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!