From the Guidelines
Pregnant patients requiring inpatient detoxification should be managed with careful medication protocols that prioritize both maternal and fetal safety, with buprenorphine (Subutex) generally preferred over buprenorphine-naloxone (Suboxone) for opioid use disorder, and a symptom-triggered benzodiazepine protocol using lorazepam (Ativan) for alcohol detoxification. For opioid use disorder during pregnancy, buprenorphine (Subutex) is preferred at doses of 2-4mg initially, titrated to 12-16mg daily based on withdrawal symptoms, as it lacks naloxone, which theoretically could precipitate withdrawal in the fetus, though recent evidence suggests Suboxone may also be safe 1.
Key Considerations for Detoxification Protocols
- For alcohol detoxification in pregnancy, a symptom-triggered benzodiazepine protocol using lorazepam (Ativan) is recommended, typically starting at 1-2mg every 1-2 hours as needed for withdrawal symptoms, with close monitoring using the CIWA-Ar scale 1.
- Benzodiazepine detoxification follows similar protocols, with gradual tapering of lorazepam by 25% every 1-2 days.
- All pregnant patients undergoing detoxification require continuous fetal monitoring after 24 weeks gestation, frequent vital sign checks, electrolyte monitoring, and nutritional support.
- Multidisciplinary care involving addiction medicine, obstetrics, psychiatry, and social work is essential, with post-discharge planning including medication-assisted treatment continuation and prenatal care coordination.
Management of Opioid Use Disorder
- Encourage women to remain on their prescribed medications throughout pregnancy, as the goals of MAT are to suppress symptoms of cravings and withdrawal and prevent illicit opioid use that can lead to adverse pregnancy outcomes 1.
- Counsel women that acute detoxification or attempting to wean or stop opioids before delivery is not recommended for most women, due to the risk of acute maternal withdrawal and relapse.
- For women who are taking chronic opioids for pain, consideration can be made for a slow titration toward a lower dosage of systemic opioids over the course of the pregnancy, ideally managed with a pain specialist.
From the FDA Drug Label
All patients treated with opioids require careful and frequent reevaluation for signs of misuse, abuse, and addiction, because use of opioid analgesic products carries the risk of addiction even under appropriate medical use Buprenorphine hydrochloride, like other opioids, can be diverted for nonmedical use into illicit channels of distribution. The concomitant use of benzodiazepines or other CNS depressants, including alcohol, can increase the risk of hypotension, respiratory depression, profound sedation, coma, and death
The FDA drug label does not provide a specific protocol for pregnant inpatient detox using Suboxone or Subutex, including for alcohol and Ativan. However, it does mention that buprenorphine can be used in pregnant women, but with caution, as it can cause respiratory depression and neonatal abstinence syndrome.
- Key considerations for using buprenorphine in pregnant women include:
- Careful monitoring for signs of misuse, abuse, and addiction
- Avoiding concomitant use with benzodiazepines or other CNS depressants, including alcohol
- Monitoring for signs of respiratory depression and sedation
- Considering alternative treatment options for alcohol and Ativan dependence
- Consulting the FDA drug label for buprenorphine 2, 2, and 2 for more information on its use in pregnant women.
From the Research
Protocol for Pregnant Inpatient Detox
- The current recommendation is not to perform detoxification during pregnancy due to potential risks for preterm labor, fetal distress, or fetal demise 3.
- However, studies have shown that opioid detoxification can be accomplished safely during pregnancy in selected patients 4.
- A retrospective analysis of 301 opiate-addicted pregnant patients who underwent detoxification during pregnancy found no adverse fetal outcomes related to detoxification 3.
- The rate of neonatal abstinence syndrome was high, but primarily when no continued long-term follow-up occurred 3.
Treatment with Suboxone or Subutex
- Buprenorphine, the active ingredient in Suboxone and Subutex, has been shown to be effective in opioid detoxification 5, 6.
- A study comparing the effectiveness of different doses of sublingual buprenorphine and clonidine in opioid detoxification found that both low and high doses of buprenorphine were comparable in controlling withdrawal 6.
- Buprenorphine substitution/detoxification is one of the protocols outlined in a clinical manual for opiate detoxification 5.
Treatment for Alcohol and Ativan Dependence
- There is limited information available on the treatment of alcohol and Ativan dependence in pregnant inpatients.
- However, it is known that benzodiazepine withdrawal, such as from Ativan, can be severe and potentially life-threatening, and should be managed under medical supervision.
- A comprehensive treatment plan for pregnant inpatients with substance dependence should include counseling, support, and medical management of withdrawal symptoms.