Once care has been established with an addiction treatment program, care can be coordinated very easily. The decision to refer a patient should be based on physician experience, community access, and coexisting medical decisions. Providers should remember that a referral to an addiction medicine specialist should be integrated into the management plan and is not a handoff of care.1 Nurses also play a crucial role in caring for these women; they typically spend a substantial amount of time with these patients once they come to the hospital. Nurses should have a good understanding of the causes underlying drug addiction so they can potentially improve nursing care for these women and their infants. “Treating addiction as a chronic disease instead of a moral deficiency will be more supportive to women who abuse drugs because it creates an atmosphere of objectivity rather than an attitude of rationalization and justification of defiance.”10

Once maintenance therapy has been established with a methadone treatment center or with the appropriate dose of buprenorphine, the patient continues prenatal care as usual. Because methadone has been shown to reduce certain fetal behaviors, there may be an indication to perform antenatal testing. Observations have been noted of decreased fetal baseline heart rate, heart rate variability, number of heart rate accelerations, fetal breathing movements, and fetal tone. Because of these observations, it may take longer to achieve reactive nonstress tests (NSTs), and there is a higher incidence of nonreactive NST results. Reactivity is determined by the presence or absence of heart rate accelerations. NSTs show increased fetal heart variability and increased acceleration patterns in the buprenorphine-treated fetus than in methadone-treated fetuses.9 Because few studies have been conducted on this subject, no recommendations or guidelines exist on antepartum fetal surveillance. If performing NSTs or fetal biophysical profiles, it is recommended to delay the test at least 4 to 6 hours after taking the daily dosage of methadone.7