Original Article

Prevention of Neonatal Abstinence Syndrome in an Outpatient Prenatal Buprenorphine Tapering Program

Authors: Martin Olsen, MD

Abstract

Objectives: Many addicted pregnant patients receiving buprenorphine medication-assisted therapy (MAT) wish to discontinue this medication while pregnant. This study was undertaken to determine whether outpatient detoxification from buprenorphine during pregnancy is safe and effective when confirmed with postdetoxification urine drug screens (UDSs).

Methods: This case series reports the maternal and neonatal outcomes for 21 patients who ended MAT with buprenorphine while pregnant. A retrospective chart review of both maternal and newborn electronic medical records was performed to obtain results. Newborn neonatal abstinence syndrome (NAS) diagnosis, need for morphine, maternal safety and fetal/newborn complications were assessed. Maternal sobriety was documented with UDSs at the time of admission for delivery. Umbilical cord blood also was assessed for substances of abuse. An additional 182 pregnant women who lowered their buprenorphine doses but did not decide to end MAT were assessed via routine quality assurance methods.

Results: None of the women who stopped buprenorphine during their pregnancy as confirmed by UDSs and umbilical cord sampling delivered neonates who had NAS. Eleven patients ended MAT with medical assistance and 10 ended MAT without medical assistance. No overdoses were reported for the 182 additional pregnant patients who indicated an intention to taper buprenorphine dosage while pregnant but who did not decide to end MAT; the neonatal benefits were obtained without any identified maternal harm.

Conclusions: The neonates of pregnant women enrolled in an outpatient buprenorphine MAT tapering program who are able to completely stop taking buprenorphine (as documented by negative urinary drug screen) are very unlikely to have NAS. Further research will be important.
Posted in: Pregnancy29

