I recently heard from a person who had been told by her physician that she ‘must get off Suboxone before even thinking about getting pregnant.’  I’ve mentioned a number of times that I’ve had about 15 patients go through pregnancy and delivery on buprenorphine, and all have done well.  I encourage people thinking about pregnancy to search this blog for articles related to that topic, as there are a number of posts including some that have recent articles from the scientific literature about buprenorphine and pregnancy.

I’m writing now because I noticed that my newsfeed that carries the most recent scientific reports about buprenorphine has a number of articles about pregnancy.  You will find the newsfeed in a couple places–  at the bottom of www.addictionremission.com , my portal page to all of my sites about addiction, and also at www.bupenews.com , a site that has the feed as a centerpiece.

JJ

A reader’s question:

I have been on Suboxone for 2 years. My addiction was Oxycontin.  I had knee replacement surgery and was successfully able to take pain meds and then get off them and go back to Suboxone. My medical Doc and I noticed that when I restart the Suboxone, I get 2-3 plus pitting edema in my legs, severe enough to require diuretics– and they don’t even work very wel. When I have stopped Suboxone in preparation for surgery, I immediately lose 15 lbs and the edema goes away. My Suboxone Doc says that there are no side efffects. I am 53 and have heart disease, and I know that this extra fluid is not good for my heart. My kidneys are normal. Have you heard other comments of this nature? Is it dose related?  This is a serious situation for me.

Reply:

I have had two or three patients with similar complaints.  To put things into perspective, though, over 5 years I have treated over 400 people with Suboxone or buprenorphine.  One person in particular had very bad edema, that caused a great deal of pain in his legs– so much that he stopped the Suboxone and went back on opioid agonists.  In his case, though, the edema did not lessen on agonists and he still struggles with edema a couple years later.  I don’t know if he had edema before I met him and started Suboxone;  he claimed that the edema was a new development, but I have learned that people sometimes notice things related to their health status that differs from the perspective of an independent observer.  This is why, by the way, I don’t fully jump into agreeing with people who report tooth decay ‘that starts after starting Suboxone.’  I had a patient with that complaint, and to look into things we got a copy of his dental records;  they showed that the decay was well underway years before he took Suboxone, at least according to dental notes and x-rays.  But in his mind, it all started after the Suboxone.  The mind sometimes plays tricks on us.

When I worked as a psychiatrist in the WI prison system, women in the maximum security prison reported leg edema from many different medications.  I never knew what to make of it, to be honest.  Most of the time the medications complained about were easy to replace;  if someone felt that the Seroquel caused edema, we could change it to Risperdal.  If someone complained about Risperdal causing leg edema, we could change it to Seroquel.  It reminded me of the old Dr Seuss story about the Star-Bellied Sneetches.  I strongly recommend the story for those who haven’t read it…

I like to think in terms of mechanisms, and I don’t have a good theoretical mechanism for leg edema from buprenorphine or from naloxone.  The collection of edema in the legs usually comes from an imbalance of the natural forces that should be in equilibrium;  gravity or ‘hydrostatic pressure’ causes fluid to leak out of blood vessels into the interstitial spaces, salts in the plasma and interstitium create ‘osmotic pressure’ that becomes balanced, with a neutral overall effect on fluid movement; and proteins in the plasma cause ‘oncotic pressure’ that draws fluid back into the blood vessels.  Veins in the legs are emptied by the effects of muscles that squeeze them during walking or exercise; one-way valves prevent the blood from moving backward or standing in place during this activity.  Taking all of this into account, edema is favored during immobility, when the legs are ‘dependent’ (not elevated), when protein levels are low from malnutrition or liver failure, or when the valves in leg veins have become damaged by standing too much in life.

Preventing edema involves keeping legs elevated as much as possible, reducing salt intake, wearing support stockings, and sometimes taking diuretics or ‘water pills’ to eliminate extra fluid at the kidneys.    Opioids do have effects on a number of hormones;  there are large protein molecules that are cut into smaller pieces that include endorphin and enkephalins, the brain’s ‘natural opioids’.  Other parts of those same large molecules have effects on fluid balance, among other things– the inter-relationships are complex and not entirely predictable.

