Novel Approaches for Opioid Use Disorder in 3rd Trimester Pregnancy: Successful Slow and Rapid Micro-Initiation of Buprenorphine

Virtual

Presenting Author(s)

Sharon B. Madanes, MD, MFA

Assistant Professor of Clinical Psychiatry
Weill Cornell Medical College
New York, New York

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Co-Author(s)

Lisa Linde, MD (she/her/hers)

Clinical Assistant Professor
NYU Langone
New York, New York
CATHY A. KONDAS, MD, MBS

Associate Chief of Psychiatry and Director of Consultation Liaison Psychiatry
NYU Grossman School of Medicine at NYC Health + Hospitals / Bellevue
NEW YORK, New York
Arslaan (Ari) Arshed, MD, MS, MHA (he/him/his)

Clinical Assistant Professor
New York University
New York, New York

Abstract: Background
Opioid use in pregnancy and fetal exposure to repeated withdrawal is associated with an increased risk of adverse complications including hemorrhage, preterm delivery, placental abruption, maternal mortality, an increased risk of fetal congenital malformations and neonatal opioid withdrawal syndrome (NOWS). Medications for opioid use disorder (OUD) are recommended in pregnancy by both ACOG and SAMHSA as the risks associated with untreated OUD outweigh the risks of medications. Buprenorphine is preferred in pregnancy over methadone as it carries a lower risk of NOWS, preterm birth, small for gestational age and low birth weight. Given the prevalence of fentanyl and precipitated withdrawal, even more care is needed in buprenorphine initiation, as pregnant people with multiple initiations have significantly increased odds of using non-prescribed opioids, preterm delivery, and decreased odds breastfeeding and bonding.

Despite new case-reports this year that document suboxone micro-initiation protocols, none compare the differences between macro-initiation, rapid and slow micro-initiation protocols. We present two cases of pregnant people with extreme social circumstances without prenatal care, who were emergently admitted for fetal monitoring and opioid withdrawal. Both pregnant people were initially treated with methadone to prevent withdrawal.

Methods
Patient 1 and patient 2 were both admitted and evaluated by the consultation-liaison (C-L) addiction psychiatry service and had inpatient follow-up with the reproductive psychiatry fellows. On discharge, they were connected to a chemical dependency outpatient program.

Patient 1: 39-year-old female, 32 weeks pregnant with OUD, suspicion of xylazine-laced heroin exposure, who was transitioned to suboxone via low dose micro-initiation with Belbuca over 8 days while on methadone 50mg AM+10mg PM.

Patient 2: 29-year-old female, 29 weeks pregnant with opioid use disorder. She was initially macro-initiated on 32mg of suboxone, however declined for two days due to withdrawal, then transitioned back to suboxone via rapid micro-initiation over 3 days. She received methadone 40mg AM+10mg PM for 3 days and Belbuca four times a day for 2 days, followed by suboxone.

Results
Both patients remained in the hospital during their slow and rapid micro-initiation protocols. Throughout the process, there were no fetal concerns and no signs of withdrawal.

Discussion
With the increased risk of precipitated withdrawal with fentanyl, increased caution must be taken when starting pregnant people on medications for OUD. Our literature review and two case examples highlight strategies to safely transition pregnant people from methadone to suboxone while preventing withdrawal. This process allows for more pregnant people to be initiated on suboxone during pregnancy, thereby improving maternal, fetal and infant outcomes.

Conclusions
Future research and proposed guidelines would increase the ability and confidence of C-L psychiatrists within interdisciplinary teams, to both initiate, and treat those on buprenorphine during pregnancy, thereby improving access to the medication and maternal and fetal outcomes.

References
REDDY, M. S., & Martin, C. E. (2024). Low Dose Buprenorphine Induction during Pregnancy: A Case Report. AJOG Global Reports, 100308.
Swift, R. M., Dudley, M., DePetrillo, P., Camara, P., & Griffiths, W. (1989). Altered methadone pharmacokinetics in pregnancy: implications for dosing. Journal of substance abuse, 1(4), 453–460.

Presentation Eligibility: Not previously published or presented.

Diversity, Equity, and Inclusion: This presentation highlights the intersecting disparities withing social determinants of health, mental health, and substance use disorders amongst marginalized and minoritized communities. We present cases of two patients that were unstably housed, did not have access to prenatal care in the first two trimesters, and sought out care from an integrated OBGYN and C-L psychiatry team to address their needs. Despite legislation perpetuating stigma surrounding reproductive and substance use care, our collective belief is that access to healthcare should be equitable for all individuals regardless of their race, gender, or socioeconomic status.