What Standard of Care for Mothers on Suboxone?
Newborn abstinence syndrome from buprenorphine provokes strong emotions. Expectant patients rightly anticipate harsh attitudes from doctors and nurses. They read in forums and chat rooms about experiences of women who say that CPS was called after delivery, or about babies who were kept on opioid tapers, in the hospital, for weeks or even months after mom’s discharge. And in the absence of appropriate support from the medical profession, they worry that their use of buprenorphine will cause the baby to suffer from withdrawal.
A member of SuboxForum recently wrote that the hospital where her doctor had privileges required that she sign a formal policy about babies born to mothers on buprenorphine. She was told that her baby must go to the NICU for at least 10 days after delivery, regardless of condition, and she was not allowed to refuse that level of treatment.
Meanwhile, one of my buprenorphine patients came to her appointment last week, five days after the birth of her baby. Mom and baby left the hospital together less than 48 hours after deliver, and she brought the baby to her appointment. I realize that hospitals discharge patients more quickly these days but her discharge seemed a bit fast, but not because of anything related to buprenorphine. I just believe that new moms, who are frequently anemic and sleep-deprived, should have a bit more rest before taking on an infant’s schedule.
How can the ‘standard of care’ vary so greatly? What role does insurance coverage play in decisions about opioid tapers, NICU admissions, and discharge schedules? After having dozens of patients go through the process uneventfully, without intervention by a neonatologist, I have to wonder if newborns are always positively served by such efforts.
Realize that I respect neonatologists probably more than most people. As an anesthesiologist, there were times when a baby had to be delivered, whether or not a pediatrician had made it into the hospital. Doctors in our group (and in others across the country) argued whether an anesthesiologist had the duty to assist in the resuscitation of the newborn while simultaneously caring for the mother—a difficult decision that resolved as soon as the baby-doctor arrived on the scene. A good man knows his limitations— and I am not an expert in treating newborns. But I understand buprenorphine and opioid withdrawal. After seeing so many babies born to mothers on buprenorphine go home at the normal time, I question the wisdom of using an opioid agonist to taper from a long-half-life, partial agonist.
According to research studies, half of babies born to women on buprenorphine have no objective signs of ‘withdrawal’— a misleading word for the infant’s experience. I have no doubt that in the typical nursery, neonatal abstinence symptoms are grossly over-diagnosed. Pointing out neonatal abstinence syndrome is similar to modern-day complaints about global warming, where a phenomenon is blamed for weather that is too cold or too hot, too violent or too calm, or too frozen or too thawed. Regardless of the presence or absence of climate change, there is nothing scientific about such an approach. To validate a theory, that theory must be used to make predictions that are then observed– not the other way around, where every unexpected deviation supports a new version of the theory. Mothers on buprenorphine describe a similar diagnostic approach to their newborns, where babies who cry are ‘too agitated’, and babies who sleep are ‘too sedated’ (I’m just realizing that climate change is probably too hot a topic, and I should have used ‘the three bears’ instead—and the story about ‘porridge’, whatever that is).
Even in babies who exhibit clear symptoms, do the symptoms warrant ten days in the NICU? Is a baby distressed by mild neonatal abstinence better off in mom’s lap, nursing with breast milk that has small amounts of buprenorphine, or lying in a plastic incubator under fluorescent lights with multiple IV lines? Some local docs and nurses allow moms on buprenorphine to nurse, a policy that makes tons of sense from an anatomical and developmental perspective. As the baby’s liver matures, ingested buprenorphine is eventually completely destroyed through first-pass metabolism. The process allows for a gradual, natural taper, without the misery and cost of IV infusions and monitoring systems.
Decisions about monitoring and length-of-stay revolve around safety. I question whether the various approaches to buprenorphine abstinence in the newborn are based on informed, intellectual consideration, or are instead are just best guesses by people who don’t care to understand buprenorphine. Given the 180-degree difference between the approaches of different hospital systems, somebody is doing it wrong.
I’ve complained about how research studies about drug addiction are so-often focused on things like demographics or social policy. The best approach to treatment of babies born to mothers on buprenorphine should be near the top of someone’s list. The hard part will be identifying (and following) the conclusions that are derived from science, vs. those that come from concerns about litigation (where the costliest and most-intense treatments always win out).
Baby getting injection image available from Shutterstock.
Junig, J. (2014). What Standard of Care for Mothers on Suboxone?. Psych Central. Retrieved on March 24, 2018, from https://blogs.psychcentral.com/epidemic-addiction/2014/02/what-standard-of-care-for-mothers-on-suboxone/