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.