Improving treatment outcome in pregnant opiate-dependent women (original) (raw)
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Methadone and the pregnant user: a matter for careful clinical consideration
The Australian and New Zealand Journal of Obstetrics and Gynaecology, 2001
The practice of placing all pregnant heroin users on methadone as the treatment of choice needs to be questioned. While it may be suitable for those who stabilise their illicit heroin use at or shortly af€er conception, its suitability for those who show little movement away from regular heroin use and its associated lifestyle is more circumspect. Neonates of women who continue heroin use throughout pregnancy are likely to be below birthweight and/or premature. As a consequence, they are in a less than optimal condition to cope with the additional assault caused by prescribed methadone such as neonatal withdrawal. This may help explain why the relative risk of neonatal mortality in women who continue illicit heroin use during pregnancy and are prescribed methadone, is greater than for those who continue to use heroin but are not prescribed methadone. Clinicians must take the time of maternal presentation and the likelihood of continued maternal heroin use into consideration when determining who is suitable for methadone and whether a reduced level of methadone will suffice. A number of different clinical scenarios are identified and possible management strategies discussed. The need to develop innovative services appropriate for pregnant women who continue regular heroin use, and for welldesigned studies that define best practice for the management of these women is evident.
New Approaches in the treatment of opioid dependency during pregnancy
Heroin Addiction and …, 2009
Although methadone maintenance therapy has been used in pregnant women for over 40 years, no randomized trials comparing dosing regimens have been published on which to base specifi c therapeutic recommendations. It has been recommended that dosages should be individually determined which will keep the woman and fetus subjectively comfortable and clinically stable. Although the health and comfort of the pregnant opioid dependent woman remain paramount considerations, higher dosages of methadone (60-150 mg/day) early in pregnancy have been reported to be associated with more normal fetal growth. Data on the relationship between maternal methadone doses, especially late in pregnancy, and subsequent severity of neonatal abstinence have been variable causing considerable confusion for clinicians involved in treating these women. The development of neonatal abstinence has precipitated much controversy and emotional reactions by parents and medical staff. Studies have shown the variability of methadone pharmacokinetics in pregnant women in comparison to non-pregnant individuals. Plasma methadone levels during pregnancy show marked intra-patient and inter-patient variability and usually
Maternal methadone dose during pregnancy and infant clinical outcome
Neurotoxicology and Teratology, 2013
In recent decades there has been an increase in the methadone dosages prescribed for opioid dependent women during pregnancy. Using prospective longitudinal data from a cohort of 32 methadone exposed and 42 non-methadone exposed infants, this study examined the relationship between maternal methadone dose during pregnancy and a range of infant clinical outcomes. Of particular interest was the extent to which any observed associations might reflect the direct causal effects of maternal methadone dose and/or the confounding effects of adverse maternal lifestyle factors correlated with methadone use during pregnancy. Findings revealed the presence of clear linear relationships between the mean methadone dose prescribed for mothers during pregnancy and a range of adverse infant clinical outcomes. With increasing maternal methadone dose there was a corresponding increase in infants' risk of being born preterm, being symmetrically smaller, spending longer periods in hospital and the need for treatment for Neonatal Abstinence Syndrome. After due allowance for potentially confounding maternal health and lifestyle factors, maternal methadone dose during pregnancy remained a significant predictor of preterm birth, growth, and the duration of infant hospitalization post delivery. These findings suggest a need to examine more closely the potential impacts of recent trends towards the use of higher methadone dose levels during pregnancy.
Changes in methadone maintenance therapy during and after pregnancy
Journal of Substance Abuse Treatment, 2011
Objective: The aim of this study is to better understand anticipated changes in daily methadone doses as a guide for prescription during pregnancy. Methods: This retrospective case series involved a single cohort longitudinal design of 139 consecutively chosen women who began methadone therapy before 26 completed gestational weeks. Changes in the single daily dose were based on a standard opiate withdrawal scale and determined from early pregnancy until 6 weeks postpartum. Results: As gestation advanced, the methadone dose increased (86%) rather than remained the same (8%) or decreased (7%). This gradual increase in daily dose during pregnancy (mean increase = 24 mg, 95% confidence level = 20-28 mg) was statistically significant (p b .001) regardless of the initial maintenance dose. By the sixth postpartum week, most subjects (85%) took within 10 mg of their dose at delivery (mean change in dose = −4 mg, 95% confidence interval = −6 to −2 mg). Conclusions: Daily doses of methadone increased until the third trimester, then remained essentially unchanged through the sixth postpartum week.
Methadone in pregnancy: treatment retention and neonatal outcomes
Addiction, 2007
Aim To examine the association between retention in methadone treatment during pregnancy and key neonatal outcomes. Design Client data from the New South Wales Pharmaceutical Drugs of Addiction System was linked to birth information from the NSW Midwives Data Collection and the NSW Inpatient Statistics Collection from 1992 to 2002. Measurements Obstetric and perinatal characteristics of women who were retained continuously on methadone maintenance throughout their pregnancy were compared to those who entered late in their pregnancies (less than 6 months prior to birth) and those whose last treatment episode ended at least 1 year prior to birth. Findings There were 2993 births to women recorded as being on methadone at delivery, increasing from 62 in 1992 to 459 births in 2002. Compared to mothers who were maintained continuously on methadone throughout their pregnancy, those who entered treatment late also presented later to antenatal services, were more likely to arrive at hospital for delivery unbooked, were more often unmarried, indigenous and smoked more heavily. A higher proportion of neonates born to late entrants were born at less than 37 weeks gestation and were admitted to special care nursery more often. Conclusion Continuous methadone treatment during pregnancy is associated with earlier antenatal care and improved neonatal outcomes. Innovative techniques for early engagement in methadone treatment by pregnant heroin using women or those planning to become pregnant should be identified and implemented.
