Is it safe to treat opioid addiction with Suboxone during pregnancy?
If you take Suboxone films or tablets and you have just found out that you are pregnant, should you keep taking it? Is it safe for the baby? In most cases, the safe side is to keep taking your medication and call your doctor.
Suboxone contains buprenorphine, a partial opioid that prevents withdrawal and quiets cravings, and naloxone, an opioid blocker that is added to discourage injecting. What follows applies to all of the buprenorphine films and tablets, including ZubSolv and the generics.
No medication is free of risk in pregnancy, and Suboxone is no exception. Yet, the choice is never between Suboxone and nothing. It is between Suboxone and what happens after you stop.
The Suboxone prescribing information, approved by the Food and Drug Administration (FDA), is blunt about that second risk. It says that untreated opioid addiction in pregnancy is associated with low birth weight, preterm birth, and fetal death, and that it often results in continued or returning use of illicit opioids.
Are there risks to the fetus from Suboxone? Does it cause birth defects?
The prescribing information says that the data on buprenorphine in pregnancy are limited, and that those data do not indicate an increased risk of major malformations, meaning birth defects, specifically due to buprenorphine.
While that is reassuring, it is not a guarantee. The label adds that studies in rats and rabbits found harm at some doses, and that the information on naloxone taken under the tongue is too limited to judge. No doctor can honestly promise you a risk of zero.
So, the fair question is whether Suboxone is safer than the alternative. The alternative is withdrawal, cravings, and, for many women, a return to street opioids such as fentanyl. The risk of staying on your medication is small and uncertain. Unfortunately, the risk of stopping is large, and we know it well.
Do I have to switch from Suboxone to Subutex while I am pregnant?
For years, doctors moved nearly every pregnant patient from Suboxone to Subutex, the old brand name for the buprenorphine-only tablet, so that the baby would not be exposed to naloxone.
Many doctors no longer insist on the switch, because very little naloxone is absorbed when a film or tablet dissolves under the tongue. Still, the label calls the data on naloxone in pregnancy too limited to judge.
I recommend buprenorphine without naloxone, the buprenorphine-only tablet, during pregnancy. If you are taking Suboxone when you learn that you are pregnant, do not stop it. Talk with your prescriber about a planned switch, so that you are never left without medication, and keep your obstetrician informed.
Should I stop taking Suboxone for the sake of the baby?
Unfortunately, stopping buprenorphine during pregnancy is generally not advised, and stopping it suddenly is the worst version of the idea. Withdrawal is stressful for a pregnancy, and the larger danger comes afterward. Cravings return, tolerance is gone, and a return to street opioids at that point is more dangerous than it ever was.
Addiction can also play tricks on the mind. If the thought of quitting your medication for the baby’s safety comes to you, think carefully about where it is coming from, because it is an idea you will not want to argue with.
Should I lower my Suboxone dose during the pregnancy?
Pregnancy can change how long a dose lasts, because your body may clear the medication faster as the months go by.
The prescribing information says that higher doses may be required during pregnancy, even for a patient who was stable on her dose before. If you feel withdrawal creeping in before the next dose is due, does that mean you are failing? It does not, and your prescriber needs to hear about it.
The answer may be a higher dose, or the same daily dose divided into two or three smaller ones. While lowering the dose to spare the baby sounds logical, a dose that leaves you in withdrawal does the baby no favors. A lower dose is not a safer dose.
What if I still want to wean off of Suboxone while I am pregnant?
That is your decision to make. While your doctor will probably advise you to wait, a patient who is determined to taper is safer tapering with a doctor than without one.
The only safe shape for it is slow. The prescribing information says to taper buprenorphine gradually, because stopping abruptly or tapering fast brings on withdrawal. In practice, that means small reductions, each one a modest fraction of the dose you are taking at that point, with time in between to see how you feel.
The taper should be patient directed, with one condition. If withdrawal or cravings appear, the taper slows down, holds, or goes back up a step. Never quit cold turkey.
How do I detox drugs out of my system now that I am pregnant?
