Management of opioid dependence during breastfeeding

Methadone is considered relatively safe to use while breastfeeding. The concentration in breastmilk is low, regardless of maternal dose. Provided they have no medical contraindications to breastfeeding (illicit drug use, HIV), patients taking methadone should be strongly encouraged to breastfeed. Pharmacokinetics change after delivery; patients usually need to have their methadone dose incrementally reduced in the postpartum period to avoid oversedation, especially when caring for infants. Symptoms of withdrawal may occur in the first week in 60% of infants born to patients who were taking methadone during pregnancy; the concentration of methadone in breastmilk is insufficient to prevent withdrawal. Infants in withdrawal are often very difficult to breastfeed (irritable and hypertonic with poor suck and swallow coordination); involvement of a lactation consultant is desirable.

Buprenorphine has not been associated with adverse effects on the breastfed infant in a small number of reports, and transmission to breastmilk is low. Breastfeeding with buprenorphine is not contraindicated; however, data are lacking on long-term outcomes for exposed infants. No data are available to support the use of buprenorphine plus naloxone while breastfeeding.

Patients who are stable on methadone or buprenorphine should be supported if they choose to breastfeed.