Methadone Maintenance for Pregnant Women

Methadone Maintenance for Pregnant Women



Deborah J. Powers
State Opioid Treatment Authority (SOTA)
Division of Mental Health & Substance Abuse Services
Bureau of Prevention, Treatment and Recovery
Specific Treatment Needs of Pregnant Women Who Use Drugs

Family planning
Money management
Issues of loss
Literacy
Developing a support network
Nutrition counseling
Maintaining employment
Sexual abuse
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OB/GYN care
Interview, job-skills training
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Child care during treatment
Parenting skills
General health care
Drug Use and Pregnancy
Majority of pregnant women who abuse drugs do not seek prenatal care early in their pregnancy
Early signs of pregnancy, such as nausea and fatigue, are often mistaken for drug withdrawal, particularly heroin/opioid withdrawal
Delay in confirmation of pregnancy, due date, and prenatal testing
Prevalence of Opioid Drug Use
During Pregnancy
Approximately 7,000 opioid-exposed babies are born each year
Methadone is the recommended treatment for opioid dependent women
Over 30 years of experience and research
Not appear to have teratogenic potential
Opioids and Pregnancy
Opioids cross the placenta and enter the fetal bloodstream
Abuse of opioids during pregnancy
increases the risk of medical and obstetrical complications, potentially adversely affecting mother and baby2
Increased Risk of Obstetrical Complications
 Spontaneous abortion (miscarriage)
 Placental insufficiency (poor circulation)
 Abruptio placentae (premature separation of placenta from uterus)
 Eclampsia (life-threatening condition involving high blood pressure and seizures)
 Intrauterine growth retardation
 Breech presentation (cesarean section)
Premature labor and birth (respiratory distress syndrome, amnionitis, chorioamnionitis, sepsis), postpartum hemorrhage 
 Effects on fetal EEG, breathing activity, and glucose regulation
 Increased fetal distress, aspiration pneumonia, and stillbirth
 None of the opioid drugs, including heroin and methadone, have been shown to produce physical birth defects, although some research has found higher incidence of visual defects (strabismus)
Methadone Treatment
Pregnant women who abuse drugs have specific needs that must be addressed to facilitate better access and utilization of obstetric and substance abuse treatments
History of Methadone Treatment During Pregnancy
Occurrence of neonatal drug withdrawal associated with maternal opioid abuse dates back to late 1800’s
Upward trend of heroin use in the 1950’s and 1960’s raised concern about the effects of opioids on the developing fetus
As a result of studies conducted in the late 1960’s and early 1970’s, methadone was the recommended treatment for pregnant opioid addicts and in 1997 NIH Consensus Panel recommended methadone as standard of care
History of Methadone Treatment During Pregnancy
In 1973 the FDA declared that all women with confirmed pregnancy were required to undergo detoxification within 21 days after acceptance into a federally licensed methadone program
FDA decision reversed following reports of adverse events, including fetal demise
related to opioid withdrawal
History of Methadone Treatment During Pregnancy
Previous FDA regulations required the lowest “effective” dose
In early 1970s, medical experts recommended MMT for opioid-dependent pregnant women. Recommendations emerged for pregnant women to be maintained on low dose (< 20 mg/day)
Such low dose recommendations were based on efforts to reduce or eliminate neonatal drug withdrawal and were contrary to the therapeutic objectives of methadone treatment
Methadone and Pregnancy
 Methadone can be safe and effective during pregnancy
Prevents erratic blood levels of drugs that put unborn through dangerous withdrawal
Reduces medical complications both before & during childbirth, allowing for healthier newborn
Research shows that methadone is safe for pregnant women and offers greater chance for a healthy baby3
Methadone Treatment Works Best When:
Given in appropriate doses
Given in the context of prenatal care and women-centered treatment
Current research shows that doses below 60 mg are not effective and hence not appropriate and low dose policies for pregnant patients are often associated with increased drug use as well as reduced program retention
Clinical Consideration of Methadone Treatment During Pregnancy
Potential Benefits
{Greater birth weight
{Longer retention in treatment
{Reduced exposure to unknown chemicals from ‘cutting agents”
{Opportunity to engage in other medical and psychosocial interventions
Clinical Consideration of Methadone Treatment During Pregnancy
Potential Risks
{Fetal exposure to psychoactive substance
{Potential for neonatal withdrawal
Opioid Withdrawal Syndrome - Fetus
Despite dramatic appearance, opioid withdrawal syndrome is rarely lifethreatening or permanently disabling to the adult
However, there is good evidence that the fetus may be more susceptible to opioid withdrawal than the mother
Methadone Treatment
It has been shown that comprehensive care of the mother addicted to opioids has a positive impact on the outcome of her pregnancy