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Warren MD, Miller AM, Traylor J, et al. Implementation of a statewide surveillance system for neonatal abstinence syndrome. MMWR Morb Mortal Wkly Rep 2015;64:125–128. 2. Olsen M, Breuel K, Alexander C. High prevalence of buprenorphine in prenatal drug screens in an Appalachian city. South Med J 2020;113:111–115. 3. Bell J, Towers CV, Hennessy MD, et al. Detoxification from opiate drugs uring pregnancy. Am J Obstet Gynecol 2016;215:374.e1–374.e6. 4. Dashe JS, Jackson GL, Olscher DA, et al. Opioid detoxification in pregnancy. Obstet Gynecol 1998;92:854–858. 5. Luty J, Nikolaou V, Beam J. Is opiate detoxification unsafe in pregnancy? J Subst Abuse Treat 2003;24:363–367. 6. Stewart RD, Nelson DB, Adhikari EH, et al. The obstetrical and neonatal impact of maternal opioid detoxification in pregnancy. Am J Obstet Gynecol 2013;209:267.e1–267.e5. 7. Lund IO, Fitzsimons H, Tuten M, et al. Comparing methadone and buprenorphine maintenance with methadone-assisted withdrawal for the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes. Subst Abuse Rehabil 2012;3(suppl 1):17–25. 8. Wang MJ, Kuper SG, Sims B, et al. Opioid detoxification in pregnancy: systematic review and meta-analysis of perinatal outcomes. Am J Perinatol 2019;36:581–587. 9. Armstrong MA, Gonzales OV, Lieberman L, et al. Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes. J Perinatol 200;23:3–9. 10. Goler NC, Armstrong MA, Taillac CJ, et al. Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. J Perinatol 2008;28:597–603. 11. Tennessee Department of Health. Neonatal abstinence syndrome surveillance: May 2019 update (data through 06/01/2019). https://www.tn.gov/content/dam/tn/health/documents/nas/May_2019__NAS_Monthly_Update.pdf. Accessed February 21, 2020. 12. Bianchi DW, Gillman MW. Addressing the impact of opioids on women and children. Am J Obstet Gynecol 2019;221:123.E1–123.E4. 13. Terplan M, Laird HJ, Hand DJ, et al. Opioid detoxification during pregnancy: a systematic review. Obstet Gynecol 2018;131:803–814. 14. Centers for Medicare & Medicaid Services. Opioid oral morphine milligram equivalent (MME) conversion factors. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCOvCOntra/Downloads/Opioid-Morphine-EQ-Conversion-Factors-Aug-2017.pdf. Accessed October 23, 2019. 15. Committee on Obstetric Practice, American Society of Addiction Medicine. Opioid use and opioid use disorder in pregnancy Committee Opinion Number 711. Obstet Gynecol 2017;130:e81–e94. 16. Treatment of morphine-type dependence by withdrawal methods. JAMA 1972;219:1611–1615. 17. Ecker J, Abuhamad A, Hill W, et al. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019;221:B5–B28. 18. Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy: stillbirth incidence with a case report. Am J Obstet Gynecol 1973;116:1152–1156. 19. Zuspan FP, Gumpel JA, Mejia-Zelay A, et al. Fetal stress from methadone withdrawal. Am J Obstet Gynecol 1975;122:43–46. 20. Towers CV, Terry P, Rackley B, et al. Fetal outcomes with detoxification from opioid drugs during pregnancy: a systematic review. Am J Perinatol 2020;37:679–688. 21. Haabrekke KJ, Slinning K, Walhovd KB, et al. The perinatal outcome of children born to women with substance dependence detoxified in residential treatment during pregnancy. J Addict Dis 2014;33:114–123. 22. Jones HE, Heil SH, Baewert A, et al. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012;107(suppl 1):5–27. 23. Fajemirokun-Odudeyi O, Sinha C, Tutty S, et al. Pregnancy outcome in women who use opiates. Eur J Obstet Gynecol Reprod Biol 2006;126:170–175. 24. Oei JL, Melhuish E, Uebel H, et al. Neonatal abstinence syndrome and high school performance. Pediatrics 2017;139:e20162651. 25. Fill MA, Miller AM, Wilkinson RH, et al. Educational disabilities among children born with neonatal abstinence syndrome. Pediatrics 2018;142:e20180562. 26. Hunt RW, Tzioumi D, Collins E, et al. Adverse neurodevelopmental outcome of infants exposed to opiate in-utero. Early Hum Dev 2008;84:29–35. 27. Davis DD, Templer DI. Neurobehavioral functioning in children exposed to narcotics in utero. Addict Behav 1988;13:275–283. 28. Sundelin Wahlsten V, Sarman I. Neurobehavioural development of preschool-age children born to addicted mothers given opiate maintenance treatment with buprenorphine during pregnancy. Acta Paediatr 2013;102:544–549. 29. Caritis SN, Panigrahy A. Opioids affect the fetal brain: reframing the detoxification debate. Am J Obstet Gynecol 2019;221:602–608. 30. Brogly SB, Saia KE, Werler MM, et al. Prenatal treatment and outcomes of women with opioid use disorder. Obstet Gynecol 2018;132:916–922. 31. Howland RH. A question about the safety of buprenorphine/naloxone and benzodiazepine drugs. J Psychosoc Nurs Ment Health Serv 2015;53:11–14. 32. Paone D, Tuazon E, Stajic M, et al. Buprenorphine infrequently found in fatal overdose in New York City. Drug Alcohol Depend 2015;155:298–301. 33. Walker JJ, Olsen ME. Provision of buprenorphine to pregnant women by for-profit clinics in an Appalachian city. South Med J 2018;111:575–578. 34. O’Connor AB, O’Brien L, Alto WA. Maternal buprenorphine dose at delivery and its relationship to neonatal outcomes. Eur Addict Res 2016;22:127–130. 35. Jones HE, Dengler E, Garrison A, et al. Neonatal outcomes and their relationship to maternal buprenorphine dose during pregnancy. DrugAlcohol Depend 2014;134:414–417. 36. Dooley R, Dooley J, Antone I, et al. Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario. Can Fam Physician 2015;61:e88–e95.