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 Post subject: Bup and Breastfeeding
PostPosted: Sat Jan 17, 2015 11:24 am 
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Back story: After trying (and almost, almost succeeding) to completely taper off bup, it became apparent that the taper was becoming more harmful than good. I've been on subs for almost 3 years. I'm not sure if it was the withdrawal or the underlying medical conditions that caused me to start pain treatment in the first place, but I just wasn't functioning on a healthy level. I also have gestational diabetes, and the side effects of PAWS were interfering with a healthy diet, or any diet at all. I was throwing up alot, had no appetite, and my sugars were suffering. So I decided the best thing to do was go to the Sub doc, get a prescription, and go through the official treatment route. I previously was getting my subs from a family member and splitting the cost with him because the expense of official treatment was a concern. Being pregnant, I decided that the expense now was worth it.

I now take approximately 2mg pf Subutex but do hope to taper that down some more in the coming weeks as long as it is tolerated well. I had tapered down to under .25mg in the beginning but it didn't last, as described. I do think that I can slowly get back down to atleast around 1mg before birth. I just started my 3rd trimester and am 29wks.

Question: My sub doc has said that if I want to breastfeed, I have to taper completely off. I don't think that this is an option or I would have done it before. The nurses at the hospital have also mentioned that breastfeeding on subs is not supported at the local hospital. I really have a different viewpoint. I know that there are risks with everything, but I believe that the benefits in this case outweigh the risks. I would really like to advocate for this for my baby (unless I'm wrong, in which case I want to figure that out too). I am hoping to 1) hear some personal stories about breastfeeding while on bup, and 2) find some real research that I can take back to my doctor to show that this is a good option.

I am worried that if I breastfeed my baby against their medical advice, I can get in big trouble. I also don't want to do anything to put her in danger so I need to make sure that my instinct is right here. I want to do what is best for her, and I believe that includes breastfeeding. I believe that it will help with any NAS but also provide her with all of the amazing things that breast milk has in it.

Any information you can provide will be greatly helpful.

Thanks!
Stephanie


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PostPosted: Sat Jan 17, 2015 1:33 pm 
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The doctor who runs this forum, Dr. Junig, has a different viewpoint from what you've been hearing. He believes that the miniscule amount of bupe that makes it into your breastmilk, and at 2mg/day the amount would be even smaller, is actually beneficial to the baby. And it makes the baby less likely to go through withdrawals. He is a bupe presciber himself and has prescribed for many woman who are pregnant and then breastfeed. I'll look around and see if I can find something he wrote about it. Perhaps if you show your doctor another opinion by a seasoned professional, it will change his mind.

Amy

Edit: I found this excellent article by Dr. Junig. There is a search function on his website where you can search for more information.

http://suboxonetalkzone.com/newborn-bup ... d-of-care/

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PostPosted: Sat Jan 17, 2015 2:40 pm 
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Forcing a woman to choose between Subutex and the benefits of breastfeeding is misguided. (Perhaps cruel?) While pregnant the bup gets to the fetus directly from the mother's bloodstream to the infant. After delivery the only bup the baby can get is via the breast milk, and babies are not very good at holding their saliva for 10 minutes to get max absorption.
At your dose the chance of NAS is quite small and the skin to skin contact of breastfeeding is going to be helpful if it does occur. As long as you are holding the baby, nurses and doctors can't be fussing and making mountains out of molehills.
Our clinic supports and encourages moms to breastfeed, and most of the OBs are on board as well.
I would encourage you to print off the link Amy provided and show it to your doctor.
PAX


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PostPosted: Sat Jan 17, 2015 2:46 pm 
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Below is the summary article from UP TO DATE, a website many hospitals and doctors subscribe to.
See the bottom bullet for their recommendation.


