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Treating opioid dependence during breastfeeding

Published
Topics: BuprenorphineBuprenorphine + NaloxoneMental health and illness · MethadoneNaltrexoneSafety in Breastfeeding ·

Methadone is the preferred choice of treatment for opioid dependence during breastfeeding. Recommendations apply to full term and healthy infants only.

Contents

  1. General considerations
  2. Recommendations
  3. Clinical Considerations
  4. Infant withdrawal
  5. Specific recommendations
    1. Methadone
    2. Buprenorphine
    3. Naltrexone
  7. Patient Information
  8. Contact us
  9. About our recommendations
  10. Bibliography

General considerations

It is important to complete an individual risk assessment (SPS page) for your patient and to apply the principles of prescribing in breastfeeding (SPS page) when looking at the available information and making treatment decisions.

Recommendations

Methadone is the preferred choice of treatment for opioid dependence during breastfeeding as there is more evidence and experience of its use.

There is less evidence and experience for the use of buprenorphine (including in combination with naloxone), or naltrexone.  However these are still considered compatible with breastfeeding.

Infants exposed to methadone, buprenorphine, or naltrexone during pregnancy can breastfeed as normal after delivery.

Breastfeeding has benefits to an infant who has been exposed to maternal opioids during pregnancy and may reduce any withdrawal symptoms in the infant.

The National Institute for Healthcare Excellence (NICE) advises avoiding sharing a bed with the infant when sedating medication has been used, due to the increased risk of sudden unexpected death in infancy.

Clinical Considerations

Treating opioid dependence in breastfeeding is a complex scenario. As well as the risks associated with exposing infants to substitution therapies through breast milk, wider clinical and social implications also need to be considered. The National Institute for Healthcare Excellence (NICE) Clinical Knowledge Summaries (CKS) provides further advice.

Infant withdrawal

Infants exposed to opioids during pregnancy should be observed for withdrawal symptoms. Opioids present in breast milk may decrease withdrawal symptoms, but may be insufficient to allow dose reduction of any treatment of the infant.

Withdrawal symptoms in the infant may also occur during breastfeeding if the mother stops taking the medication suddenly or breastfeeding stops suddenly.

Specific recommendations

Use with caution

Methadone is the preferred choice during breastfeeding as there is more experience of its use, but infant monitoring is still required.

Infant monitoring

Monitor infants for drowsiness, adequate weight gain, respiratory problems, constipation, looking pale, and developmental milestones, especially in infants up to one month old and exclusively breastfed infants.

Further information

There is a moderate level of evidence and experience of use in breastfeeding, and small amounts pass through into breast milk.

Side effects are more likely to occur in infants not exposed to methadone during pregnancy or when the mother is receiving a high maintenance dose.

Use with caution

Buprenorphine can be used with caution during breastfeeding, including in combination with naloxone, but infant monitoring is still required.

Infant monitoring

As a precaution, monitor infants for drowsiness, adequate weight gain, respiratory problems, constipation, looking pale and developmental milestones, especially in infants up to one month old and exclusively breastfed infants.

Further information

Buprenorphine is compatible with breastfeeding. Published information has shown it is excreted into breast milk in very small amounts.

No side effects have been reported in breastfed infants.

Buprenorphine in combination with naloxone can also be used whilst breastfeeding, and breast milk levels are likely to be low.

Use with caution

Naltrexone can be used with caution during breastfeeding due to negligible amounts in breast milk, but monitoring is still required.

Infant monitoring

As a precaution, monitor infants for drowsiness, adequate weight gain, respiratory problems, constipation, looking pale, and developmental milestones, especially in infants up to one month old and exclusively breastfed infants.

Further information

There is very limited published evidence of use during breastfeeding. However, negligible amounts of naltrexone and active metabolite were found in breast milk.

No side effects have been reported in breastfed infants.

Patient Information

The NHS website provides advice for patients on the use of specific medicines in breastfeeding.

Contact us

Get in touch with the UK Drugs In Lactation Advisory Service (UKDILAS) (SPS page), our specialist breastfeeding medicines advice service if you need support in the following situations:

  • you need further advice
  • the medicine in question is not included here
  • the infant is unwell or premature
  • multiple medicines are being taken

About our recommendations

Recommendations are based on published evidence where available. However, evidence is generally very poor and limited, and can require professional interpretation. Assessments are often based on reviewing case reports which can be conflicting and lack detail.

If there is no published clinical evidence, assessments are based on: pharmacodynamic and pharmacokinetic principles, extrapolation from similar drugs, risk assessment of normal clinical use, expert advice, and unpublished data. Simulated data is now increasingly being used due to the ethical difficulties around gathering good quality evidence in this area.

Bibliography

Full referencing is available on request.