Maybe you are not taking Suboxone at all, and you are using pain pills, heroin, or fentanyl. The pregnancy test is positive, and you want every drug out of your body today.
People make wrong assumptions about a woman who is pregnant and using drugs. Yet, many women in that position hold a job, raise a family, and hide it from everyone close to them. They deserve respect and support, not assumptions.
Getting the drugs out is the easy part, because all you have to do is stop. The problem is what your body and mind do next, which is withdrawal, then craving, and then, far too often, using again with less tolerance than before.
That is why detox is the wrong instinct for opioids in pregnancy. The treatment is to replace the street opioid with buprenorphine or methadone, keep you steady through the pregnancy, and leave the question of coming off for later.
Alcohol and benzodiazepines, such as Xanax (alprazolam) or Klonopin (clonazepam), are a different and more urgent matter. Never stop a benzodiazepine suddenly, because sudden withdrawal can trigger seizures and can be life-threatening. The same is true of heavy daily drinking, so if you drink every day, see a doctor or go to an emergency room today, and let them manage the withdrawal.
A benzodiazepine is tapered gradually under medical supervision, and for some women, staying on it through the pregnancy may be the right informed choice. The Suboxone prescribing information warns that a benzodiazepine taken with buprenorphine raises the risk of dangerous breathing problems, and it also says that treatment should not be denied for that reason. Tell both prescribers what you take, and do not stop either one on your own.
Should I see my doctor first or go straight to rehab?
See a doctor first, whether that is your family doctor, your obstetrician, an urgent care, or an emergency room. Doctors once needed a special federal waiver to prescribe buprenorphine, and Congress eliminated it at the end of 2022. A doctor with a standard Drug Enforcement Administration (DEA) registration may now be able to start you.
If you are in trouble right now, do not wait for an appointment. Call 911 for an overdose, for anyone who is hard to wake or breathing slowly, or for any emergency in the pregnancy.
Do you need to go to rehab? Usually not. Opioid dependence in pregnancy is most often treated with medication-assisted treatment (MAT) while you live at home, keep working, and keep your prenatal appointments.
Still, some women do need a safe place to stay, and a residential program that provides buprenorphine or methadone along with prenatal care can be the right choice. A program that promises to have you off of everything in a few weeks is not. A rehab stay ends when the insurance does. A pregnancy does not.
Is methadone or Suboxone better for pregnancy?
Both are standard treatments for opioid dependence in pregnancy, and both are far safer than continuing to use.
The advantage of methadone is that you can usually start right away, without waiting to feel sick. The downside is that methadone for opioid dependence is dispensed only at a licensed clinic, which usually means a visit every morning, at least at first.
Buprenorphine comes from a pharmacy with a prescription, and because it is a partial opioid, overdose is less likely than with methadone. Yet, it is usually not started until you are in moderate withdrawal, which the prescribing information puts at no less than six hours after the last opioid use. With street fentanyl the wait is often longer, which is why a start with very small doses is sometimes used.
For the newborn, the comparison favors buprenorphine. In the trial described in the Suboxone prescribing information, about the same number of babies needed treatment for withdrawal in both groups. Yet, the babies exposed to buprenorphine needed less medicine, about 4 days of treatment against about 10, and went home about a week sooner.
If buprenorphine is an option, I recommend it over methadone for most pregnant patients, because it is a safer drug, and it does not tie a new mother to a daily clinic visit.
While that is my preference, it is not a rule. More of the women taking buprenorphine in that same trial left treatment before delivery, and a woman who is already stable on methadone should not switch on her own, because the change can bring on withdrawal.
Can I get Sublocade shots during pregnancy?
Sublocade is buprenorphine given as a monthly injection under the skin. The Sublocade prescribing information says that it should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, and it notes that one ingredient of the gel that carries the drug caused harm in animal studies.
For that reason, your doctor may move you back to films or tablets for the pregnancy. If you receive Sublocade and you are pregnant, or planning to be, call the doctor who gives the injection before the next one is due. Do not simply skip it.