BREASTFEEDING — Several guidelines from national organizations have considered use of buprenorphine compatible with breastfeeding [1,66-69]. The drug’s poor bioavailability when taken orally means it is unlikely that significant absorption will occur from intake of breast milk. However, breastfed infants should be monitored for sedation, appropriate feeding, and attainment of developmental milestones, especially in younger, exclusively breastfed infants [68]. A single case of infant withdrawal symptoms after sudden cessation of breastfeeding has been reported [70].

SUMMARY AND RECOMMENDATIONS

●Pregnant women with substance dependence (table 1) are candidates for opioid substitution therapy. (See 'Candidates for opioid-substitution therapy' above.)


●Methadone remains the standard treatment for opioid dependence during pregnancy. We prefer methadone to buprenorphine because of the lack of data on pregnancy outcomes after first trimester buprenorphine exposure, along with the paucity of information on long-term neurodevelopmental outcomes after in utero exposure. The available evidence supports the use of buprenorphine as an alternative treatment and some organizations are advocating that buprenorphine be used as a potential first-line medication for pregnant opioid-dependent women who are new to treatment. Factors to consider in making this choice include program availability, availability of comprehensive obstetrical and substance abuse care, and patient preference. (See 'Buprenorphine or methadone?' above.)


●Neonatal withdrawal syndrome appears to be less severe with buprenorphine substitution than with methadone maintenance therapy. (See 'Neonatal abstinence syndrome' above.)


●Maternal treatment retention appears to be greater with methadone than with buprenorphine. (See 'Maternal treatment retention' above.)


●Buprenorphine can only be prescribed by physicians who have undergone appropriate credentialing. (See 'Initiation of buprenorphine and subsequent management' above.)


●To minimize the risk of buprenorphine-induced withdrawal symptoms, it should only be initiated when a woman shows objective, observable signs of moderate opioid withdrawal, usually 6 hours or longer after the last dose of a short-acting opioid, and potentially longer (24 to 48 hours) following the use of long-acting opioids. (See 'Initiation of buprenorphine and subsequent management' above.)


●Drug dosing for buprenorphine is similar to that in nonpregnant women. (See "Treatment of opioid use disorder", section on 'Buprenorphine'.)


●The combination of buprenorphine and naloxone (Suboxone) is not recommended for use during pregnancy due to safety reasons. (See 'Buprenorphine versus buprenorphine plus naloxone' above.)


●For women who consistently demonstrate good compliance with buprenorphine therapy, routine antenatal fetal surveillance is probably unnecessary. However, for women with evidence of recidivism and/or polysubstance abuse, or women who have other indications for fetal surveillance (eg, preeclampsia, fetal growth restriction), weekly or twice weekly testing during the third trimester is reasonable. (See 'Antenatal fetal surveillance' above.)


●Usual buprenorphine dosing should be maintained intrapartum and postpartum. (See 'Management of pain during labor, delivery, and postpartum' above.)


●The goal of peripartum pain management is to provide adequate analgesia while avoiding both overmedication and withdrawal. (See 'Management of pain during labor, delivery, and postpartum' above.)


●Opioids, such as morphine, can be used safely in early labor and postpartum. Higher doses may be required to achieve good pain control. Opioid antagonists or agonist-antagonists can precipitate acute withdrawal and should be avoided. (See 'Labor and delivery' above and 'Postpartum' above.)


●For pain control, we suggest opioids without acetaminophen rather than combined preparations (Grade 2C). The opioid dose required for pain control often exceeds the safe upper limit for acetaminophen in combined preparations. (See 'Postpartum' above.)


●Buprenorphine use is acceptable in nursing mothers. (See 'Breastfeeding' above.)


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PostPosted: Mon Jan 19, 2015 5:19 pm 
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Wow-- good references! Our hospital in Wisconsin encourages breast feeding by moms on buprenorphine. Realize that whatever level of buprenorphine the baby is exposed to in the uterus will be higher than the amount in breast milk. Also, the small amount of buprenorphine in breast milk is swallowed by the baby, and metabolized at the liver.