Guidelines for comprehensive care include:
Intensive perinatal management for high-risk pregnancy, general medical care, psychosocial counseling, education classes on prenatal care and parenting, psychiatric care, and methadone maintenance when indicated
Barriers to Treatment
Fear of criminal prosecution and removal of children by legal system or regulatory agencies
Absence of adequate child care resources for existing children
Lack of transportation services
Poor access to obstetrical care
Social stigmatization by medical providers
Lack of treatment services addressing women’s issues4
Methadone Treatment During Pregnancy
 Methadone substitution is the standard treatment for heroin/opioid addiction
 Compared to heroin, methadone treatment during pregnancy has been associated with increased fetal growth, reduced numbers of premature births, preeclampsia, and fetal mortality, reduced risk for hepatitis and HIV,
increased likelihood that the infant will be discharged to his or her parents, and increased retention in treatment
Methadone Treatment During Pregnancy
Improves the pregnant woman’s ability to participate in prenatal care, addiction care and other treatment services
Enhances the pregnant woman’s ability to prepare for birth of the infant and begin making a home
Reduces obstetrical complications
Methadone Treatment During Pregnancy
Reduces use of illegal opioids and other drugs
Helps remove the pregnant woman from the drug environment and eliminates the associated illegal behavior
Prevents fluctuations of maternal drug levels, which occurs throughout the day with opioid drugs
Helps result in improved maternal nutrition, fetal growth, and fetal weight
Comprehensive Treatment Services
General medical care
Obstetrical care
Psychological services
Psychiatric care
Support services
Addiction treatment
Methadone treatment for heroin/opioidaddiction
What is the best methadone dose?
No single best dose for pregnant women
Must be individually determined to controldrug craving and prevent withdrawalsymptoms
Dose may need to be increased and/orsplit
Dose and Plasma Levels
It is important to obtain serum methadone levelsin making dosing decisions for pregnant women              Many studies suggest that higher doses aremore effective than lower doses in reducing illicit drug and needle use in the mother; however, …
There is evidence to suggest that doses lessthan 20 mg daily at the time of birth reduce theincidence of neonatal abstinence syndrome5
Methadone Dosing Strategy
Women in methadone maintenance treatment who become pregnant during treatment can bemaintained on their present dose
A majority of women do not seek treatment untilafter they become pregnant
Require comprehensive medical, obstetrical,and psychological evaluation, especially adequate dose of methadone
Methadone Dosing Strategy
Establish tolerance by determining theamount and frequency of drug use, the pattern of drug use, the usual route of administration, purity of the drug
Detailed history of drug use within the past 24 to 48 hours (sometimes less)
Evaluate for signs and symptoms of withdrawal
Methadone Dosing Strategy
Once the patient appears comfortable and thereare no further signs or symptoms of withdrawal, begin dosing once daily, keep the patient at this dose for several days, and continue to adjust dose as necessary
As pregnancy progresses, patients report increasing withdrawal symptoms and frequently require increases in dose to maintain stable plasma levels and remain free of withdrawal
Methadone Dosing Strategy
 Methadone metabolism increases during the third trimester due to increased levels of progestin in the mother, so a given dose may produce significantly lower plasma levels and can result in withdrawal symptoms
Single daily doses of methadone have been found to affect the behavior of the fetus
significantly, whereas split dosing produces plasma levels that fluctuate less and result in a more stable pattern of fetal behavior
Methadone and Childbirth Pain
After delivery, women should continue receiving their regular methadone dose
Methadone is a painkiller, but the body becomes accustomed to pain-relievingqualities – patients will feel pain just like anyone
During labor & delivery, same choices forpain relief should be available – possibly including opioid pain medications
After childbirth
Methadone dose should be continued daily as usual while in the hospital
Breast feeding is recommended while taking methadone; methadone dose show up in breast milk but is too small in amount to affect or harm the child
Breast feeding is not recommended if there is use of alcohol or street drugs or have HIV infection or hepatitis6
Initial Prenatal Evaluation
 Prenatal care should be initiated as soon as possible
 General physical examination
 Estimated due date
 Assessment for medical, obstetrical, genetic, and psychosocial risks
 CBC, UA, urine culture, blood group, Rh factor, antibodyscreen, syphilis test, cervical culture for gonorrhea,Chlamydia screen, hepatitis B and C, HIV, Pap smear
 PPD
 Baseline ultrasound (if indicated)
 Patient education
How is baby affected?
