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Epidural clonidine for pain management of parturients on buprenorphine therapy
Abstract Number: S-39
Abstract Type: Case Report/Case Series
Introduction: Opioid dependence during pregnancy is associated with obstetrical and neonatal complications. Pharmacological treatment of opioid dependence with methadone and buprenorphine improve both maternal and fetal outcomes with reports concluding that neonates exposed to buprenorphine have better outcomes than their methadone counterparts. Given the excessive opioid requirements for those on buprenorphine therapy, alternate analgesic use is warranted. The following cases demonstrate the use of epidural clonidine.
Case One: A 22yo G1P0 on buprenorphine maintenance presented in active labor. An epidural was inserted, bloused, and a PCEA infusion of bupivacaine 0.1%+clonidine 2mcg/mL+epinephrine 0.0012mg/mL was started at 10mL/hr. Both the parturient and fetus remained hemodynamically stable throughout labor, pain was controlled and a spontaneous, non-assisted vaginal delivery resulted. The epidural was removed approximately 4 hours post-partum with no complaints of pain. She was continued on her buprenorphine therapy throughout her hospitalization and her postpartum pain regimen consisted of acetaminophen and NSAIDs.
Case Two: A 25 year old G2P0 on buprenorphine therapy presented in active labor. An epidural was placed and an infusion of bupivacaine 0.125%+fentanyl 2 mcg/ml was started. Six hours later, the obstetrician called for an emergency cesarean section. The epidural was continued for postoperative pain control employing bupivacaine 0.0625%+clonidine 4 mcg/ml. Buprenorphine was maintained throughout. The epidural was removed 22 hours later with reports of adequate pain control with NSAIDs and oxycodone/acetaminophen therapy.
Discussion: Given buprenorphine's unique mechanism of action, women on this therapy present challenges in pain management both during labor and after a cesarean section. Both women presented here had low pain scores without excessive opioid use suggesting that the non-narcotic adjuvant of epidural clonidine is effective for those parturients on buprenorphine maintenance.
Conclusion: Our experience thus far suggests epidural clonidine is a useful adjunct for pain management in parturients undergoing buprenorphine therapy. Further investigation of use and optimal dosage is warranted.
1. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol; 119 (5); 1070-6.
2. Meyer M, et al. Intrapartum and postpartum analgesia for women maintained on buprenorphine during pregnancy. Eur J Pain
3. William A, et al. Management of women treated with buprenorphine during pregnancy. American Journal of Obstetrics &
Gynecology. 2011; 205 (4): 302-8.
4. Jones HE, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. NEJM. 2010; 363:2320–31.
5. Jones HE, et al. Post-Cesarean pain management of patients maintained on methadone or buprenorphine. Am J Addict