We had a tragic incident where a baby died at 6 weeks from events unrelated to buprenorphine. But the mother was on buprenorphine, and nursing the baby. At autopsy the baby had no measurable buprenorphine in the bloodstream. A tragic case-- but I suspect the findings are consistent with most babies nursing from moms on buprenorphine.


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PostPosted: Wed Jan 21, 2015 8:40 pm 
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suboxdoc wrote:
Wow-- good references! Our hospital in Wisconsin encourages breast feeding by moms on buprenorphine. Realize that whatever level of buprenorphine the baby is exposed to in the uterus will be higher than the amount in breast milk. Also, the small amount of buprenorphine in breast milk is swallowed by the baby, and metabolized at the liver.

We had a tragic incident where a baby died at 6 weeks from events unrelated to buprenorphine. But the mother was on buprenorphine, and nursing the baby. At autopsy the baby had no measurable buprenorphine in the bloodstream. A tragic case-- but I suspect the findings are consistent with most babies nursing from moms on buprenorphine.


That is really tragic but at least some good came out of it in the medical findings that the baby had 0 traceable amounts of buprenorphine in its bloodstream. I also was not thinking about the fact that the baby is swallowing the miniscule amount of buprenorphine thus it being metabolized in the liver and rather ineffective. I feel for all pregnant mothers that are opioid dependent. Just the constant feeling of judgement from others must be rather difficult. I've watched it first hand with methadone and the baby was in the NICU for 7 weeks being weened down on oral morphine. It was not something I ever wanted to watch again honestly. She is a healthy 3 year old now from what I've heard but to me personally I think buprenorphine would actually be an easier process due to the breastfeeding afterwards giving it the tiny itty bity amounts it needs to be comfortable. Im also a big advocate of breast feeding for all mothers.


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PostPosted: Wed Jan 21, 2015 10:27 pm 
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I have worked in the medical field for 30 years (yikes) and my son and son in law are in the field now. The answer to why hospitals & a lot of primary care doctors don't know how to treat sub patients is LACK of EDUCATION! My son in law works in the ER in a major city hospital where gun shot victims are a regular nite for him but someone comes in on suboxone and it sends everyone into a tizzy.

The hospital doesn't want to pay for training and after working a 12 hour shift to go home and deal with family life there isn't time for many to educate themselves.

One thing my son in law said was it would be smart for EVERYONE to have a list of meds they are on next to their license (in case a person can't talk or remember) and for people to wear "alert" jewelry.

Dr. J has good information we can print out and talk about with our doctors on a routine visits. Maybe they would take time to learn a little. It should NOT be up to us but it is our lives and we can do some things to protect ourselves.

This subject makes me crazy. Hospitals and doctors should at least be advised to educate themselves. Pharmacy companys have seminars to push the new drug, Suboxone makers should offer a free seminar/dinner to help the people that now take the medication they promote...urghh rant over :)


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PostPosted: Wed Jan 21, 2015 11:15 pm 
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Thank you, each one, for your replies. This information is exactly what I needed. I hope to show it to my doctor and hope that I don't come off as someone who thinks they know more than their doctor but instead as a mother who wants to do what is right for her baby. Everything in me screams that breastfeeding is in my baby's best interest. I am grateful to have some real info to back that up. Thanks again!


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PostPosted: Thu Jan 22, 2015 2:13 am 
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Worst-case scenario: Pump your milk until baby comes home and then nurse your baby anyway!

Amy

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PostPosted: Thu Jan 22, 2015 11:01 am 
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Amy-Work In Progress wrote:
Worst-case scenario: Pump your milk until baby comes home and then nurse your baby anyway!

Amy


I have considered this, Amy. Hopefully it won't come down to this, as I would really like the support of a lactation consultant and the nurses. This is my 4th child, and I have always bottle fed because of various reasons, mainly going back to work. This time, my husband supports me being a stay-at-home mom so I have the time and energy to dedicate to nursing. I'm nervous that I might not succeed, though, so I really hope that the staff will support me.