I am posting this in case others have noticed similar effects, or in case a good endocrinologist or nephrologist has a pet theory.  Anyone?

Look mom-- no neonatal abstinence syndrome!

The article below describes a presentation at a recent meeting of ACOG, the American College of Obstetricians and Gynecologists, that compared the use of buprenorphine or  methadone for treating opioid addiction during pregnancy.  I hear from pregnant women often, who write out of frustration that their OBs have never heard of buprenorphine or Suboxone and asking what they should do to educate their physicians.  Let’s hope that studies like this one help get the word out!  If you search this blog you’ll find a number of my posts about pregnancy, opioid dependence and buprenorphine.  Some of the posts include articles about neonatal abstinence, breast feeding while taking buprenorphine, and comparisons between buprenorphine and methadone.  I also recommend, of course, the forum, where you will find many other women who have already wrestled with this issue.

Buprenorphine Favoured Over Methadone for Opiate Addiction in Pregnancy

By Fred Gebhart

SAN FRANCISCO — May 19, 2010 — A recent study in Maine among women addicted to opiates has found that buprenorphine is safer for neonates than traditional treatment with methadone.

The research was presented in an oral paper on May 18 at the American College of Obstetricians and Gynecologists’ (ACOG) 58th Annual Clinical Meeting. The paper won ACOG’s Donald F. Richardson Memorial Prize.

“It has been shown that patients on methadone are more stable in terms of their physical and mental health and are more likely to receive standard prenatal care, but methadone has clear effects on the child,” noted lead author Michael Czerkes, MD, Maine Medical Center, Portland, Maine. “Buprenorphine is an attractive alternative, but there are few data on the effects on neonatal outcomes. Since our patient population uses both agents, we decided to find out.”

The key objection to methadone from the infant’s perspective is the appearance of neonatal abstinence syndrome (NAS), a combination of symptoms that include dysfunction of the autonomic nervous system, gastrointestinal tract, and respiratory system. NAS has a number of short-term consequences, including prolonged hospital stays, prolonged monitoring, and an increased need for intravenous medications. Methadone is also inconvenient for the mother, requiring daily clinic visits, and it is subject to diversion because it is a euphoric agent.

Limited data on buprenorphine suggest that it may carry less risk for perinatal morbidity, but trials have been small and somewhat contradictory. Buprenorphine can be dispensed in 30-day packaging, which eases the burden on the mother, and is less subject to diversion because it significantly less euphoric than methadone.

Researchers at the Maine Medical Center conducted a retrospective chart review of women addicted to opioids who were using either buprenorphine or methadone and who delivered their babies at the institution between 2004 and 2008. There were 101 methadone patients and 68 buprenorphine patients available for analysis. There were no significant maternal differences between the 2 groups.

The differences between offspring of mothers in the 2 groups were dramatic, said Dr. Czerkes. The mean NAS score for buprenorphine infants was 10.69 compared with 12.5 for methadone infants (P = .0012). While the difference was statistically significant, Dr. Czerkes cautioned that it might not be clinically significant.

Other outcomes were both statistically and clinically significant. Buprenorphine infants spent a mean of 8.4 days in the hospital compared with 15.7 days for methadone infants (P < .0001) and only 48.5% of buprenorphine infants required treatment compared with 73.3% of methadone infants (P < .001).

Among buprenorphine infants who needed treatment, withdrawal symptoms appeared by day 3 or did not appear at all. Withdrawal symptoms in methadone infants appeared anywhere between days 2 and 6. “That may be a clinically significant finding,” said Dr. Czerkes. “If you don’t see withdrawal in these babies by day 3, they may not have withdrawal at all.”

Overall, he concluded, buprenorphine appears to be safer for neonates than methadone. Researchers are recruiting patients for a larger randomized controlled trial.

[Presentation title: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes]

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. 

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.  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!

I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction.  I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother.  My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response.  Read on:

There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.
It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction!

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about THAT discomfort—at least not from the baby’s perspective! I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal! Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s (!), babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose!

