Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone

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.


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

Please like & share:

7 thoughts on “Suboxone and Epidural Anesthesia; pregnancy, delivery, and C-sections on Suboxone”

  1. 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

  2. I HOPE A MOTHER WHO IS PRGNANT OR BREASTFEEDING WHILE TAKING SUBOXONE CAN READ THIS AND FIND PEACE OF MIND. DONT FRET LIKE I DID. THE STESS ALONE ALOMST KILLED ME. I WAS SNEAKING THEM FROM MY BOYFRIEND WHO THOUGT I HAD QUIT COLD TURKEY. I DIDNT TELL ANYONE AND ALMOST HAD AN ANXIETY ATTACK EVERY TIME I PUT A PEICE UNDER MY TOUNG. I FOUND THIS BLOG, THAK YOU SOOO MUCH FOR WRITING IT I WISH I WOULD HAVE FOUND THIS WHILE I WAS PREGNAT. THERE ARE NOT ALOT OF PREGNAT WOMEN WHO JUMP ON LINE AND EXCLAIM THEIR DRUG ADDICTION. I WISHE THEY DID. SO I AM. MY LITTLE GIRL HAS NO SIDE EFFECTS NO WITHDRAWL. I BREASTFED, NO DIALATED PUPLIS, NO HARD STOOLS, AND NO NAUSIA LIKE ME. SHE WAS HAPPY GAINIG WEIGHT AND OVER ALL IN GOOD HEALTH. I WORRIED ABOUT WHEN I HAD TO GO BACK TO WORK. WOULD SHE WITHDRAWL? SHE DIDNT, SHE WAS FINE, THANK THE GOOD LORD. I WANT TO SAY AGAIN TO THE WRITER OF THIS BLOGG YOU HAVE MADE ME FEEL LIKE A GOOD PERSON AGAIN. THIS IS MY SECOND TIME ON THIS BLOG. I FIRST FOUND IT THE DAY IT CAME OUT. I BROUGHT MY FRIEND WHO IS NOW GOING THROUGH THE SAME. I HOPE IT HELPS ALL THESE OTHER GOOD PEOPLE OUT THERE WHO NEED THE REASSUANCE, THAT YOU ARE DOING THE RIGHT THING, THE BEST THING FOR YOU BABY vs THE OPIATE.

  3. 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 & 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 & 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 & 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.

  4. Great blog – very interesting and helpful

    I’m a maternal fetal medicine doc who’s new to the use of buprenorphine in pregnancy instead of methadone. I’ve recently had a patient who’s in her third trimester – 34 weeks – and is on 8 mg/day of Subutex.

    I’ve read what I could find on buprenorphine, though there is little in an organized format regarding total pregnancy care.

    Can you please give your comments on the below points ??

    1. Early/mid pregnancy care – assuming that switch to methadone is not an option. Given overall smallish amount of pregnancy-related data, wise to use lowest effective dose – makes sense to decrease fetal exposure as long as mom is effectively treated, though smaller doses don’t necessarily mean lower rate of NAS (similar to methadone data).

    2. Prior to elective delivery (by induction or cesarean), wean dose to off – preferably for 24 + hours. (I’d imagine that long half-life should keep WD symptoms at a minimal).

    3. Pain control with epidural (with vaginal delivery or cesarean). Ideally anesthesia consult (and NICU) prior to delivery.

    4. Post vaginal delivery – Restart Buprenorphine – Suboxone SL. Standard NSAID/Tylenol therapy for pain control.

    5. Post cesarean delivery – Keep epidural in place for as long as possible – dilute local anesthetic. Restart Buprenorphine – Suboxone SL. NSAIDS/Tylenol as above. IV/PO narcotics as needed – though dosing may be difficult to figure out.

    6. Breastfeeding probably okay with Suboxone.

    Thanks

    Peter

  5. I know this is an old post, but I really feel like I should add my experience in case other pregnant women find this site. Im 28 years old and just had my 3rd baby 11 days ago. I was on suboxone during the entire pregnancy and stressed really bad that soemthing would be wrong with my daughter due to my sub use. I havent had a drug since March 2008 and have been on subs since that date. It has worked wonders for me. Just the fact that I havent had a relapse in all this time is HUGE for me. So anyway….due to personal reasons I didnt tell the doctors I was on subs. I planned on getting off of it on my own before my due date. After several attempts to do so, I gave in and took my last dose the morning before my scheduled csection. My daughter was born weighing 7lbs. 3 oz. and was withdrawal free!! I have watched her very carefully and havent seen a single sign of anything. She is just as healthy and alert as my first 2 kids that were born drug free. I spent 9 months stressing like crazy for something that I shouldnt have. Im not recommending that anyone do it the way I did. Its always best to work with your doctor in a situation like this. But that wasnt an option for me. The only complaint that I had was finding pain relief after the surgery. The nurses and drs didnt know so when I said I was still in pain they looked at me like I was crazy. But that part is over and I am back on my subs. I still have 14 of the 20 percs that they sent me home with. Imagine that….an addict with pills in the house. Never thought I could do it. But I love suboxone. I dont want to be high. I want to live a normal life like I have been for the past 3 years. So any pregnant women that find this….try not to stress. It will all work out.