Suboxone (buprenorphine) and Opiate Withdrawal in Newborns

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.
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.

8 thoughts on “Suboxone (buprenorphine) and Opiate Withdrawal in Newborns

  1. I gave birth to a healthy 8lb 12oz baby boy 6 days ago I was on 4milligrams a day of subutex which i was switched to from suboxone after becoming pregnant on accident. The Dr. who was covering at the hospital for my normal Dr. came in the room and in front of my family started repremanding me telling me I just cant take any pills I want to when the nurse informed him I had taken Subutex, instead of looking at my records he just assumed I was a pill popping junkie who scored a pill from somewhere! After realizing HIS mistake and rush to judgement I spent 6 hours in hard labor with him minimizing my pain and refusing to give me anything for pain relief I guess to try to punish me, some of the nurses were no better offering their opinions on subutex. My baby sneezes a couple times a day and gets a rash under his chin and now they will not let me take him home, if he was in distress I would understand and now I do not know the future for my child and I feel helpless.

    • All three of my babies sneezed from time to time, and the rash, from drooling, is common too– and they had no opioid exposure. It is really too bad; studies show that about 20% of infants from bupe moms show signs of w/d when they aren’t labelled that way ahead of time. I had two patients deliver in the past two weeks, at two hospitals. One baby was held 7 days, and placed on a morphine infusion, and is now at home tapering off morphine. The other baby (at a hospital that, in my opinion, has much better care in general) was discharged on day 2 along with mom, and came to my appointment on day 3. He slept through the appoinment, as normal babies of his age do— although it would have been just as normal if he screamed the entire time.

      The problem is ‘selection bias’– the common phenomenon that makes people see things once they start looking for them. Doctors used to at least have some exposure to science– including knowing how to detect bias, and knowing why we ‘blind’ studies. But now, all it takes i one idiot in the care chain to freak out, and suddenly every member of the care team wants to show influence by exerting control over the baby’s care.

  2. I have a question so I am 8 months pregnant and i was a herione addict, when i found out i was pregnant actually the day i found out i stopped using and started on suboxone i didnt have a doc so i took my boyfriends till i got my own doctor, i take 2 mg a day, my question is or worries for that matter are is my baby going to withdrawl really bad I feel like the worst person in the world when i think about it. And I wonder will I be able to bring her home from the hospital with me or is she going to have to stay, I cant even sleep when i think about this…I dont know anyone who would be able to give me advice so will somebody please….

    • Your baby is better off with you taking Suboxone than heroin– but it would be better if you had your own doctor, because taking your BF’s meds could cause him to get kicked out of treatment. I can’t predict what social service does, but you will be at risk if someone visits your home and finds needles and paraphernalia. If you have a doctor, and you are on Suboxone, I wouldn’t expect any problems along that line– assuming you are keeping a home that is safe for a baby in other ways.

  3. I was told by my doctor that our newborn was addicted to buprenorphine and they told me he will experience seizures and organ failure if he does not get treatment is this true?

    • No. Of course nobody should ever say ‘it could NEVER happen’, because there are always very bizarre things that happen in the field of medicine that can’t be explained. But I’ll provide some information to guide your decisions….

      First, understand that when babies are involved, medicine always goes to the most extreme, safe position (unless the baby is unwanted, in which case the field of medicine has no problems with ending pregnancies by the most barbaric means possible… but that’s another discussion). In the cases of ‘desired pregnancies’, doctors will go to great lengths to make sure that money is spent on every possible test. Part of that is because babies are deemed ‘innocent’ of the actions of their parents, and not treated with the same disdain as how hospitals and doctors treat grown-ups suffering with addictions. And part of it is because when a baby is harmed, lawsuits are based on an entire lifetime of earning potential, i.e. the numbers go to the sky. I hope I don’t sound cynical, by the way.

      For example, many states do not allow the use of plain buprenorphine in any condition…. except pregnancy. There is no known harm to the fetus caused by naloxone, but the people who make the rules still insist that babies shouldn’t have to risk even trace exposure to naloxone. They say that ‘since the naloxone doesn’t do anything, why expose a baby to it?’ Of course I always say, ‘since naloxone doesn’t do anything, why do we expose ANYONE to it?’ But apparently babies deserve much, much mroe protection from innocuous substances than grown people, so the rules persist.

      My point is that the doctors will err on the safe side with babies. But understand that seizures and organ system failure are NOT typical consequences of opioid withdrawal. Firstly, many studies have shown that only about half of babies born to moms on buprenorphine have ANY withdrawal symptoms. When withdrawal does occur, it tends to be much more mild than withdrawal from agonists like heroin or oxycodone. So your baby may not have any withdrawal at all, and if he/she does, it will be mild.

      As an aside, no baby is born ‘addicted’ to buprenorphine. The baby may by physically dependent on opioids, a totally different concept. A doctor who uses the word ‘addiction’ in regard to a newborn is at best insensitive, and at worst, ignorant or mean, trying to take a good ‘dig’ into you for being such a horrible, drug-addicted person.

      If your baby has symptoms of NAS or neonatal abstinence syndrome (the proper term), you’ll see some tremor, more crying, increased tone, and possibly problems nursing (one of my kids had problems nursing, and he was NOT opioid-dependent– so the relationship is not 100%). In most cases, the symptoms pass on themselves. They take a few days to start, so treating the symptoms is never an emergency. The issue comes down to whether the baby is taking in enough hydration, judged by having a wet diaper every few hours. If not, then the baby should receive treatment. But ‘multi-organ system failure’ will only be an issue after several days of severe dehydration, when the kidneys would start to fail. A few days later you would see problems with other organ systems.

      The safest thing, of course, is to do what the doctor says. That would allow you to sue the doctor if anything goes wrong, whereas if you go on your own, everything is ‘on you’. Since we’re talking about a baby, I err on the side of caution. See? I even do it too!!

  4. My son’s girlfriend was taking suboxone, purchased on the street, while pregnant with my grandson. She felt he was having withdrawls and, rather than take him to the doctor and be honest, she put the drug in his bottle. I found this out the night that he died. The medical examiner ruled his death as SIDS but I can’t help but think that he died as a result of her ignorant and selfish actions. She is pregnant once again and continues to take suboxone and benzos, have also been told she is taking oxycodone, but that is not something that i am certain of. I simply cannot go through another devastation like this. I have read so many different things about affects on unborn babies and newborns. please educate me. From what I have read, you seem to know a great deal on the matter.

    thank you

    • Horrible- I’m very sorry. Would you like me to reply privately to the email you used to register to post?

      A newborn to a mom using heroin or a high dose of methadone will have a high opioid tolerance, which increases the risk of withdrawal but also adds some protection from overdose. But it is possible that your grandson was exposed to a very small fraction of buprenorphine in the uterus– to low to develop tolerance. Buprenorphine rarely causes death because people taking it are protected by the ceiling effect and by tolerance. But a newborn doesn’t have the same protection by the ceiling effect of the drug, and in your grandson’s case may not have had tolerance. Adding buprenorphine in that situation would be like adding any other opioid, including heroin or oxycodone.

      I would recommend you speak with child protective services so that they can protect the baby. It is NEVER safe to add narcotic to formula, except by people who understand all of the pharmacology involved– and in those cases, generally only in monitored settings at least until the proper dosages are established.

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