My points are twofold, and are not intended to encourage more births of physiogically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right. Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

A person added a comment asking a question related to pregnancy. I have moved her comment/question up here:

Please help. I am confused by the information I am finding on the internet. I am on Suboxone, it will be 2 years in April ’09. I was planning on getting off Suboxone this summer — as I teach &amp; summer would be the best time to try to get off this med. The reason I am pushing to get off Suboxone right now is because I want to have a baby. And of course it would be in the best interest of the baby to be off. Here is the problem —- FIRST, I may be pregnant right now. This terrifies me because I was pregnant last November &amp; I had a miscarriage. I have one child, so I know I can be pregnant. The OBGYN said I could have miscarried for a number of reasons, it didn’t necessarily have to do with Suboxone. IF I AM PREGNANT, what should I do? I suffer from chronic pain — which is what lead me to become addicted in the first place. With Suboxone I was able to live a normal life, without a high. And so I am terrified to be WITHOUT the drug &amp; terrified to be WITH the drug. Any advice from anyone, especially any woman who delivered a child while on Suboxone would be a blessing. PLEASE, PLEASE, help me…I am terrified.

My Thoughts:

There certainly is a great deal of confusing information out there– it is concern about that mess that fuels my blogging.  Something to notice about the information– there is something about having an addictive disorder that causes people with no training to consider themselves ‘experts’.  The phenomenon is somewhat unique to addiction;  you don’t people with heart disease or prostate cancer arguing with physicians over which treatment is best– at least not in a way where the person with no medical education is putting out advice counter to the medical experts, and people are trying to decide which one to choose!  Then again, you don’t see patients with heart disease who are managed medically get their undies in a bundle over the fact that some other patients are being managed surgically!  Only with addiction do we have both of those things– 1.  An intense nosiness of some people about the treatment choices of others;  and 2. People with no training in addiction treatment, no years spent learning about how the mind works;  no education or research into mechanisms of tolerance at the receptor level…  who based on their own (often limited) sobriety feel confident enough about their knowledge to make recommendations to others.  Intrusiveness and ignorance–  THAT’S a dangerous combination if there ever was one!

Anyone see The Apprentice tonight?  Wow– Trump doesn’t like drunk drivers very much, does he?  I was in a bookstore the other day and I browsed through one of his books– he has a bunch of them, but they are all pretty much the same– this one called ‘Think big and KICK ASS!’ I’ll confess to something… one of the reasons I looked though it is because of the comments that I sometimes receive on this blog.  A person wrote the other day something I considered helpful– he wrote that I seemed to take another person’s comments about Suboxone personally.  One thing I have learned as a psychiatrist:  a person cannot figure himself out, no matter how smart or insightful or deep he may be.  If you want to understand yourself– REALLY understand yourself– you need to listen to others, and to accept what others are saying.  At least when you hear it more than once, anyway.  The writer was correct;  I do take the comments personally… and that bothers me.  If anyone is an expert with Suboxone and opiate dependence, it should be me– (geez, I get a bit uncomfortable saying that).  After the person’s comments about taking things ‘personally’ I realized that it is tough to be an expert;  people always take shots at the person who takes a stand, whether the stand is based on facts, morality, idealism… if you are going to ‘put it out there’, people are going to try to cut it off.  Gosh, this is running on forever….  OK– I read Trump’s book because I wondered how he ‘feels’ about all of the stones thrown his way.  No, I am no Trump!  But reading his book I realized that the awkward, lonely feeling of being an ‘expert’ happens to other people as well, and the way Trump recommends dealing with them is to just talk LOUDER, assert your expertise more STRONGLY, and GET EVEN– ALWAYS!

I would never be able to pull all of that off… but I will try to let things roll off my back a bit more.  I’m not sure whether it is good advice to keep boasting about one’s expertise;  it works for Trump, but he has become a bit of a caricature of himself.  Plus there can only be one ‘Trump’!

