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Choosing Treatment for Pregnant Women Addicted to Opioids

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Doctors caring for pregnant women addicted to opioids may face a difficult choice—should they treat with methadone or buprenorphine? While a study published in 2010 in the New England Journal of Medicine provides some guidance, physicians must consider the individual circumstances of the mother, says study co-author Karol Kaltenbach, PhD, Director of Maternal Addiction Treatment Education and Research at Jefferson Medical College in Philadelphia.

She spoke recently about treating pregnant women for opioid addiction at the 2012 Ruth Fox Course for Physicians, part of the American Society for Addiction Medicine annual conference.

Methadone is the recommended treatment for pregnant women who are addicted to opioids. When properly used, methadone is considered relatively safe for the newborn. But it is associated with neonatal abstinence syndrome (NAS), a group of symptoms caused by opioid withdrawal in the newborn that often require medical treatment and long hospitalization.

The 2010 study found that compared with methadone, buprenorphine resulted in similar maternal outcomes, but buprenorphine was better than methadone in reducing withdrawal symptoms in the newborns. This meant babies required less medication and less time in the hospital.

The Maternal Opioid Treatment: Human Experimental Research (MOTHER) trial included 131 pregnant women who were addicted to opioids, such as heroin or prescription pain medication, with low rates of other illicit drug use. This meant the researchers knew that cases of NAS were caused by opioids, and not other drugs, said Dr. Kaltenbach, who is also Professor of Pediatrics and Professor of Psychiatry and Human Behavior at Jefferson Medical College.

Buprenorphine is a newer medication, and less is known about its effect in pregnant women and their babies. “Our study was not seeking to replace methadone as an option for treatment of opioid dependence,” Dr. Kaltenbach says. “We wanted to clearly delineate the different effects of the two medications.”

There have been no changes in the recommendations for treatment of opioid-addicted pregnant women since the study was published, she notes. “A physician’s decision has to be made on what’s clinically best for the mother,” she says. “If a woman has been successfully maintained on buprenorphine, she should continue on that drug, and the same holds for methadone.”

She says the transition from methadone to buprenorphine can be difficult. “Even though the infant outcomes are better at birth, and we want to minimize the hospital stay for the babies, we also need to consider the health of the mother—if methadone is effective for her, she should stay on it.”

Pregnant women who are addicted to opioids who have never been treated for their addiction are probably good candidates to start buprenorphine, Dr. Kaltenbach states. “If that doesn’t prove to be effective, she can easily be transferred to methadone.”

Many doctors are uncomfortable starting pregnant women on buprenorphine, since there is less experience of using buprenorphine in this population. “Our trial had very rigorous monitoring conditions, in that we hospitalized all of the women for induction onto buprenorphine or methadone so we could maximize their safety and ensure they weren’t going into withdrawal,” Dr. Kaltenbach says. “But that’s not necessarily feasible in community-based organizations or private practices that are treating pregnant women with opioid addiction.”

The study also focused on women who were addicted to opioids, but not to other substances, such as benzodiazepines or alcohol. “In real life, most women using opioids also use benzodiazepines, which affects NAS, making it longer in duration and harder to treat,” she notes.

Dr. Kaltenbach and her colleagues received additional funding to follow the infants in the study through their first three years to see how they developed. The data is currently being analyzed.

8 Responses to this article

  1. SUE / June 7, 2014 at 9:30 am

    hi im a pregnant herion addict and need advise aswell as someones help,could anyone plz be kind enough to reply to me.i want to stop using herion but I dnt know which way to go there are no rehabs near me that have enough knowledge about herion abuse it has only recently become a known drug.Which is a better option to take suboxone or methodone,what are the effects of both medications on babies is it safe to take while been pregnant unfortunately her in South Africa no1 has a clue abt herion its only wat I can get on the web.pls plz reply back im really deperate.

  2. Avatar of haley keen
    haley keen / October 16, 2013 at 12:52 pm

    I just had my son and I was an opoid user in the begining of my pregnancy many people fought with me about having to go into a drug replacement Program through my pregnancy but on was lucky enough to know of a program that treat pregnant women safely in a hospital ain plantation Florida the program is called MAP (maternal addiction program) my son came is perfectly and beautiful not one problem. I did not have to go into a drug replacement program. There are programs that can and will fully detox pregnant women safely! Today I am a proud sober mother with perfectly fine baby boy! Before you think of drug replacement program do your research! I know people who have been on methadone for years because they thought they had no other options when they got pregnant and if they stop they will go thru intense with drawls I think god everyday for this program!

  3. Chevies Newman / March 23, 2013 at 7:01 pm

    I meant that with dependant but not addicted would mean LESS risk to the maternal-fetal system, thanks.

