What is the protocol for pregnant inpatient detoxification, including treatment with Buprenorphine (Suboxone) or Buprenorphine (Subutex) for opioid, alcohol, and Lorazepam (Ativan) dependence?

From the Guidelines

Pregnant patients requiring inpatient detoxification should be treated with buprenorphine (Subutex) at doses of 8-24 mg daily, as it is generally preferred over buprenorphine-naloxone (Suboxone) due to the avoidance of naloxone exposure to the fetus 1.

Key Considerations for Opioid Detoxification

• Induction typically begins with 2-4 mg when the patient is in mild-moderate withdrawal, with additional 2-4 mg doses as needed up to 8-12 mg on day one, then stabilizing at an appropriate maintenance dose 1.
• A daily dosage of 16 mg is sufficient to suppress illicit opioid use in most pregnant women with OUD, but sufficient dosages vary and can range from 4-24 mg daily 1.
• For alcohol detoxification, a symptom-triggered benzodiazepine protocol using lorazepam (Ativan) is recommended, starting with 1-2 mg every 1-2 hours based on CIWA-Ar scores above 8-10, with vital sign monitoring and thiamine supplementation (100 mg daily) 1.

Benzodiazepine Taper and Fetal Monitoring

• Benzodiazepine tapers for those dependent on Ativan or similar medications should be gradual, typically reducing by 10-25% every 1-3 days depending on symptoms and gestational age.
• Throughout detoxification, fetal monitoring is essential, particularly in the second and third trimesters, with daily non-stress tests and obstetric consultation.

Multidisciplinary Care and Support

• Multidisciplinary care involving addiction specialists, obstetricians, and neonatologists is crucial, as is addressing nutritional needs, providing psychosocial support, and planning for postpartum care to prevent relapse.
• This approach minimizes withdrawal risks while protecting both mother and developing fetus.

Additional Recommendations

• All pregnant women should be screened for substance use at the first prenatal visit with the use of a validated questionnaire, such as the National Institute on Drug Abuse (NIDA) Quick Screen Tool 1.
• Pain management for women who are taking opioids for chronic pain or who have OUD during pregnancy and during and after delivery involves a multidisciplinary approach that may include an anesthesia consultation 1.

From the FDA Drug Label

Use of high doses of sublingual buprenorphine in pregnant women showed that buprenorphine passes into the mother's milk Clinical Considerations Breast-feeding is not advised in nursing mothers treated with buprenorphine hydrochloride. Females and Males of Reproductive Potential Infertility Use of opioids for an extended period of time may cause reduced fertility in females and males of reproductive potential.

The treatment with Suboxone (buprenorphine) for pregnant inpatients undergoing detox is possible, but caution is advised due to the potential risks, including:

• Respiratory depression
• Neonatal abstinence syndrome
• Reduced fertility However, the provided drug label does not directly address the protocol for pregnant inpatient detox using Suboxone or Subutex, including for alcohol and Ativan. Key points to consider:
• Buprenorphine passes into breast milk, and breastfeeding is not advised in nursing mothers treated with buprenorphine hydrochloride 2.
• Opioid use for an extended period may cause reduced fertility in females and males of reproductive potential 2.

From the Research

Protocol for Pregnant Inpatient Detox

• The current recommendation regarding the management of a pregnant patient with opioid dependence is not to perform detoxification during pregnancy due to potential risks for preterm labor, fetal distress, or fetal demise 3.
• However, a study found that over 5.5 years, 301 opiate-addicted pregnant patients were fully detoxified during pregnancy with no adverse fetal outcomes related to detoxification identified 3.
• The rates of newborns treated for neonatal abstinence syndrome were also assessed, with varying rates depending on the detoxification method used, ranging from 17.2% to 70.1% 3.

Treatment with Suboxone or Subutex

• Medication-assisted treatment, including Suboxone or Subutex, is recommended for individuals with an opioid use disorder, including pregnant women 4.
• Medically supervised withdrawal (detoxification) has demonstrated a low risk of fetal death and low rates of relapse and neonatal abstinence syndrome, but the rates of relapse and neonatal abstinence syndrome are still a concern 4.
• A study found that opioids adversely affect the human brain, primarily the developing oligodendrocyte and the processes of myelinization, connectivity between parts of the brain, and the size of multiple brain regions 4.

Treatment for Alcohol and Ativan

• The use of medication for the treatment of pregnant women with an alcohol use disorder appears to be rare due to the lack of available data regarding the safety of these medications in pregnancy 5.
• However, acamprosate and naltrexone do not appear to be associated with substantial risks of congenital malformations or other serious consequences, and their use should be considered for the treatment of pregnant women with AUD based on the current evidence base 5.
• Benzodiazepines, such as Ativan, are commonly used by individuals seeking treatment for opioid use disorders, with anxiety being the most common reason reported for their use 6.
• The most common reason for benzodiazepine use was significantly associated with the most likely source of benzodiazepines, with persons who got their benzodiazepines from a prescriber more likely to report benzodiazepine anxiety as their primary reason for use 6.

Systematic Review of Opioid Detoxification During Pregnancy

• A systematic review found that study quality ranged from fair to poor due to the lack of a randomized control or comparison arm and high risk of bias across all studies 7.
• Detoxification completion and illicit drug relapse rates varied widely across studies, and the reported rate of fetal loss was similar among women who did and did not undergo detoxification 7.
• Evidence does not support detoxification as a recommended treatment intervention due to low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery 7.