Sorry about going on a bit.. So, why is it that addicts tend to act like ‘experts’?  I think a big reason is that addicts are playing doctor all the time, when they are using!  No addict ever reads the instructions on a bottle of pain pills– sometimes I will tell a patient to ‘take the pills as they are prescribed– as written on the bottle’ and the person acts as if the concept has never occurred to him!  This brings us to a point about ‘getting better’ on Suboxone, or in Recovery without Suboxone:  you must stop treating yourself as your own physician.  Even doctors must stop playing doctor on themselves.  This is a boundary critical to sobriety;  once a person starts to treat himself, he is on a slippery slope that leads back to using– eventually if not right away.  But back to the point of the original question:  as to the confusing mass of information and the contradicting comments across the web, I strongy recommend that you screen out the medical comments made by people who are not trained in medicine.  That’s not to say that a person’s experiences are not useful;  but often the experiences are translated into comments that are simply silly.  Whenever you read anything about ‘endorphins coming back to normal’ or needing ‘amino acids to remake neurotransmitters’, you are reading nonsense.  I have a PhD in Neurochemistry, and I can tell you with complete certainty that WE HAVE NO IDEA what ‘endorphin levels’ do during addiction, especially at the synapse, where all of the action occurs.  Yes, I could come up with a neat story about what they ‘might’ do… but when I do that, I will try to say ‘this is all just made up on my part’.  Unfortunately the people who know the least seem to make up the most complicated, detailed stories– and act the most certain about them!

I will take on the pregnancy issue in my next post, since I wasted the night with this other stuff.  I don’t want to simply repeat myself though, so please search the blog for ‘pregnancy’, as there are a few posts already.  One of the posts includes several articles about having babies while taking Suboxone.  A couple quick points:  the least safe thing is to be on nothing, and relapse once or several times, exposing the baby to several drugs and possibly to hypoxia or toxins.  The safest thing is to be in solid recovery, off all medications.  Somewhere in the middle like buprenorphine and methadone.  I have seen no published evidence (or anecdotal evidence) for miscarriage caused by buprenorphine or naloxone.  I have had six patients who were on Suboxone throughout their entire pregnancies;  the only sigificant problems were related to fear on the part of uneducated doctors– by that I mean doctors who should have/could have read up on buprenorphine ahead of time, and didn’t,  and so they treated the newborns as if they had been born to mothers on methadone– despite evidence that the NAS (neonatal abstinence syndrome) is much more mild with buprenorphine.

Finally, in the right sidebar you will see a list of news stories about Suboxone, including one relating to pregnancy;  I might write about the article at some point as an example of a very bad ‘study’ in a throw-away journal.  There is no randomization, no control group– a subset of 15 babies are described, out of a patient population of 150… with no description of why they chose THOSE babies.  There are also many confounding factors– for example, the fact that many of the babies were in special education later in life– we know nothing about their addict-mothers, their upbringing, their nutritional status, whether they were physically abused, etc.  One can always find data to support a certain position– particularly if there is no need to explain where the data comes from!

I do recommend that women trying to become pregnant or who are pregnant change from Suboxone to Subutex;  we don’t know of danger from the naloxone, but it is always good practice to expose the baby to as few drugs as possible, and since Suboxone and Subutex work in an identical fashion there is no reason to stay on Suboxone.

More later…

SD/SuboxoneTalkZone.com

I received an e-mail today related to an article I had placed on a different web site about using Suboxone during pregnancy:

My son was born November 19th 2008 and is still in the hospital because the mother is on Suboxone. He has tremors, has trouble sleeping and is excessively strong and ‘tight’. The doctors placed him on methadone to treat these symptoms and they are weaning him off the methadone. It is a very emotionally frustrating, confusing and strained time for us all. I see the side effects of the Suboxone and they are real and do happen. For more info. on my case email me. I would be happy to fill you in on more. I am dealing with it right now.

I am frequently frustrated by the lack of knowledge about Suboxone among physicians;  the manufacturer of Suboxone sponsors educational seminars and courses, but doctors tend to see addiction as something other than a fatal illness that deserves their best efforts.  In just my own collection of patients I have had several encounters with physicians who were literally just ‘guessing’ over their management of patients on Suboxone;  they weren’t reading the literature (which there is plenty of), they weren’t asking for consultation from other doctors (who would guess that doctors have egos!); and worst of all, in some cases they were treating the patients on Suboxone with patronizing or disdainful attitudes.

