Medication-Assisted Treatment for Opioid Addiction During Pregnancy

MedEdTa:

• No evidence of fetal abnormalities
• Methadone provides pharmacological / physiological stability for the developing fetus at adequate doses for opioid dependent pregnant women
• Dose changes should be made using the same principles as in non-pregnant patients
• Pregnant patients may need an increase methadone dose especially in the third trimester
• Non-dose related neonatal withdrawal is likely but treatable
• Breast feeding should be encouraged unless otherwise contraindicated

Effects of Neonatal Outcome

Infants prenatally exposed to opioids have a high incidence of neonatal abstinence syndrome (NAS), characterized by hyperactivity of the central and autonomic nervous systems that is reflected in changes in the gastrointestinal tract and respiratory system (Kaltenbach et al. 1998). Withdrawal symptoms may begin from minutes or hours after birth to 2 weeks later, but most appear within 72 hours. Preterm infants usually have milder symptoms and delayed onset. Many factors influence NAS onset, including the types of substances used by mothers, timing and dosage of methadone before delivery, characteristics of labor, type and amount of anesthesia or analgesic during labor, infant maturity and nutrition, metabolic rate of the infant’s liver, and presence of intrinsic disease in infants. NAS may be mild and transient, delayed in onset or incremental in severity, or biphasic in its course, including acute neonatal withdrawal signs followed by improvement and then onset of subacute withdrawal (Kaltenbach et al. 1998). Although NAS can be more severe or prolonged with methadone than heroin because of methadone’s longer half-life, with appropriate pharmacotherapy, NAS can be treated satisfactorily without any severe neonatal effects.

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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
Conflict resolution
Housing
HIV prevention
Finding employment
Transportation
Self-esteem
Communication skills
OB/GYN care
Interview, job-skills training
Depression and anxiety
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

