Methadone maintenance is optimal in pregnancy.
(adapted from the Journal of Psychoactive Drugs, 26:155-161, 1994)
The Brown University Digest of Addiction Theory and Application, Feb 1995 v14 n2
Full Text COPYRIGHT 1995 Manisses Communications Group Inc.
Despite possible complications and public policy controversy, methadone maintenance during pregnancy is stiff the treatment of choice for opioid addicted women, according to a recent article in the Journal of Psychoactive Drugs. The course results in better fetal outcomes and helps stem the tide of HIV infection in mothers and their children.
According to Margaret A.E. Jarvis, M.D., and Sidney H. Schnoll, M.D., Ph.D., from the Medical College of Virginia, the risks to mother and fetus in methadone maintenance are far fewer than those associated with cycles of sudden withdrawal and reintoxication by street drugs, as well as the related lifestyle dangers including high-risk HIV related behaviors. Women denied or removed from methadone maintenance during pregnancy are highly likely to relapse into heroin use.
Jarvis and Schnoll based their conclusions on a review of the literature. Although there are few studies on the effects of opioids in human fetuses, animal studies indicate that such drug use produces fetal stress. Precipitated withdrawal is worse than intoxication, but cycles of abuse and withdrawal are particularly harmful.
"It is clear that devastating consequences of opioid use during pregnancy occur with repeated episodes of intoxication and withdrawal," they say.
Methadone maintenance is the best way to provide stabilization, although infants born to methadone maintained mothers may undergo a withdrawal syndrome after birth. Infant withdrawal "combines the symptoms of the adult withdrawal syndrome, with irritability, poorly coordinated sucking and, in the most severe cases, seizure and death." Lowering the methadone dosage can lessen or even eliminate this withdrawal syndrome, however. The authors report that "at methadone doses of less than 20 mg per day, little or no neonatal abstinence is seen."
Of course, lowering the methadone dosage may affect the mother's ability to remain drug free, especially since some studies have indicated that methadone metabolism accelerates during the last trimester of pregnancy. Thus, "increasing the dose of methadone might be necessary to prevent withdrawal symptoms late in pregnancy." Alternatively, "splitting the dose of methadone into a twice-daily schedule" may help to avoid the need to increase the dosage.
Methadone treatment for pregnant women works best in "well-coordinated multidisciplinary care settings" where good obstetrical and medical care, as well as counseling and parenting education, can be provided.
Although opioid withdrawal during pregnancy is dangerous for the mother and the fetus, in some cases, it cannot be avoided. If the patient refuses methadone maintenance, lives in a place where maintenance is not available, or has been stable for some time and wants to become completely drug free, she may need to be withdrawn from opioids.
The authors say that a careful, controlled, and slow withdrawal should not endanger the fetus during any stage of the pregnancy. If withdrawal is necessary, the woman should be provided with extensive psychosocial support, so that she will be less likely to return to heroin use once drug free.
However, the authors emphasize that they "discourage" withdrawal from methadone during pregnancy except under unusual circumstances.
Suggested readings:
Doberczak, T.M., Kandall, S.R., Friedman, P. Relationships between maternal methadone dosage, maternal-neonatal methadone levels and neonatal withdrawal. Obstetrics and Gynecology, 81:936-940,1993.
Giles, W., Patterson, T., et al. Outpatient methadone programme for pregnant heroin using women. Australian and New Zealand Journal of Obstetrics and Gynecology, 29:225-229, 1989.
Maas, U., Kattner, E., et al. Infrequent neonatal, opiate withdrawal following maternal detoxification during pregnancy. Journal of Perinatal Medicine, 18:111-118, 1990.
Margaret A.E. Jarvis, Sidney H. Schnoll "Methadone Treatment During Pregnancy," Journal of Psychoactive Drugs, 26:155-161, 1994. Reprint requests to: Dr. Jarvis, Division of Substance Abuse Medicine, Box 980109, Medical College of Virginia, Richmond, VA 23298.