Methadone is harder for newborns to kick than Suboxone.

As a Suboxone patient you bear the burden of educating yourself and perhaps educating your physician.  Do not assume that every doctor knows what he or she is doing in regard to buprenorphine;  you may want to seek second opinions, particularly if your doctor recommends something that isn’t consistent with what you have learned about the actions of Suboxone and buprenorphine.

My response to the e-mail about the newborn with tremors:

Thank you for writing, and I am sorry about your son.  I don’t know how you will take what I am about to say, but I am not interested in an argument so please don’t reply with one—I would not read it even if you did, as the issue is your son—not my opinions.

For your own interest, and for your own concerns taking care of your son and finding your son the best care, understand that there is a vast amount of information on buprenorphine, the active ingredient in Suboxone.  Unfortunately, there are also more and more examples of improper diagnosis and care related to doctors not knowing enough about buprenorphine.  I have seen a number of mistakes made by physicians because of their lack of knowledge about buprenorphine, including mistakes by obstetricians and neonatologists.  I don’t know where your son is, but to be frank, their use of methadone to treat ‘Suboxone withdrawal’ is so improper that I have to think that your son is not where he should be.  I am sharing some articles with you that will likely make you more knowledgeable than your son’s doctors;  I encourage you to read and learn about buprenorphine so that someone can lobby for proper treatment of your son.

I am someone who does know about buprenorphine;  I have worked with it for over 10 years, and buprenorphine has been around for over 30 years.  In fact, before epidurals buprenorphine was used to treat pain DURING LABOR, as it doesn’t carry the same risk of respiratory depression as other opiates.  So understand that buprenorphine has been used for years as a ‘good medication’ for treating pregnant women in labor.  It is NOT a ‘new drug’—only the patent and formulation are new.

I keep current in the literature about buprenorphine and Suboxone.  There are a number of articles that provide information about the medication, although simply understanding the typical actions of opiate agonists and antagonists is sufficient to understand that it makes no sense to treat Suboxone withdrawal with methadone.  You can read the articles, but one pertinent conclusion from the review article is:

“

From these reports it appears that buprenorphine use during pregnancy induces a more mild withdrawal syndrome in neonates, when compared with methadone.

From another of the attached papers:

Regarding Subutex and buprenorphine:  it does not seem to be teratogenic in humans or animals. Administered in monotherapy form as Subutex, it has been used successfully in opioid-dependent pregnant women as a maintenance replacement opioid.  A 2003 review of the available clinical studies has been published covering approximately 300 pregnancies. Compared with methadone, a lower incidence of NAS (neonatal abstinence syndrome) has been reported in buprenorphine-exposed neonates. The severity of NAS is reduced as assessed by total opiate required to treat and length of hospital stays. Some data suggest that the placental transfer of this opioid may be limited in comparison with others, such as methadone, thereby limiting fetal exposure and the development of dependency. Deshmukh and colleagues have demonstrated that a large proportion of buprenorphine is metabolized to Norbuprenorphine, the only metabolite formed as determined by high-performance liquid chromatography and mass spectrometry, by placental aromatase (CYP 19) within the microsomal fraction of the trophoblast.

From the attached case report:

If methadone cannot be withdrawn before birth, mild to strong withdrawal signs in the newborn are frequent.4 The present case suggests that buprenorphine might be considered for the treatment of pregnant women addicted to heroin because (1) it does not induce teratogenic or embryotoxic effects in animals, (2) it apparently induces only a weak withdrawal syndrome in the newborn, and (3) the dose absorbed through maternal milk is negligible.

I don’t know the cause of your son’s tremors, but I strongly doubt they are related to the mother’s use of Suboxone or Subutex.  Attributing the tremors to those medications would require tossing out all of what we know about the medications—which is a large amount of data.  One thing that we absolutely DO know is that methadone causes a much greater ‘abstinence syndrome’ than does buprenorphine—and so if anything, the tremors are likely due to the methadone withdrawal!  Since neither buprenorphine nor methadone harm the fetus, however, I would be most concerned that your son’s doctors are doing what is unfortunately typical—focusing on the buprenorphine since it is something they don’t know enough about, and perhaps overlooking the real cause of your son’s tremors.  I encourage you to print and share the attached papers with your son’s doctors.

