What is the protocol for transitioning a 9-week pregnant woman from heroin to buprenorphine (Subutex)?

From the Guidelines

The recommended protocol for transitioning a pregnant woman at 9 weeks gestation from heroin to buprenorphine involves a carefully managed induction process, where the woman should first abstain from heroin use for at least 12-24 hours before starting buprenorphine, as recommended by experts in the field 1.

Key Considerations

• The initiation of buprenorphine requires that women must be experiencing opioid withdrawal, with the presence of at least mild withdrawal symptoms verified by the administration of a validated opioid withdrawal scale 1.
• The initial dose of buprenorphine is typically 2-4mg, with additional 2-4mg doses given as needed for continued withdrawal symptoms, up to a maximum of 8-12mg on day one.
• On subsequent days, the total dose from day one can be given as a single daily dose, with gradual increases of 2-4mg daily as needed to control cravings and withdrawal, typically stabilizing between 16-24mg daily, as found in a recent meta-analysis 1.

Transitioning to Buprenorphine

• It is crucial to monitor the woman's response to buprenorphine and adjust the dose as needed to prevent precipitating acute opioid withdrawal.
• The transition should occur in a medically supervised setting, ideally with obstetric consultation, to ensure the best possible outcomes for both the mother and the fetus.
• Regular prenatal care, substance use counseling, and monitoring for relapse are essential components of treatment, as they can help improve maternal and fetal outcomes by preventing withdrawal cycles and reducing illicit drug use.

Comparison with Methadone

• Buprenorphine is preferred over methadone for many pregnant women due to potentially less severe neonatal abstinence syndrome, shorter hospital stays, and reduced need for pharmacological treatment for the newborn.
• However, in patients who are unable to tolerate buprenorphine or in whom buprenorphine is found to be ineffective, methadone is recommended, as stated in the SMFM Special Report 1.

From the Research

Transitioning from Heroin to Buprenorphine in Pregnancy

• The provided studies do not directly address the protocol for transitioning a woman from heroin to buprenorphine during pregnancy, specifically at 9 weeks gestation.
• However, a study by 2 discusses transitioning pregnant women from methadone to buprenorphine, which may provide some insight into the process.
• The study by 2 used a standardized protocol with low buprenorphine doses to minimize withdrawal symptoms, under careful obstetric and psychiatric monitoring.
• Women in the study were maintained on an average methadone dose of 44 mg/day and were successfully transitioned to 12.60 mg/day of buprenorphine.

Buprenorphine Use in Pregnancy

• A systematic review and meta-analysis by 3 compared pregnancy outcomes between pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone and those undergoing treatment with other forms of medication-assisted treatment.
• The study found no serious adverse maternal or neonatal outcomes associated with maternal buprenorphine-naloxone use, and women prescribed buprenorphine-naloxone were less likely to have neonates requiring treatment for neonatal abstinence syndrome.
• Another study by 4 found that buprenorphine decreased the length of NAS treatment and hospital length of stay compared to morphine or methadone.

Considerations for Transitioning to Buprenorphine

• A study by 5 notes that buprenorphine is a Food and Drug Administration-approved product for treating adult opioid use disorder during the perinatal period, and its label includes pregnancy, neonatal, and lactation information.
• The study by 6 discusses the clinical utility of buprenorphine, clonidine, methadone, and naltrexone in treating opiate addiction, but does not specifically address transitioning from heroin to buprenorphine during pregnancy.