On a positive note, I'm older (36) so I do feel comfortable advocating for myself in a way that I fear younger mothers might not feel comfortable doing. I like to go in with facts that health professionals will respect. Like someone mentioned above, I fear a lack of education is a huge hindrance in issues like this. I am seeing my OB today, so I am going to see where she falls. If anything, I know that she has close ties to Ohio State University. I am pretty sure that they ARE knowledgeable and will likely support the breastfeeding. She has already consulted them once for me on a bupe issue. I may ask her to do so again.

Thanks again!


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PostPosted: Fri Mar 27, 2015 4:24 pm 
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I'm late to reply, but I wanted to report that I have breastfed my son while taking anywhere from 8 to 20 mg of Subutex daily for 20 months and going, with no ill effects. I'm actually currently 23 weeks pregnant, on Subutex, and breastfeeding.
One thing I did have trouble with was milk supply...I worked with 2 lactation consultants and we tried EVERYTHING to boost my supply but I never made enough to exclusively breastfeed. The LC thought Subutex *may* have been part of the reason but we both agreed that it wasn't worth it for me to stop. I supplemented with donor breastmilk and formula and gave him as much of my milk as I could. I'm interested to see how supply goes with this new baby, as my son who I had supply issues with had some other issues that could have hurt supply (a 10 day NICU stay, unrelated to w/d (jaundice) and a tongue tie that wasn't corrected till 3 weeks.

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PostPosted: Sat May 16, 2015 8:30 pm 
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Iam currently breastfeeding my one month old and have been since the day she was born. I am on and was on 12 mg of subutex all throughout my pregnancy. She seems to be doing well with it. She did go through mild withdrawal when she was born and the worst started around day 3 and subsided around day 8. She didn't need morphine or phenobarbital. I personally believe breastfeeding helped her withdrawal and my OB was all for me doing it. So were the doctors and nurses in the L&D unit. As for not knowing if she's going to go through withdrawls again when i stop breastfeeding (which I plan on doing at least til she's a year old) nobody knows. I'm going to taper down to 2mg or less or be off of it completely by that time. There are alot of doctors out there that are for breastfeeding while on Subutex and there's not really a whole lot of evidence to not support it. By the way, if you are really really planning on doing something in particular with your child, like breastfeeding or bottle feeding, do not let the hospital stop you because they don't agree with it. Screw them. You're the mom which makes it totally your call. Good Luck with whatever you choose to do.


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PostPosted: Thu May 28, 2015 9:23 am 
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Just an update: I had my sweet baby 11 wks ago. She did amazing in the hospital. She did have some low nas scores, but the nurses explained that even non-bupe exposed newborns can score a 2 or 3 just because some of the symptoms are also normal normal symptoms, such as sucking, sneezing, etc. She came home with me at our normal discharge date.

As for breastfeeding, I have been able to breastfeed her for the past 11 weeks with no issue. I am in the beginning process of weaning (for other non-related reasons) but am thrilled to have made it this far. I have enough frozen to get her to almost 4 months! I did have some supply issues in the beginning and because of lip/tongue ties, I became an exclusive pumper. The struggle has been real, lol, but the work has been worth the reward. She is thriving. I am going to transition her to formula slowly to avoid the chance of withdrawal, though I understand it is small.

I know without a shadow of a doubt that my sweet baby Ally would not be here if I weren't on bupe. I couldn't have carried the pregnancy nor could I have taken care of her since her birth. I have severe chronic pain, sometimes can't walk well, but bupe has helped me with all of that. Its not as effective as the short acting opiates that I use to take, but I believe its the best option for me. Good luck to any mom who is pregnant/nursing while on bupe. As long as you are doing what is best for you and your baby, you can be extremely proud of that, including bupe treatment!


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