Methadone vs buprenorphine in pregnancy

Methadone is a full agonist of the µ-opioid receptor and has been utilized since the 1970s as the standard treatment for OUD in pregnancy.¹ It is dispensed on a daily basis by registered comprehensive addiction treatment programs. Currently, it is not legal for physicians outside of such licensed treatment facilities to prescribe methadone to treat OUD (although the drug can be prescribed on an inpatient basis for continuation or initiation of MAT). All providers should be aware that potential significant medication interactions exist with methadone – including, but not limited to, some nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors, antiretroviral medications, protease inhibitors, tricyclic antidepressants or rifampin. In addition, there is a risk of maternal respiratory depression and QTc prolongation.

Buprenorphine is a partial agonist of the µ-opioid receptor, thereby giving it an improved safety profile. It decreases the activity of full opioid agonists (e.g., methadone, heroin, morphine, oxycodone). Accumulated recent evidence supports use of buprenorphine in pregnancy² and it is available as either a mono-product (buprenorphine alone, Subutex) or as a combined product with naloxone (buprenorphine/naloxone, [e.g., Suboxone). The naloxone component is not active if taken in the proper fashion (sublingually); however, a patient will experience significant withdrawal symptoms if she injects the medication (naloxone is an opioid antagonist that will displace opioids from receptors). For that reason, the combined product is used to prevent improper intravenous use of the buprenorphine. Historically, providers have had concerns about providing the combined product in pregnancy; however, accumulating data support use of buprenorphine/naloxone in pregnancy.^3,4

For more information on OUD in pregnancy - The opioid crisis: Prenatal and postnatal care

References:

1. American College of Obstetricians and Gynecologists. Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. Obstet Gynecol. 2017;130:e81–94.

2. Jones HE, Kaltenbach K, Heil SH e tal. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363(24):2320-2331.

3. Debelak K, Morrone WR, O’Grady KE, Jones HE. Buprenorphine + naloxone in the treatment of opioid dependence during pregnancy-initial patient care and outcome data. Am J Addict. 2013;22(3):252-254.

4. Lund IO, Fischer G, Welle-Strand GK et al. A Comparison of Buprenorphine + Naloxone to Buprenorphine and Methadone in the Treatment of Opioid Dependence during Pregnancy: Maternal and Neonatal Outcomes. Subst Abuse. 2013;7:61-74.