At birth, infant may have slightly lowerthan average birth weight – temporary andcan usually be avoided with proper carebefore childbirth – no smoking or alcohol
Methadone crosses placental barrier so infant can experience some withdrawal
symptoms during first few days
Withdrawal usually develops slowly and is routinely treated by the baby’s doctor
Methadone and Breastfeeding
Endorsed by the American Academy of Pediatrics and the American Osteopathic Association
To minimize possible infant exposure, mother could take her dose of methadone right after breastfeeding and prior to the infant’s longest period of sleep
Methadone Dose and Neonatal Abstinence Syndrome (NAS)
Many addicts feel intense guilt about theirdrug use and make a concerted effort toreduce the amounts and frequency of drug use during pregnancy
Carry this same line of thinking to dose of methadone, believing that a lower dose will be less harmful to the baby at the time of birth
Methadone Dose and Neonatal
Abstinence Syndrome
Ongoing debate regarding relationship between maternal dose and NAS
Often recommended to reduce maternal dose to reduce or avoid NAS
Sub-therapeutic maternal dose may promote supplemental drug use and resultin greater danger to the fetus
Methadone Dose and Neonatal
Abstinence Syndrome
Current research shows that doses below 60 mg are “not effective and hence not appropriate” and “low dose policies for pregnant patient are often associated with increased drug use as well as reduced program retention”
 Methadone dose should be “individually determined by absence of subjective and objective abstinence symptoms and the reduction of drug hunger” (Kandall, 1993)7
Neonatal Abstinence Syndrome
Infants exposed prenatally to heroin or methadone have a high incidence of NAS
Neonatal abstinence syndrome may be more severe and/or prolonged with
methadone than heroin
Research indicates that 60 to 87% of infants born to methadone mothers require
treatment for NAS
Neonatal Abstinence Syndrome
Central nervous system hyperirritability
Gastrointestinal dysfunction
Respiratory distress
Yawning, sneezing, fever
Attempt to suck frantically on fists or thumbs, yet sucking reflex may not be coordinated or effective
Neonatal Abstinence Syndrome
Sneezing
Tremulousness
Poor sleep pattern
 Irritability
Hypothermia Apnea
Unpatterned sucking
Photophobia
Voracious sucking
Hyperacusis
Skin mottling
Hyperreflexia
Diaphoresis
High-pitched crying
Inadequate weight gain
Rubbing or scratch marks
Hypertonicity
Respiratory alkalosis
Diarrhea
Respiratory  Distress
Fever
Hyperactivity
Watery eyes Twitching Sneezing Vomiting
Wakefulness Seizures Stuffy nose Hiccups
Yawning Coarse tremors Runny nose Salivation
Neonatal Abstinence Syndrome
Onset of withdrawal can vary from minutes to hours after birth
Majority of symptoms are present within 72 hours after birth
Premature infants exposed to methadone have less severe abstinence syndrome relative to full-term infants
Neonatal Abstinence Syndrome
In summary, it appears that a majority of studies suggest no relationship between dose of methadone and severity of withdrawal
When weighing the risk-to-benefit ratio for mother and infant, an adequate dose eliminates or reduces illicit opioid use and, therefore, reduces other risks, including HIV and hepatitis
Administration of an adequate dose of methadone appears to be a safer alternative for both mother and fetus, rather than lower doses or none at all
Detoxification During Pregnancy
A majority of treatment practitioners in the field of perinatal addiction medicine hold the belief that methadone should be maintained for the duration of pregnancy to reduce the possibility of illicit drug use,
to minimize the risk of HIV infection, and to maintain contact with the pregnant woman, which might not occur if she was not on methadone8
Detoxification During Pregnancy
Pregnant woman may need to move to a geographic area where methadone treatment is not available
May request detoxification from methadone before delivery
May be too disruptive in treatment necessitating removal from the clinic
Detoxification During Pregnancy
Risks of withdrawal must be explained clearly before initiated, especially that going off methadone places her fetus at great risk for fetal stress
Literature on the use of methadone in pregnant women suggests that withdrawal from methadone be performed without informing her of the dose or the rate
Detoxification During Pregnancy
Suggested rates of withdrawal are patient dependent
Should be performed only in conjunction with obstetrician who can monitor mother and fetus
Fetal death has been documented even when performed under optimal conditions,
such as hospitalization and close fetal monitoring
Detoxification During Pregnancy
Detoxification should not be attempted before the 14th week of pregnancy because it carries the potential for inducing spontaneous abortion (miscarriage)
Detoxification should not be attempted after the 32nd week pregnancy because of possible fetal distress and premature labor induced by withdrawal