Integrated care for pregnant women on methadone maintenance treatment
Canadian Family Physician, 2013
Web exclusive editor's key points • This national cohort of opioiddependent pregnant women was characterized by a mean age of 29.7 years, white or aboriginal ethnicity, and reliance on social assistance. A history of concurrent psychiatric disorders was also prevalent in this population. • All 3 programs had excellent clinical outcomes, with marked reductions in heroin, prescription opioid, alcohol, cocaine, and cannabis use from the initial visit to the time of delivery. Despite the variability in services at the 3 sites, the programs were equally effective. This might be attributable to their common treatment philosophy-providing care in a safe environment where women are treated with respect and dignity. This article has been peer reviewed.
Neurotoxicology and Teratology, 2013
Pregnant women with substance dependency are a high-risk psychiatric and obstetric population, with their infants also at elevated neonatal risk. This paper draws on prospective, longitudinal data from a regional cohort of 81 methadone-maintained (MM) and 107 comparison women and their infants to describe the obstetric, socio-familial and mental health needs of women in methadone maintenance treatment during pregnancy. Of particular interest was the extent and pattern of maternal licit and illicit drug use over the course of pregnancy. Results showed that MM women had complex reproductive histories, chronic health problems, and were subject to high rates of socioeconomic adversity and comorbid mental health problems. During pregnancy, more than half continued to use licit and illicit drugs, although there was a general trend for drug use to reduce over time. No differences were observed between women maintained on low (12.5-61.0 mg/day) and high (61.1-195.0 mg/day) doses of methadone, with the exception of opiate abuse which was higher in the low dose group (p = .07). Findings highlight that pregnant women enrolled in MMT and their infants represent a vulnerable group with complex, social, obstetric and psychiatric needs. They also reinforce the need for services that can provide on-going wrap-around, multidisciplinary and multiagency care for these high risk dyads, both during pregnancy and in the transition to parenthood.
Comparison of methadone and slow-release morphine maintenance in pregnant addicts
Addiction, 1999
Aim s. To investigate whether the neonatal abstinenc e syndrom e (N AS) is different in children born to wom en m aintained on slow-release morphine, com pared with those m aintained on m ethadone, and to com pare additiona l drug consu m ption in these groups of wom en. D esign , S ettin g and Participan ts. An open, random ized trial was conduct ed in an established clinic. Forty-eight pregnant wom en who presente d to the clinic as opiate or polysubstance abusers were enrolled and maintained on either m ethadone (24 wom en) or slow-release morphine (24 wom en) up to and following delivery. The program m e include d psychosocial therapy and support for their opiate-addicted partners. M easu rem ents. Standard urinalysis m ethods were used to m easure consu m ption of cocaine and benzodiazepines during pregnancy. Injectio n sites were m onitore d to indicate additiona l opiate use. N AS was m easured accordin g to Finnega n score and the am ount of phenobarbiturates prescribed to alleviate the sym ptom s. F in dings. N o difference was found in the number of da ys that NAS was experienced by neonates born to m ethadone or morphine maintained mothers (mean 5 16 and 21 da ys, respectively). All children were born healthy and no serious com plication s arose. Few er benzodiazepines (p , 0.05) and fewer additiona l opiates (p , 0.05) were consu m ed by the m orphinem aintained wom en com pared with those who took m ethadone , but no difference was seen in cocaine consu m ption. N icotin e consu m ption was reduce d signi® cantly in both groups during pregnancy (p , 0.02). C on clusions. Both methadone and morphine are suitable m aintenan ce agents for pregnant opiate addicts . M aintenan ce agents that result in a less prolonged N AS should be studie d in further trials.
Changes to methadone clearance during pregnancy
European Journal of Clinical Pharmacology, 2005
Objective Measurement of plasma methadone concentration to investigate the rate of clearance of methadone prescribed for heroin dependence in the first, second and third trimesters of pregnancy. A secondary objective was to evaluate the outcome of pregnancy. Methods Longitudinal within subject study of nine pregnant opioid dependent subjects prescribed methadone at the Leeds Addiction Unit, an outpatient community based treatment centre. Plasma concentration versus time data for methadone was collected during each trimester and post-partum for our subjects. Data was available for the first and second trimesters for 4/9 cases. All but one of the subjects provided data during the third trimester and data post-partum was collected from three respondents. Measurements of methadone levels in plasma were carried out using high performance liquid chromatography (HPLC). Results Trough mean plasma methadone concentrations reduced as the pregnancies progressed from 0.12 mg/L (first trimester) to 0.07 mg/L (third trimester). The weight-adjusted clearance rates gradually increased from a mean of 0.17 to 0.21 L/hr/kg during pregnancy, although patterns differed substantially between the nine women. An assessment of relative clearance of methadone using two patients for whom we have had all three CL values (trimester 1–3) demonstrated notable change of CL (P=0.056) over time. Eight of our subjects delivered (3 males), within two weeks of their due date the ninth (male) was premature (21 days). The mean length of gestation was 39.7 weeks (SD=10 days) and none of the neonates met criterion for ‘low birth weight’ mean 3094, SD 368 g). Five neonates spent time (0.5–28 days) in a special care baby unit (SCUBU) and 4 of these displayed signs of methadone withdrawal. Conclusions General Practitioners and hospital doctors should recognise the significant benefits of prescribing methadone for heroin-dependent women during pregnancy. We recommend that if a pregnant opioid user complains of methadone withdrawal symptoms (i.e. that the methadone dose does not “hold” them) the prescribing clinician takes this observation seriously and considers a more detailed assessment. Further work on key factors undergoing changes during pregnancy accounting for differences in methadone metabolism in the mother, fetus and neonate are required.