Frequently Asked Questions(FAQ) about Methadone and Pregnancy

Frequently Asked Questions(FAQ) about Methadone and Pregnancy


Created in consultation with Robert Newman M.D., director of Beth Israel Medical Center’s
Baron Edmond de Rothschild Chemical Dependency Institute
What is methadone?
• Methadone is an opioid medication used to treat individuals who are dependent on opioid drugssuch
as heroin and the prescription drug Oxycodone; it has also been used extensively in recent years for
management of chronic pain.
• Methadone maintenance treatment (MMT) reduces cravings for opioid drugs, prevents the onset of
withdrawal and blocksthe effects of other opiates.
i
• Forty years of well-documented experience with MMT throughout the world has consistently
demonstrated a marked reduction in illicit drug use and the medical and social consequences of such
use – including a major drop in likelihood of overdose and death.
• MMT is most effective when accompanied by availability of counseling and other supportive
services.
What are the main concerns for pregnant women who experience opiate addictions or who try to
overcome them?
• Use of injection drugs during pregnancy is generally associated with poor nutrition and anemia, high
risk of infectious diseases such as hepatitis and HIV, and inadequate prenatal care
ii
, as well as
exposing the patient to significant risk of overdose.
iii
These consequences place both the expectant
mother and the fetus at risk.
• Opiate detoxification (whether by going “cold turkey” or gradually with the aid of medication)
always is associated with a significant risk of relapse to illicit drug use, but is particularly dangerous
during pregnancy because withdrawal can cause uterine contractions, miscarriage or early labor.
i
Is methadone a safe and effective way to manage opiate addiction during pregnancy?
• Yes, there is a scientific consensus recognized by US government authorities and researchers that
methadone issafe and effective for the management of opioid dependence during pregnancy.
iv
*
• Women can conceive, have normal pregnancies and give birth to and raise healthy children while
receiving methadone treatment.
v
• Methadone maintenance should be continued at therapeutic levels throughout pregnancy to prevent
withdrawal symptoms or relapse to illicit opioid use. It is well established that metabolic changes
during pregnancy often require an increase in the dosage of methadone to ensure optimal therapeutic
results.
• Some newborns born to women receiving methadone maintenance may experience “mild to modest
opiate withdrawal signs and symptoms in the early postnatal period…”vi
When such withdrawal
occursit isreadily managed by appropriate treatment with an opiate medication; there is no evidence
indicating any long-term adverse consequences.
vi
• A review of “the methadone maintenance pregnancy” concluded: “Methadone treatment during
pregnancy offers overwhelming advantages . . . [and] has been shown to be an invaluable and often
an essential ingredient in bettering the health of women during pregnancy, in improving the
outcomes of those pregnancies, and in offering opiate-addicted women a chance to improve both
their lives and the lives of their families.”
vii
• A study published in 2005 found that “high doses of methadone were not associated with increased
risks of neonatal abstinence symptoms but had a positive [i.e., favorable] effect on maternal drug
abuse.”
viii
• It is noteworthy that federal regulations require methadone treatment programs to give priority to
pregnant women who seek treatment and explicitly document reasonsfor denying them admission.
ix
* Buprenorphine is an alternatives medication to methadone. Initial experience has also found it to be safe
during pregnancy, although more research is needed.2
Are women who use methadone in pregnancy “abusing” their fetuses?
• No, in fact, MMT for pregnant women protects their fetuses from the harmful effects of opioid
withdrawal and/or resumption of illicit drug use. For women who are addicted to heroin or other
opiates, MMT isthe most thoroughly researched option to improve their health and birth outcomes.
x
• Methadone does not harm the developing fetus, but maternal withdrawal and detox may create
significant risks of harm.
iv
• Methadone does not cause birth defects or other long-term health problems.
iv
• Babies born to mothers on methadone do as well as other babies and much better than babies born to
mothers using heroin.
i
Are women who use methadone capable of being good parents?
• Yes, people who are on MMT are capable of being good parents. Like any group of parents, some
mothers reportedly benefit from additional services to address co-occurring mental health issues and
to develop parenting skills.
xi
• A review of the scientific literature reveals that methadone is compatible with breastfeeding as the
amount of methadone in breast milk is very small.
xii
The Bottom Line: As a brochure entitled, “Methadone Treatment for Pregnant Women,”
produced and distributed by the US Department of Health and Human Services, sums up:
“Methadone maintenance treatment can help you stop using drugs. It issafe for the baby,
keeps you free of withdrawal, and gives you a chance to take care of yourself.”
i
i
U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration.
Methadone Treatmentfor PregnantWomen. Publication number SMA 06-4124. 2006.
ii
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
Medication-Assisted treatment for opiod addiction during pregnancy. In Medication-Assisted Treatment for Opiod
Addiction in Opiod Treatment Programs, TIP 43. 2005, 211-224.
iii
U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration.
OxyContin: Prescription Drug Abuse. Breaking Newsforthe Treatment Field, 1(1). 2001.
iv
Kaltenbach K, Silverman N, Wapner R. Methadone maintenance during pregnancy. In: Center for Substance Abuse
Treatment. State Methadone Treatment Guidelines. DHHS Publication No. (SMA) 93-1991. Rockville, MD: U.S.
Department of Health and Human Services. 85-93. 1993; Finnegan LP. Treatment issues for opioid-dependent women
during the perinatal period. Journal of Psychoactive Drugs. 23,191-201. 1991; Finnegan LP. Clinical perinatal and
development effects of methadone. In: CooperJR, et al., eds. Research on the Treatment of Narcotic Addiction: State of
the Art. Rockville, MD: U.S. Department of Health and Human Services. 26, 155-61. 1983; Rayburn, WF &
Bogenschutz, MP, Pharmacotherapy for pregnant women with addictions. American Journal of Obstetrics &
Gynecology, 191(6), 1885-97. 2004.
v
The Lindesmith Center-Drug Policy Foundation. About Methadone. 2000.
vi
Institute of Medicine. Federal Regulation of Methadone Treatment. Washington, DC: National Academy Press;
1995:203-4.Retrieved on 8/27/09 from http://www.nap.edu/openbook.php?isbn=0309052408
vii
Kandall, S.R et al. The Methadone-Maintained Pregnancy. Clinicsin Perinatology, 26(1), 173-183. 1999.
viii
McCarthy,J.J. et al. High-Done Methadone Maintenance in Pregnancy: Maternal and Neonatal Outcomes. American
Journal of OBGYN, 193, 606-610. 2005.
ix
Addiction Treatment Forum,retrieved on 8/28/09 from www.atforum.com/newsletters/2009summer.php.
x
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
Medication-Assisted treatment for opiod addiction during pregnancy. In Medication-Assisted Treatment for Opiod
Addiction in Opiod Treatment Programs, TIP 43. 2005, 211-224.
xi
Dawe S, Harnett P. Reducing potential for child abuse among methadone-maintained parents: results from a
randomized controlled trial. Journal of Substance Abuse Treatment, 32(4), 381-90. 2007; Luthar SS, Suchman NE,
Altomare M. Relational Psychotherapy Mothers' Group: a randomized clinical trial for substance abusing mothers.
Developmental Psychopathology, 19(1),243-61. 2009.
xii
Jansson LM, Velez M, Harrow C. Methadone maintenance and lactation: a review of the literature and current
management guidelines.Journal of Human Lactation, 20(1), 62-71. 2004

