Buprenorphine or Methadone: Which One is Better for the Treatment of Opioid Use Disorder in Pregnancy?

With the opioid crisis in the United States, we have viewed expanding fees of opioid use across various sectors of our populace, such as women of all ages of reproductive-age. The threats of opioid use are significant, in particular all through pregnancy, when opioid use is linked with increased chance of pregnancy decline, adverse being pregnant outcomes, and neonatal abstinence syndrome. 

In 2017, around 8.2 for every 1000 deliveries ended up afflicted by opioid use ailment in this region, with even bigger fees noticed in females who had been publicly insured, with an approximated 14.6 for each 1000 deliveries afflicted. Normal treatment for dealing with opioid use ailment all through being pregnant is opioid agonist treatment with possibly buprenorphine or methadone.  

Medication therapy of opioid use problem during pregnancy has unequivocal advantages and is affiliated with enhanced adherence to prenatal care, lessen incidence of preterm birth, lowered recurrence of opioid use, and lessened threat of opioid overdose and demise from opioid overdose.  Typically methadone has been used for the treatment of OUD in the course of being pregnant much more not long ago buprenorphine has develop into a 1st-line remedy.  

Even so, there are important differences in between the two alternatives. Methadone is a comprehensive agonist with superior action at mu opioid receptors, while buprenorphine is a high-affinity partial agonist with minimal action at mu opioid receptors. Even though methadone must be administered all through everyday in-individual visits to federally controlled opioid treatment method systems buprenorphine may perhaps be prescribed by permitted vendors and self-administered by patients. A recent analyze appears at the variations among these two cure alternatives in phrases of neonatal and maternal outcomes. 

 In this examine, Suarez and colleagues used nationwide Medicaid info to establish pregnancies from 2000 by 2018. They evaluated maternal and neonatal results amid individuals who obtained buprenorphine monotherapy or buprenorphine-naloxone mixture therapy versus methadone. Neonatal abstinence syndrome was assessed in relation to remedy administered in the 30 days previous supply. 

The examine integrated 2.5 million pregnancies resulting in a stay birth. In early pregnancy, 10,704 people were exposed to buprenorphine and 4,387 to methadone in late pregnancy (7 days 20 or afterwards), 11,272 and 5,056 have been uncovered, respectively. The greater part of pregnant clients who had been exposed to medicine-assisted treatment method in late being pregnant acquired therapy within 30 times of delivery.

Fewer Adverse Functions in Buprenorphine-Exposed Pregnancies

The research noticed a lot less adverse events in buprenorphine- compared to methadone-exposed pregnancies, whilst premiums of Cesarean portion and severe maternal problems in the two groups were identical.  

Neonatal abstinence syndrome happened in 52.% of the infants who were being exposed to buprenorphine in the 30 times prior to supply as in comparison with 69.2% of those exposed to methadone (modified relative risk, .73 95% CI, .71 to .75). 

Preterm start transpired in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of these exposed to methadone (adjusted relative hazard, .58 95% CI, .53 to .62) 

Modest dimension for gestational age in 12.1% and 15.3%, respectively (modified relative risk, .72 95% CI, .66 to .80) and

Lower birth weight in 8.3% and 14.9% (aRR, .56 95% CI, .50 to .63). 

Premiums of supply by cesarean section were similar in the two teams: 33.6% in buprenorphine- vs. 33.1% in methadone-exposed pregnancies (aRR, 1.02 95% CI, .97 to 1.08).

Charges of severe maternal issues were being related in the two groups: 3.3% and 3.5%, respectively (aRR .91 95% CI, .74 to 1.13). 

Clinical Implications

The present-day research — the greatest to day — observes a decreased chance for adverse neonatal results with the use of buprenorphine as opposed to methadone used during pregnancy in a substantial cohort of persons with opioid use condition. Having said that, the threat of adverse maternal results was equivalent between persons who been given buprenorphine and those who obtained methadone. Though methadone employed to be applied much more usually, the outcomes of this review point out that buprenorphine need to be viewed as as a 1st-line procedure for women who are expecting or of childbearing age. While buprenorphine is linked with fewer adverse events, the authors remind us that any treatment method for opioid use condition in being pregnant is improved than no therapy. 

In an accompanying editorial, Elizabeth Krans, MD, of the University of Pittsburgh, discusses some of the troubles in providing care to pregnant patients with OUD, noting that the selection to use buprenorphine or methadone should reflect individual preferences, former procedure, and medication availability. She also notes that as there has been an boost in the use of significant-efficiency artificial opioids like fentanyl, procedure with buprenorphine is a lot more hard.  For the reason that buprenorphine is a partial opioid receptor agonist, it may well not entirely mitigate opioid cravings and could lead to withdrawal in clients who use fentanyl.

Ideally selections about the variety of best treatment method of opioid use disorder should choose location ahead of pregnancy. Even so, about 80% of pregnancies in women of all ages with OUD are unplanned. In addition, several ladies initiate treatment with medicine for OUD after conception. What ever options are produced, we have to assist our sufferers who are pregnant or setting up to conceive, reminding them that possibly therapy is better than no treatment method.

Ruta Nonacs, MD PhD

Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Jones HE, Connery HS, Davis JM, Grey KJ, Lester B, Terplan M, Mogun H, Bateman BT. Buprenorphine compared to Methadone for Opioid Use Problem in Pregnancy. N Engl J Med. 2022 Dec 1 387(22):2033-2044.