Is it necessary to use buprenorphine monotherapy during pregnancy as opposed to a combination buprenorphine/naloxone product? What about breastfeeding?
It is acceptable to use the buprenorphine/naloxone combination product in pregnancy. There is essentially no absorption of naloxone sublingually: naloxone was added to the buprenorphine when the FDA formulated the medication to lower the abuse potential (IV and snorting, the naloxone is active). Many institutions prescribe only the combination product and many patients prefer no changes to medications. Since there is no maternal absorption, there is no passage from mother to breastmilk: therefore women are strongly encouraged to breastfeed if no other contraindications (ie: HIV or active cocaine/methamphetamine abuse).
How should pain control during labor and after delivery be managed in women on MAT?
Intrapartum pain control can be managed with IV full opioid agonist (if desired) in early labor and epidural analgesia (PCEA) during labor. Nalbuphine and butorphanol are contrainidicated: they are both partial opioid agonists and will precipitate withdrawal in women with opioid dependence (if withdrawal is inadvertently precipitated, administer enough full opioid agonist (morphine, dilaudid) to make the patient more comfortable and the fetal effects should be reversed as well). Intraoperative pain can be managed with spinal and/or epidural anesthesia. Opioids are rarely indicated followed routine vaginal birth and should not be routinely prescribed in the hospital or at discharge without other circumstances (such as extensive perineal laceration). Following cesarean delivery, patients may need 50-70% more opioid medication for pain control, but adherence to the current opioid-sparing guidelines is also appropriate with the use of long acting intrathecal opioids (ie: morphine, although whether they are as effective in the setting of MAT is unknown), NSAIDS, and acetaminophen. Transverse abdominal plane (TAP) blocks can be considered in place of intrathecal opioids but the impact of this intervention on post-operative opioid use in the non-opioid dependent patient is equivocal. Discharge prescribing for a limited number of pills of full agonist with close follow-up is prudent.