The ADD ADHD MYTH Does the disease really exist?

NIMH cant define the disease they are treating millions of kids for.. These are the guys we trust as we pop meth into our kids mouth everyday? O I'm sorry, I forgot they call it Ritalin now..

The symptoms of this made up disease are simply due to evolution as a species, fast paced advertising, and deterioration of the brain due to watching television way too much.

It started with MTV, and faced paced commercials, then movies and now everything we watch on TV has fast flip camera angels or fast paced advertising. After 30 years of this, we have evolved and expect our information faster and faster, and the children of today are smarter then their 40 and 50 year old teachers. This is the real reason they suggest drugging.

There are natural remedies for all the things the Psychiatric and Pharmacutial Industry has claimed to cure, spend time doing research and try to think outside of the box. Wake up America...

Source :
http://topdocumentaryfilms.com/the-dr...

We already have unjust secret courts

We already have unjust secret courts - Telegraph:

Behind a wall of secrecy, the family courts routinely turn all the familiar principles of justice upside down.

There was outrage last week over government plans to extend the degree to which our courts can operate in secret. David Davis, former shadow home secretary, claimed that such “a regime of secret courts and hidden judgments”, where defendants could not even be “told the evidence against them”, were worthy only of “despotic one-party states such as Syria, Iran and North Korea”. A letter from 57 of the 69 lawyers already familiar with such practices, from their work on terrorist cases, protested that extending this system would “represent a departure from the foundational principles of natural justice that all parties are allowed to see and challenge all the evidence relied on before the court”.

However shocking this may sound, though, it is already the system which operates in our family courts.

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Open up family court hearings, says senior judge

Open up family court hearings, says senior judge - Telegraph:

A senior judge has made an important ruling in favour of transparency in the family courts.

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A victory for common sense -Battle Over Secret Courts Not Over

A victory for common sense - Telegraph:

A judge was prepared to listen to arguments, but the battle over secret courts is not over

Last week, 702 lawyers, including 38 QCs, signed a letter calling on the Government to drop its Justice and Security Bill, allowing judges to sit in secret on cases involving national security. According to the lawyers, allowing judges to hold their hearings behind closed doors would be “dangerous”, “contrary to the rule of law”, would “erode the core principles of our civil justice system” and would “fatally undermine” the right to a fair trial and open justice. What the lawyers did not say, however, was that we already have a devastating confirmation of all these points in the workings of our family courts, in too many of those tens of thousands of cases every year involving the removal of children from their parents by council social workers.

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