Will my baby be born addicted to Suboxone?
No. A newborn cannot be addicted to anything. Addiction is a pattern of behavior, craving a drug and using it compulsively in spite of the harm, and a baby does none of that.
What a baby can be born with is physical dependence. Physical dependence is not addiction. It means only that the body has adjusted to a medication and reacts when the medication is taken away.
In a newborn, that reaction is called neonatal opioid withdrawal syndrome (NOWS). The signs listed in the prescribing information are irritability, a high-pitched cry, tremor, trouble sleeping, vomiting, diarrhea, and poor weight gain, and they usually appear in the first days after birth.
The same document calls NOWS an expected and treatable outcome of opioid use in pregnancy, and it warns that NOWS can be life-threatening if it is not recognized and treated. Some babies need no medicine at all, and others need medicine for a while.
So, tell your obstetrician early what you take, and plan to deliver in a hospital that knows how to watch for NOWS and treat it.
Will they take my baby away?
Will a social worker come to your hospital room? Will you have to fight to keep your baby? It is as if you did not have enough to worry about already.
The honest answer is that you should expect a conversation, and that a conversation is not a removal. A federal law, the Child Abuse Prevention and Treatment Act (CAPTA), expects states to have health care providers notify child protective services (CPS) when a newborn is affected by drug exposure or withdrawal. In many places, that includes a medication taken exactly as prescribed.
The same law says that the notification is not to be read as a definition of child abuse or neglect, and it calls for a plan of safe care for the baby and the family. How this is handled varies a great deal from state to state and from hospital to hospital.
What you can control is the record. A mother with a prescription, a prescriber who knows her, regular prenatal visits, and no street drug use is in a very different position from a mother who arrives with none of those.
Ask your obstetrician ahead of time what the hospital’s policy is, and ask your prescriber for a letter that documents your treatment. While this is a doctor’s view and not legal advice, hiding your medication from the people who are delivering your baby is the worst plan available. Do not let this fear keep you away from prenatal care.
Can I have an epidural, and can I get pain meds after delivery, if I take Suboxone?
Yes to both. Buprenorphine is ordinarily continued through labor and the hospital stay, and an epidural or a spinal works the same for you as for any other woman.
The prescribing information says that women on buprenorphine may need additional pain relief during labor. After a cesarean, you may need more pain medication than another patient would, because your body is tolerant to opioids.
An earlier version of this article suggested that a new mother on Suboxone should try to tolerate the pain. That is no longer the advice.
Two pain medications sometimes used in labor, Stadol (butorphanol) and Nubain (nalbuphine), can throw a patient on buprenorphine into sudden withdrawal. Ask that they be listed in your chart as medications to avoid.
After my baby is born, can I breastfeed while taking Suboxone?
In most cases, yes. The prescribing information reports that buprenorphine and its breakdown product, norbuprenorphine, pass into breast milk at low levels, and that the available data have not shown harm to breastfed infants. There are no data on the combination with naloxone in breastfeeding, but very little naloxone is absorbed by mouth.
The label asks for one precaution, which is to watch the baby for unusual sleepiness or trouble breathing. Call the pediatrician if you see either one, or 911 if it looks serious.
It is your choice whether to breastfeed or use formula, and what matters more is that you stay on your medication in the months after the birth. There is more detail in the article on breastfeeding while taking Suboxone.
You do not have to choose between your treatment and your baby.
Staying on your medication is not something you are doing instead of protecting your baby. It is how you are protecting your baby.
I treat opioid dependence with buprenorphine by telemedicine in Florida.
I provide buprenorphine treatment with Suboxone and its film and tablet generics to new patients throughout Florida by telemedicine, with in-office visits available in Fort Lauderdale. The first doses are taken at home with phone support, a low-dose start is used when fentanyl is involved, and visits are monthly, or weekly when they are needed. I accept pregnant new patients by telemedicine, and I coordinate care closely with your obstetrician.
If you have questions about opioid dependence treatment with buprenorphine, please reach out through the contact form.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
