The wellbeing of infants exposed to buprenorphine via breast milk at 4 weeks of age

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Oxidative stress and apoptotic index modifications in the hippocampus of rat pups born to mothers exposed to buprenorphine during lactation

Background

The effect of opioids administration during lactation on nervous system has not fully understood.

Objective

The aim of this study was to evaluate the buprenorphine (BUP) impact on oxidative stress indexes and apoptotic gene expression in the hippocampus of neonates exposed to this drug through breastfeeding.

Methods

Lactating female rats were subcutaneously injected with BUP (1 or 0.5 mg/kg). After 28 days, the pups were anesthetized, then their hippocampus were obtained for measurement of oxidative stress parameters [glutathione (GSH), thiobarbituric acid reactive substances (TBARS), total antioxidant capacity (TAC) and superoxide dismutase (SOD)] and gene expression of apoptotic indices (Bcl2, Bax and caspase 3).

Results

This study showed that BUP (0.5 and 1 mg/kg) could not markedly change oxidative stress indices levels and apoptotic markers expression in the hippocampus of pups versus controls.

Conclusion

This study did not find BUP effect on the apoptosis and oxidative stress indices in the hippocampus of pups born to mothers exposed to this drug during lactation.

Maternal Buprenorphine Maintenance and Lactation

BACKGROUND

In addition to the well-known benefits of human milk and breastfeeding for the mother and infant, breastfeeding may mitigate neonatal abstinence syndrome severity in prenatally opioid-exposed infants. However, lack of conclusive data regarding the extent of the presence of buprenorphine and active metabolites in human milk makes the recommendation of breastfeeding for buprenorphine-maintained women difficult for many providers.

OBJECTIVE

This study seeks to determine the concentrations of buprenorphine and its active metabolites (norbuprenorphine, buprenorphine-glucuronide, and norbuprenorphine-glucuronide) in human milk, maternal plasma, and infant plasma of buprenorphine-maintained women and their infants.

METHODS

Up to 10 buprenorphine-maintained women provided paired breast milk and plasma samples at 2, 3, 4, 14, and 30 days postdelivery, and 9 infants provided plasma samples on day 14 of life. All samples were analyzed via liquid chromatography tandem mass spectrometry to determine concentrations of buprenorphine, norbuprenorphine, buprenorphine-glucuronide, and norbuprenorphine-glucuronide by a fully validated method.

RESULTS

Concentrations of buprenorphine and metabolites are low in human milk and maternal plasma. Breastfed infant plasma concentrations of buprenorphine were low or undetectable and metabolite concentrations undetectable at 14 days of infant age. There were significant correlations between maternal buprenorphine dose and maternal plasma and human milk buprenorphine concentrations.

CONCLUSION

These data find low concentrations of buprenorphine and metabolites in human milk and lend support to the recommendation for lactation among stable buprenorphine-maintained women. However, the correlation between maternal dose and maternal plasma and human milk buprenorphine concentrations bears further study.

Breastfeeding and Opiate Substitution Therapy: Starting to Understand Infant Feeding Choices

INTRODUCTION

Despite research demonstrating the safety and benefit of breastfeeding in opioid substitution therapy, few women in treatment breastfeed. Understanding the factors contributing to the choices women on opioid substitution therapy make about infant feeding is important.

OBJECTIVES

The aim of this study was to better understand and support infant feeding choices and breastfeeding experiences in women on opioid substitution therapy.

METHODS

A systematic review was conducted on five databases: (1) Ovid MEDLINE(R) without revisions, (2) Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, (3) EMBASE, (4) CINAHL, and (5) FRANCIS. From 1081 articles, 46 articles were reviewed.

RESULTS

The literature supports breastfeeding as an appropriate and safe option for women on opioid substitution treatment. Breastfeeding and rooming-in reduce neonatal abstinence. Women face barriers to breastfeeding due to societal stigma and the lack of patient and health-care provider education.

CONCLUSIONS

Efforts are needed to increase the knowledge that women and health-care professionals have about the safety and benefits of breastfeeding.

ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Medication-assisted treatment of opioid use disorder: review of the evidence and future directions

Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.

[Psychotropic drugs during pregnancy and lactation: development practice]

INTRODUCTION

Pregnancy and the postpartum periods are particular for the mother's use of drugs. Therapeutic prescription must take into account the potential risk of fetal malformation, newborn's withdrawal syndrome, feeding type and potential risk of untreated maternal mental illness. Recommendations for good practice are constantly remodeling and their conclusions are sometimes contradictory.

METHOD

The aim of this work is to develop an updated review, easy to use for any professional involved in the monitoring or prescription of a psychotropic medication (antidepressants, anxiolytics-hypnotics, neuroleptics, mood stabilizers and substitution treatment of opioid dependance) for pregnant or nursing women.

RESULTS

These updates in tabular form are also based on our clinical experience as a team specializing in perinatal medicine.