Buprenorphine Microdosing Induction in Pregnancy Background As illicit

Buprenorphine Micro-dosing Induction in Pregnancy: Background • As illicit fentanyl has become a predominant opioid of abuse in New Mexico and many areas of the United States • Buprenorphine induction is becoming more difficult with women having trouble tolerating the withdrawal required to initiate buprenorphine and then having prolonged withdrawal despite buprenorphine titration. I • In pregnancy this can result in a higher proportion of pregnant women using methadone: we have gone from 70% bupe to about 20% bupe • Accompanying increase in length of stay of newborns for Neonatal Opioid Withdrawal Syndrome. • Inability or unwillingness to access daily methadone leading to women not on MOUD

Buprenorphine Micro-dosing Induction in Pregnancy overview • Initiation of buprenorphine by a microdosing protocol occurs without a need to enter withdrawal and occurs outpatient regardless of gestational age • Micro-dosing buprenorphine has been used for methadone, however, methadone to buprenorphine transition is not encouraged in pregnancy. • Addiction medicine physicians are increasingly using the micro-dosing approach in patients chronically using illicit fentanyl. • Micro-dosing buprenorphine involves the patient continuing their illicit opioids until there is adequate buprenorphine to prevent withdrawal. • As we cannot legally administer opioids other than methadone or buprenorphine for fentanyl or other opioid withdrawal, this needs to occur as an outpatient and can occur at any gestational age. • If occurring after 24 weeks an NST is required and ultrasound to rule out fetal growth restriction is recommended if not done in last 4 weeks.

Bupe Microdosing Protocol: eligibility • All women with OUD in pregnancy that plan to initiate medication assisted treatment should have a urine drug screen including urine fentanyl and a careful history of current opiate use taken. Fentanyl can be tested at Tri. Core in the UDM Pain assay or UFEN. • Women who have known fentanyl use or fentanyl in their urine drug screen or a history of difficulty in prior buprenorphine induction should be offered buprenorphine micro-dose induction however can be offered to other women

Bupe Microdosing protocol: Initiation • Women who qualify for micro-dose induction should optimally be seen in • • Tucker Milagro Clinic or one of the other Milagro sites if there is physician who can counsel and start microdosing. May also be counseled by FMOB attending or MCH fellow along with MCH resident in OB triage and given prescription: She may receive their first dose of a 1/4 film of 2 mg buprenorphine in clinic or by prescription. This should not induce withdrawal. If in clinic observing the patient for at least 30 minutes should be reassuring to both the patient and provider but it is not needed if a prescription is provided rather than dispensing. The patient will be prescribed buprenorphine strips for 4 -7 days with clinic follow-up at that time. If doing well then prescribe enough films for another 710 days and see weekly for at least two weeks

Buprenorphine/naloxone 2/0. 5 mg films for days 1 -10 (prescribe enough until the 4 -7 day recommended follow-up) and continue current opioid (heroin, fentanyl, oxycodone, etc. ) Yes this is Suboxone combination product in pregnancy! • Day 1: 1/4 film SL one time (0. 5 mg) • Day 2: 1/4 film SL one time (0. 5 mg) Day 3: 1/4 film SL in the morning and ¼ film SL at night. (1 mg) • Day 4: 1/4 film SL in the morning and ¼ film SL at night. (1 mg) Day 5: 1/2 film SL in the morning and 1/2 film SL at night. (2 mg) • Day 6: 1/2 film in the morning and 1/2 film SL at night. (2 mg) Day 7: 1 film SL in the morning and 1 film SL at night. (4 mg) • Day 8: 1 film SL in the morning and 1 film SL at night. (4 mg) Day 9: 2 films in the morning and 2 films SL at night. (8 mg) Day 10: 2 films SL in the morning and 2 films SL at night. (8 mg)

Buprenorphine/naloxone 8/2 mg films starting day 11 • Day 11 Patient should stop their current opioid (heroin, fentanyl, oxycodone, etc. ) and use at least 1 film (8 mg) SL twice a day. Then physician may increase as needed per usual buprenorphine protocol

Microdosing table for patients Buprenorphine/naloxone 2/0. 5 mg films for days 1 -10 Day Morning Dose Evening Dose Total mg/strips for the day 1 ¼ film under your tongue none 0. 5 mg (1/4 strip) 2 ¼ film under your tongue none 0. 5 mg (1/4 strip) 3 ¼ film under your tongue 1 mg (1/2 strip) 4 ¼ film under your tongue 1 mg (1/2 strip) 5 1/2 film under your tongue 2 mg (1 strip) 6 1/2 film under your tongue 2 mg (1 strip) 7 1 film under your tongue 4 mg (2 strips) 8 1 film under your tongue 4 mg (2 strips) 9 2 films under your tongue 8 mg (4 strips) 10 2 films under your tongue 2 films under your tongue 8 mg (4 strips)

Choice of Medication Assisted Treatment during Pregnancy • Women already stable of methadone: Do not offer to change to buprenorphine unless needed for reasons such as lack of geographic access to methadone or prolonged QT interval • Women already on buprenorphine may be offered opportunity to participate in the NIDA MOMS RCT of Injectable weekly Buprenorphine through Milagro program • Women on IM Naltrexone should be referred to see one of Milagro Addiction medicine specialists or fellowship faculty to discuss risks/benefit of continuing during the pregnancy. Naltrexone should not be initiated in pregnancy • Women presenting to OB triage should offered option of routine buprenorphine induction, microdose buprenorphine induction, or methadone initiation.