SuboxDoc

The papers I mentioned in my message:

Elkader A and B Sproule. Buprenorphine: Clinical Pharmacokinetics in the Treatment of Opioid Dependence. Clin Pharmacokinet 2005; 44 (7): 661-680.

Marquet P, J Chevrel, P Lavignasse, L Merle, and G Lachltre. Buprenorphine withdrawal syndrome in a newborn. Clinical Pharmacol Ther 1997; 62(5): 569-571.

Helmbrecht G, and S Thiagarajah. Management of Addiction Disorders in Pregnancy. J Addict Med 2008; 2: 1–16.

]]> http://suboxonetalkzone.com/suboxone-buprenorphine-and-opiate-withdrawal-in-newborns/feed/ 2 http://suboxonetalkzone.com/suboxone-vs-subutex-where-did-the-high-go/ http://suboxonetalkzone.com/suboxone-vs-subutex-where-did-the-high-go/#comments Sun, 07 Dec 2008 04:24:54 +0000 SuboxDoc http://suboxonetalkzone.com/?p=835

A bit of confusion over how Suboxone and Subutex work:

Subutex gave me a strong buzz during detox…After a year of being on suboxone (which completely suppressed any high the buprenorphine might give, which it did) and being switched back to subutex, one might think subutex would give me that feeling again, with the naloxone being out of my body and all. Is it a matter of tolerance? I’ve been told that tolerance is reset by naloxone…I just don’t know what the real cause is here. I’m on straight subutex, 8mg and the magic is gone. perhaps…forever? Let me know if you have any clue, or if it is just tolerance. (email me at vespafly@gmail.com

My Response:

Suboxone and Subutex are interchangable;  there is no difference between the subjective experiences of them, save for the lack of flavoring in Subutex and the ‘fruity flavor’ of Suboxone.  The naloxone in Suboxone is not absorbed from the mouth, and the naloxone that is absorbed from the intestine is broken down very efficiently by the liver, so that very little gets into the systemic circulation.

The effect one has to the initial dose of buprenorphine, whether it comes from Suboxone or from Subutex, depends on the person’s level of tolerance.  If a person has a very high tolerance, he will feel withdrawal.  If the tolerance is very low, the person will feel a ‘high’.  In either case, they will adjust to the dose of buprenorphine within a few days and feel normal.  In the case of the person who initially felt a buzz, the person becomes tolerant to the buprenorphine;  in the case of the person who felt withdrawal, the person ‘recovers’ from withdrawal as his opiate receptors adjust to the reduced level of opiate stimulation.he

To answer your question, the tolerance is what took away the ‘high’ you got from the initial dose of Subutex.  It had nothing to do with changing to Suboxone, and would have occured in the exact same way had you stayed on Subutex.  A person who is not opiate-tolerant will get a significant opiate effect (I hate to use the term ‘high’, but I guess the term is correct) from the initial dose of Suboxone or Subutex– but it will only last for a day, or maybe two at the most.  Buprenorphine has a very long half-life, so there is no significant drop in the blood level from that first dose to the next– and the constant opiate stimulation from a drug with a long half-life results in the very fast development of tolerance.

I have had a number of patients switch from Suboxone to Subutex and vice versa, sometimes a couple times (in the case of women who take Suboxone, but who change to Subutex during pregnancy to avoid the naloxone).  They have no change in how they feel;  in both cases the buprenorphine is the active substance, and since the dose is the same I would not expect them to feel any difference between the two medications.

As far as ‘naloxone resetting tolerance’, for naloxone to have an effect on human opiate receptors it would need to be given IV or IM, where it can be absorbed sufficiently.  The medication ‘Naltrexone’, on the other hand, is an opiate antagonist similar to Naloxone except for being active when taken orally.  When a person takes Naltrexone, the opiate receptors are blocked;  the neurons with the opiate receptors therefore react as if they are not receiving any input through the receptors.  In response to the lack of input the neurons up-regulate the receptors so that they are more sensitive to stimulation by opiates, which translates into a decrease in tolerance.

