Psych Central

Archive for January, 2013

Sudden Infant Death from Buprenorphine?

Sunday, January 13th, 2013

SIDS from buprenorphineIn a recent Google search about Suboxone and pregnancy, one of the top links included the frightening statement that Suboxone and buprenorphine have been linked to SIDS or sudden infant death syndrome, commonly called ‘crib death.’

The statement was from a health forum where a woman wrote about taking Suboxone during pregnancy.  She wrote that her child went through opioid withdrawal after delivery, recovered, and then died two months later from SIDS.  She then claims that her doctors told her that Suboxone was a possible reason for her child’s death.

I don’t know if the woman’s story is true. If it is, I hope my comments do not cause her pain, and I’m sorry for her loss.  But someone should comment on the information, given the number of young women on Suboxone who become pregnant and frantically search the internet for reassurance that their baby will be OK.  I know that pregnant women in my practice lose a great deal of sleep because of guilt over taking buprenorphine.  I am not a SIDS specialist, obstetrician, or pediatrician, and I do not actively follow the SIDS literature.  But I have done some reading to prepare for this post, and I’ll do my best to address the issue.

While the causes of SIDS are not completely understood, a number of factors have been associated with sudden infant death, including maternal age and socioeconomic status (higher rates in infants of poorer, younger mothers), maternal smoking, air pollution, low birth weight, season of birth (higher in infants born in the winter), too high or too low room temperature, male sex, history of premature birth, and bottle feeding (instead of breastfeeding).

One of the biggest risk factors is the easiest to correct: sleeping position. The incidence of SIDS is thought to be about twice as high for babies who are placed prone (face-down).  Since 1992, when 4895 deaths were attributed to SIDS in the US, a public relations campaign to encourage parents to place infants on their backs may have reduced the incidence of SIDS by 50%.  I write ‘may …


A Lesson in Side Effects Using Buprenorphine

Wednesday, January 2nd, 2013

side effects of buprenorphineWe can now leave naloxone out of the discussion, and focus on the side effects of Suboxone that are caused by buprenorphine.

Side effects are symptoms caused by a given medication that are not part of the therapeutic benefit of that medication.  Whether a symptom is a side effect depends on the reason for taking the medication.  For example, decreased intestinal motility is the desired effect of opioids used to treat diarrhea, but a bothersome side effect when taking opioids for pain.  The term ‘side effect’ is not on the package insert for medication, the symptoms and actions instead referred to as ‘adverse reactions.’  Package inserts also have a section entitled ‘warnings and precautions’ where the most dangerous adverse reactions are listed.

Some medications have a ‘black box warning’ for adverse reactions that are particularly common or particularly dangerous, consisting of a frightening statement at the start of the package insert (enclosed, naturally, by a black box). Black box warnings in psychiatry include the warning for increased suicidal ideation in children and adolescents treated with antidepressants, and the increased risk of death in people with dementia treated with atypical antipsychotics.

Increased risk of cancer or mutations, and effects on fertility or fetal development, are listed in yet another section entitled ‘nonclinical toxicology.’  They are listed as ‘nonclinical’ because the events do not involve the intended physiologic system or pathway targeted by the medication.  For example, slowing of intestinal activity by opium is either treatment of diarrhea or unwanted constipation, but in either case the outcome is caused by actions of opioids at opioid receptors.  If the opium molecule happened to bind to DNA and cause cancer, the cancer would be nonclinical toxicology, not a side effect.  Carbamazepine decreases the excitability of neurons to prevent seizures, and the sedation caused by the slowing of neurons is considered an adverse reaction. Carbamazepine impairs fetal development through different actions, considered nonclinical toxicology.

All of these divisions can be picked apart so that division of symptoms to one category or another will appear arbitrary.  The system …


Brain Surgery for Opioid Dependence

Tuesday, January 1st, 2013

brain surgery for opioid dependenceToday I read about the stereotactic brain surgery used to treat opioid dependence in China over the past ten years.   The procedure is relatively straightforward; the patient’s skull is clamped in place while small holes are drilled, guided by computerized, 3-dimensional maps of the brain.  Probes are inserted deeply through brain tissue to the nucleus accumbens, where electric current destroys varying amounts of brain tissue.   Patients are awake and talking during the procedure, so that surgeons know if the probes are too close to brain regions that control speech or other functions.

A large number of ablations for the treatment of addiction were performed in China about ten years ago.  The rapid growth in popularity of the technique, before full knowledge of the risks and long-term effects, led to a ban on the procedures by the Chinese Ministry of Health in 2004.  Still, ablations were performed as part of research studies, with over 1000 people treated by ablation since 2004.

The scientific community outside of China overwhelmingly condemns the technique, and medical journals are pressured to withhold publication of ablation studies.  Human rights advocates claim that such experiments are performed on people who are not fully aware of the risks, or who are pressured to participate in the studies to avoid harsh punishments for drug offenses.  The veracity of the results from ablation studies has also been challenged. Ablation treatment of opioid dependence is in the news lately because of a recent paper describing the five-year follow-up of opioid addicts treated by the procedure.

Neuroscientists distinguish between DBS (deep brain stimulation by electric current) vs. procedures where brain tissue is destroyed.  I’m surprised by the intensity of the distinction, given the similarity of the procedures.  In both cases long probes are passed through brain tissue, risking hemorrhage, stroke, or seizures.  For DBS, wires are left behind and connected to power-packs that release different patterns of electrical current.  In the ablation studies, small areas of tissue at the end of the probes are destroyed, and the probes removed.  If there is a …


 

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