[Buprenorphine in pregnancy]. / Buprenorphin in der Schwangerschaft.

The treatment of opioid dependence during pregnancy is a major challenge for doctors, social workers and gynaecologists. Continuous drug abuse during pregnancy can lead to a variety of complications in the mother, fetus and neonate. lt is recommended practice to maintain pregnant opioid-dependent women with synthetic opioids and according to international guidelines, methadone is the recommended substance so far. However, a neonatal abstinence syndrome (NAS) of varying severity is observed in 60 - 80 % of the neonates with even a longer course of duration in comparison to the NAS after heroin consumption during pregnancy. NAS is characterised by tremor, irritability, hypertonicity, vomiting, sneezing, fever, poor suckling, and sometimes convulsions. Recent studies have investigated the safety and efficacy of other synthetic opioids like sublingual buprenorphine for the treatment of pregnant patients. We present a 22 year old opioid-dependent woman, who has been maintained continuously on buprenorphine for 3 years. During the treatment episode she delivered two healthy newborns and both did not show any symptoms of NAS. The maintenance therapy with buprenorphine proved safety and efficacy during pregnancy, the mother was free of continuous heroin abuse, verified through supervised urine-toxicology. The quantitative and qualitative difference in NAS may be explained by the partial mu-receptor agonist and kappa-antagonist receptor profile of buprenorphine compared to pure mu-agonist action of methadone or heroin.

[Cocaine abuse in maintenance therapy with methadone in narcotic dependent patients]. / Kokainmissbrauch unter der Erhaltungstherapie mit Methadon bei opioidabhängigen PatientInnen.

INTRODUCTION: From a clinical point of view, additional consumption of cocaine by methadone maintained patients seems to have increased during the last few years. In order to verify this clinical impression, we carried out a retrospective analysis about cocaine abuse by opioid-dependent patients undergoing methadone maintenance therapy at the drug addiction clinic, Department of Psychiatry, University of Vienna. METHODS: Supervised urinalysis was performed on a frequent basis in 160 patients during the investigational time frame of 1997 and 1999. Concomitant consumption of opioids, cocaine and benzodiazepines in urine toxicology results (n = 2242) was compared in a post hoc analysis. RESULTS: In 1997, 45% of urine toxicology tests were positive for opioids, 14.1% for cocaine and 22.1% for benzodiazepines. In 1999, however, 33.1% urine toxicology tests showed positive results for opioids, 22.2% for cocaine and 24% for benzodiazepines. It could be shown that the number of cocaine positive toxicology results increased significantly (p < 0.05) over the course of two years, and that the number of opioid positive tests decreased significantly (p < 0.05), whereas benzodiazepine consumption did not change. Age, and the duration of opioid dependence showed a significant influence on cocaine positive urinalysis. DISCUSSION: The significant increase of additional cocaine consumption in methadone maintained patients reflects the enhanced availability of the substance in Austria, as it has been shown in other European countries and the USA. In addition, evidence based treatment trials are needed to prove the efficacy of alternative opioid maintenance therapy and to evaluate whether cocaine consumption is less of a problem.

Treatment of opioid-dependent pregnant women with buprenorphine.

AIMS: To assess the maternal and fetal acceptability of buprenorphine and neonatal abstinence syndrome (NAS) in children born to buprenorphine-maintained mothers. DESIGN AND SETTING: Open-label, flexible dosing, inpatient induction with outpatient maintenance, conducted at the University of Vienna within the existing pregnancy and drug addiction program. PARTICIPANTS: Fifteen opioid-dependent pregnant women. INTERVENTION: Sublingual buprenorphine tablets (1-10 mg/day). MEASUREMENTS: Mothers: withdrawal symptoms (Wang Scale), nicotine dependence (Fagerström Scale: FTQ) and urinalysis. Neonates: birth outcome and NAS (Finnegan Scale). FINDINGS: All subjects were opioid-, nicotine- and cannabis-dependent. Buprenorphine was well tolerated during induction (Wang Score < or = 4) and illicit opioid use was negligible (91% opioid-negative). All maternal, fetal and neonatal safety laboratory measures were within normal limits or not of clinical significance. Mean birth outcome measures including gestational age at delivery (39.6 +/- 1.5 weeks), Apgar scores (1 min = 8.9; 5 min = 9.9; and 10 min = 10), birth weight (3049 +/- 346 g), length (49.8 +/- 1.9 cm) and head circumference (34.1 +/- 1.8 cm) were within normal limits. The NAS was absent, mild (without treatment) and moderate (with treatment) in eight, four and three neonates, respectively. The mean duration of NAS was 1.1 days. CONCLUSIONS: Buprenorphine appears to be well accepted by mother and fetus, and associated with a low incidence of NAS. Further investigation of buprenorphine as a maintenance agent for opioid-dependent pregnant women is needed.

Buprenorphine versus methadone maintenance for the treatment of opioid dependence.

AIMS: To evaluate the effectiveness of buprenorphine compared with methadone maintenance therapy in opiate addicts over a treatment period of 24 weeks. DESIGN: Subjects were randomized to receive either buprenorphine or methadone in an open, comparative study. SETTING: Subjects were recruited and treated at the drug addiction outpatient clinic at the University of Vienna. PARTICIPANTS: Sixty subjects (19 females and 41 males) who met DSM-IV criteria for opioid dependence and were seeking treatment. INTERVENTION: Subjects received either sublingual buprenorphine (2-mg or 8-mg tablets; maximum daily dose 8 mg) or oral methadone (racemic D -/+ L-methadone; maximum daily dose 80 mg). A stable dose was maintained following the 6-day induction phase. MEASUREMENT: Assessment of treatment retention and illicit substance use (opiates, cocaine and benzodiazepines) was made by urinalysis. FINDINGS: The retention rate was significantly better in the methadone maintained group (p < 0.05) but subjects completing the study in the buprenorphine group had significantly lower rates of illicit opiate consumption (p = 0.04). CONCLUSION: The results support the superiority of methadone with respect to retention rate. However, they also confirm previous reports of buprenorphine use as an alternative in maintenance therapy for opiate addiction, suggesting that a specific subgroup may be benefiting from buprenorphine. This is the first comparative trial to use sublingual buprenorphine tablets: previously published comparison studies refer to 30% solutions of buprenorphine in alcohol.