Baby’s Buprenorphine Withdrawal

This morning I responded to a woman at SuboxForum.  Her baby was taken to the NICU for ‘withdrawal’, which is better identified as neonatal abstinence syndrome.  She said that the baby is eating well, but there is concern that the baby sleep only 2 hours at a stretch.  The baby is on morphine, and mom is wondering when they both can go home.  She is kicking herself for not trying to stop buprenorphine before the delivery.  I spent a while responding, so I decided to post my response here as well, in case a mom in a similar situation stops by.  My comments:

I have written a number of posts about neonatal abstinence, and I invite you to read a post in my blog about the guilt you are feeling.

First of all, you did the right thing.  Period.  Every medical specialist, study, or text will say the same thing:  that women addicted to opioids should be maintained on a long-acting opioid until the baby is born.  Traditionally, that opioid was methadone.  But women on methadone who are pregnant often end up on very high doses of that drug– pushing their tolerance to high levels, so that virtually all their newborns have significant withdrawal.   Of course, the babies do fine in the long run— and the experience of withdrawal is not among the worst things that a baby experiences, by far.

People see a shivering newborn and somehow imagine that the baby just ‘came to be’, at that moment. In reality, a couple hours earlier the baby was in the birth canal, squeezed so tightly that shoulders are sometimes broken, probably experiencing a sensation akin to suffocation.  I say that because while oxygen is being delivered via the umbilical cord, during deliver the cord is often compressed, causing changes in oxygen and carbon dioxide that would cause the same physiologic sensations as asphyxiation. The low oxygen tension and high carbon dioxide levels stimulate the ‘preborn’ to breathe, a hopeless challenge when the baby’s face is tightly wrapped by the birth canal!

And of course before that, the baby was upside down, getting pushed, squeezed, bounced… we picture this wonderful intra-uterine environment, but in reality we have no idea what it ‘feels like’ to the fetus.  All the things we see after the birth were before birth, except perhaps the shivering.  When the baby is born, there is no ‘on switch’ that suddenly starts recording his experiences!

As buprenorphine has become more-available, the trend has been to use buprenorphine instead of methadone.  There are several advantages– the tolerance of the mother is much lower, meaning any withdrawal in the baby will likely be less severe.  According to a number of studies, about half of babies born to moms on buprenorphine show signs of neonatal abstinence syndrome, compared to almost all babies born to moms on methadone.  Studies show no benefit to tapering buprenorphine to lower doses before delivery, but I tend to think that there must be value in doing so.  I wonder if those studies truly had good control over the doses that study subjects were taking.  My patients seemed to benefit by reducing to 4- 8 mg during pregnancy– but perhaps my impressions are biased.

Another biased impression of mine is that babies have experiences largely dictated by the sensibilities of their neonatologists.  Almost all of my patients who delivered at the local, small community hospital did great, and moms and babies went home at the regular time.  If there was any withdrawal, it wasn’t noticed.   Maybe it was treated by the buprenorphine in breast milk, because all of the mothers were encouraged to breast feed.  Nursing while on buprenorphine seems to me to be the ideal way to wean a baby off the medication; the baby’s immature liver gets better and better at metabolizing medications after birth, allowing the amount of buprenorphine in the bloodstream to decrease over time.

Hospitals with neonatologists and a neonatal ICU are going to USE those things.  The regular OB nurses in those environments tend to become less-familiar and less-comfortable with anything other than ‘normal’, and watch for reasons to send babies to a higher level of care.  Every nurse on the OB unit knows that this baby’s mom is an addict.  If the baby cries along with all the other babies, the nurses will believe that ‘this’ baby is suffering from withdrawal.  And when the baby is sleeping along with all the other babies, the nurses will think ‘this’ baby is sedated from buprenorphine.

They will transfer the baby to the neonatal ICU, where the environment makes ANY baby look sick and miserable, opioid withdrawal or not.   Just look at the environment, and all of the little ways that mom’s experience changes…. instead of smiling nurses wheeling the baby into the room, congratulating mom repeatedly in front of smiling family, you have busy, serious-faced nurses and doctors bent over charts or computers.  When they take time to talk with mom, the conversations are serious, and certain to instill guilt and fear.  The baby is attached to wires or tubes, perhaps wearing oxygen, under unnatural lighting that changes skin color from healthy-looking to some type of medical specimen.

The baby will remember none of this, just as the baby won’t remember the difficult journey down the birth canal… or the circumcision!  Rest assured that all of the pain and misery will reside completely in mom, which is probably where the doctors and nurses intend for it to go.  I realize, of course, that there are good doctors and nurses out there… but I know that when you get a group of people together, the urge to look down their noses at people with addictions often becomes too powerful to avoid.

Most important of all:  a couple years ago I did a talk for a large group of public health nurses, social workers, and AODA professionals about the impact of opioid dependence on pregnancy and on children born to women addicted to opioids.  I did an extensive literature search to prepare for the talk, and I was glad—and surprised— to find that there are NO known long-term effects on children from methadone or buprenorphine treatment during pregnancy.  There ARE problems in some children born to addicted moms, but when the studies are controlled for cigarette smoking, poor or absent prenatal care, use of alcohol, and other factors, the use of opioids has no long-term developmental impact.   That is VERY good news.