I understand your comment about the ‘magic’, but I don’t agree with it.  The ‘magic’, in my opinion, is the ‘normal’ feelings induced by buprenorphine.  After that first couple days patients taking Suboxone feel like non-addicts, and that is what makes it such a ‘magical’ medication.  That other feeling– the high from opiates– is only a small part of the true feelings induced by opiates– and you can’t have one without all the others.  In other words, yes, opiates give a warm, euphoric feeling… but also give an equal or greater amount of depression, fatigue, and bone-chilling coldness.  In the balance, there is no net ‘good feeling’– there is as much or more misery for every amount of ‘magic’.  Addicts stuck in a using pattern tend to see the OC or other opiate with ‘euphoric recall’, remembering only the tiny pleasant part of using, and ignoring the huge amount of misery associated with using.  I encourage addicts doing the work of staying clean to ‘bring the memory full circle’; with every pleasant recollection, be sure to think about where the use took you, and where the pleasant sensations ended.  Keep the memories attached to each other, because in reality they are not separable.

SD

SuboxoneTalkZone

A comment from an anesthesiologist:

As a practicing anesthesiologist I can only reiterate that communicating with your doctors is key. I have yet to have a patient on Suboxone or their primary doctor contact me prior to surgery. I have had to cancel cases because nothing was done with the Suboxone dose prior to surgery. This is a simple fix as long as you communicate with your anesthesiologist ahead of time. I think a lot of this has to do with a lack of knowledge in the primary care arena about Suboxone.  Eric Swetland MD

Response:

Thanks Dr. Swetland for your comment.  As a former anesthesiologist I try to get patients to plan ahead and foster communication with me, the surgeon or OB, the anesthesiologist… but it still is often left for the morning of surgery.  One of my patients had a C-section a couple months ago– she told her OB to call me and I called once and left a message, but he did not call until the morning of her stat c-section, after the case was done and she was writhing in pain in the recovery room as her SPINAL wore off.  He asked what he should do, and I said ‘an epidural would have been nice….’.  I ended up recommending that they put her in the ICU and give her mega-doses of narcotics, and that is what they did.  She was fine, but an epidural would have allowed greater comfort and less expense.

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Another patient had a vaginal delivery of a healthy baby;  the hospital, though, was not ‘comfortable’ with Suboxone and so a neonatologist was involved.  The patient begged him to call me–  I did not know at the time that this was going on– but he told her that ‘he knew what he was doing without calling some other doctor’ (oh, the ego!).  Against her wishes he put her baby on a morphine infusion to treat withdrawal;  the nurses were curt and rude, a couple making statements to assure she felt guilty about her baby’s ‘withdrawal’.  The nurses gave a number of conflicting statements about her wish to breastfeed her baby while taking Suboxone.  Afterward she told me that her baby looked like all the other babies before the morphine and after it was finally stopped– didn’t cry more, sleep less, etc… and I shared articles with her about the fact that newborns of Suboxone-using moms show minimal if any signs of withdrawal, and that breastfeeding is fine and results in no significant buprenorphine exposure for the infant.

I had a 67-y-o patient sent home from the ER after going in with a temp of 102 degrees F and sharp pains in the side of his chest– the doc told him ‘it was probably from the Suboxone’!!  I told him to go back, and I called the ER and told them it was NOT the Suboxone– they did x-rays this time and diagnosed his pneumonia!

Doctors have a bad habit of blaming symptoms on things they don’t know much about;  patients have their own problems by keeping their use of Suboxone to themselves, too embarassed to let their doctors know about their use.  I encourage everyone to communicate– this is a new drug and new paradigm, and it is important that everyone knows what they are dealing with.  OK… so much for the soapbox…

SD

Suboxone Talk Zone

I just saw a keyword from Albany NY: suboxone and epidural.  I presume this is a pregnant woman anticipating labor who is taking Suboxone.  I have had several patients deliver babies while on Suboxone;  two by C-section and one by vaginal delivery.  I also was an anesthesiologist for ten years before my opiate addiction took that away.  I miss it from time to time– it was a fun job.  The pace was perfect for my personality;  relax, relax, relax, TERROR, TERROR, relax, relax…  OK maybe it wasn’t good for me… but it was fun.  And I loved doing labor epidurals, as everyone loved me when I showed up– the women in labor, the OB nurses, the obstetrician (who could go back to bed)… even the husband, who could get some sleep as well (but only after the wife dozes off first).

As far as Suboxone, first understand that it is possible to do an epidural without using any opiate at all, and being on Suboxone doesn’t have to be a problem.  During labor for a vaginal delivery or during a C-section, either by general or by epidural (or spinal for that matter) the Suboxone is not a problem.  Yes, usually a very small amount of fentanyl is added to the infusion of and epidural and is given IV after the baby is born in a C-section.  But those steps are not critical.  In fact, my own wife hated epidural narcotics, as they always made her itch terribly, so she asked to keep them out for her last delivery.

I’ll talk about the things that are not a problem first.  It is not a problem to take Suboxone while breast feeding.  The only potential problem is that you will run into a militant breast feeding advocate who makes you feel guilty about the whole thing.  I did a literature search on the topic and found several papers for it, and one against it.  To summarize, a very small fraction of buprenorphine is excreted in breast milk;  the baby drinks the milk, and the suboxone quickly passes the mouth (skipping absorption there) and going to the stomach, duodenum, and liver.  The liver destroys almost all of the buprenorphine, as it does in adults.  For the sake of purity I do suggest using subutex at this point so that the baby is only exposed to one mosty harmless drug, instead of to two mostly harmless drugs.  In the papers I dug up there were no reports of babies becoming sedated or drugged after breast feeding from moms on Suboxone.

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Now, the problems…  it can be difficult to get good pain control in a person who dosed Suboxone on the morning of surgery.  One of my patients had it all set, to stop three days in advance… but then she had an immediate section a couple hours after dosing with 8 mg (I DO tend to reduce the maintenance dose from 16 to 8 mg in people close to surgery for this very reason;  it is half as hard to get pain relief after one pill than after two.  I was called after the surgery was over and she was in the recovery room.  They had done a spinal… my first comment was that ‘an epidural would have been nice, as we could have run dilute local anesthetic through it post-op with dilute bupivicaine to treat her pain, and it would have worked well. Since they didn’t do an epidural we ended up transfering her to the ICU, where they could keep her on oxygen monitorin and dose her with huge doses of morphine– 20-30 mg at a time.  The better way would be to stop the buprenorphine three days in advance, or at LEAST cut down to a very low dose, say 2 mg per day, and nothing on the day of surgery.  Remember, agonists will ‘out-compete Suboxone at the receptor if you have enough  of it there.

Talk to your anesthesiologist before hand.  They can be hard to find, and they don’t take ownership of cases until the last minute, but try to find on and ask him or her to do your case.  Pick the one that talks opently to you, as some anesthesiologists can be odd ducks.  Don’t let the Suboxone thing get you all worked up, and keep your focus on the wonderful new member of the family.  And it really is wonderful.

This final part is the worst part.  You might be judged, and that would be a shame, but some nurse might peg you as the ‘addict mom whose baby is withdrawing’.  First, remember that ALL babies cry.  Second, remember that YOUR experience with withdrawal is nothing like the baby’s experience.  Withdrawal is not all that painful– it is suffereing that we don’t like, not pain per se.  Think about it– we feel guilty, sad, low, we feel jealous of people who are still using;  we feel mad at ourselves for not arranging things better.  The baby feels NONE OF THIS.  Not only that, your baby just squeezed through a tunnel so tight that they had to pull on his head to get him out of there.  He was gasping like mad, using fluid-filled lungs, trying to catch his breath.  So if he is crying too much, or not crying enough, or too hungry, or not hungry enough (you get the idea) give yourself a break and just ignore what people say.  Your baby is fine;  don’t treatment him like a medical specimen.  All of the data we have shows no problems with babies born to mothers on Suboxone.

SD
Suboxinfo.com
telemedpsychiatry.com