  4. Avatar of Chevies Newman
    Chevies Newman / March 23, 2013 at 6:57 pm

    The inavailability of Methadone makes the choice unreasonable for most. Being legally committed to present to a clinic, everyday, to get the medication becomes difficult when the nearest is 50 miles away. Buprenorphone is a partial opiod agonist with high binding affinity, thus removing reward because there is no cumulative effect from other opiods. This is why an addict can get 30 days in row. Considering up to 1/3 of prescription opiod deaths include methadone, and inferring that fetal safety is dependant on maternal safety, buprenorphone must be used. Concerns include downregulation of genes that encode for ehkaphlonis, our own endogenous opiods, thus a malfunctioning opiod system, possibly passing, in dependant of environment, a predisposition to a “correction” once opiods are later introduced. The so called “activation” experienced by opiod users at first introduction, compared to the rest of us who take our Lortab after surgery, as prescribed, and wonder how others get dependant then addicted. Among this group are likely those who experience physical pain with mood disorders. Mood and pain are related like anxiety and mood.
    The American College of Obstetrics and Gynecology recommends not discontinuing narcotics in pregnancy. Withdrawel can result in seizures, seizures, no air, no air, dead baby. In reality those addicted to short acting narcotics go into withdrawel frequently, thus the anxiety over procuring drugs. Have them dependant, without addiction behavior, risk to the fetal-maternal system is increased.
    Dependence on benzodiazepines also carry risk, discontinuation with seizure is frequent in these groups; benzodiazepines are used in some cases TO treat seizures, not only acutely but chronically.
    Treatment of the maternal addict goes beyond replacing the drug. In many cases there is underlying psychiatric illness that may require a benzodiazepine and one must carefully monitor use and even then treat for bipolar disorder, unipolar depression and anxiety disorders. Masterfully done one may turn from a pregnant heroin user with loss of bowel function in withdrawel to a tax paying citizen raising their child. The rate of this positive outcome is not high without replacement. It is the result for many with opiod relacement. A partial agonist will likely have less overall effect than a full agonist. If we compare two drugs and there effect on an opiod receptor system in the newborn, along with available data, buprenorphone is well tolerated in pregnancy, has far fewer associated risk per amount dispensed and results in an average 10 day withdrawel compared to a 17 day withdrawel for Methadoe and 1/3 the Meds.
    The commentary above seems to point to the drug as the problem. There is an underlying predisposition, in the opiod system, poor functioning of it prior to use and a different physiologic reaction after use. If withdrawel then abstinence were easy, most would stop prior to their delivery date to avoid neonatal withdrawel and scrutiny. Most feel bad about being on opiods in pregnancy, but few resources exist. Suboxone use is relatively easy, safe and provides the foundation to treat; the mother, thus the fetus, are nearly impossible to treat without buprenorphone and pose greater risk to themselves, the fetus and the community, constantly loaded instead of treated, there is a difference.

    Chevies Newman, MD, FACOG

  5. Avatar of liz colten lmft cacIII
    liz colten lmft cacIII / May 11, 2012 at 6:09 pm

    this is such a shame….there is so much wrong with this article that it is discouraging to see what is happening in regards to treatment for opiod addiction….i am sad that the field is now assuming that we treat with medication…..sadder still that the medications are opiates…….and where is the documentation statistically that says most women addicted to opiods also abuse benzodiazepenes???……are the professionals in my field now insisting that we have to prolong addiction (pregnant or not) and also that there is justification to make it standard practice to guarantee fetuses remain addicted until birth……hopefully there are still voices who believe in recovery at the earliest possible opportunity….withdrawal is uncomfortable and sometimes quite painful….it is worth considering if perhaps it would be less traumatic for the unborn fetus to go thru this difficult time….mother nature has long proven that she is a harder but more successful treatment for opiod addiction than the man-made medications that our clients seem to find impossible to discontinue….

  6. Carlos / May 11, 2012 at 4:04 pm

    Last time I looked, buprenorphine did not have enough research to be approved for pregnant women. While methadone has been research for over 40 plus years, Methadone has been found to be safe for pregnant women and their fetes. The biggest problem with methadone is not the medication itself which has been found to be effective and safe but methadone has been widely stigmatized (even by professionals themselves who are ignorant of the research available) and demonized. Treatment is not about the professionals likes and dislikes but what the substantial amount of scientific data shows to be effective, ethical and safe. We seem to be in the Dark Ages of Substance Use Disorder treatment.
    Buprenorphine on the other had is a fairly recent development and cannot be compared and extrapolate. A few double blind studies I have read suggest that this neonatal abstinence syndrome (NAS) seem to be associated with the way the babies are handled after birth. Babies who are handle by nurses and staff that do not know that the patients are addicted to opiate or mother taking methadone have substantially less withdrawal syndromes that babies whose doctors, nurses and staff know that they mother is addicted and/or are on methadone. AS far as I can tell SAMHSA buprenorphine guidelines do not approve of use of buprenorphine with pregnant women. Although the withdrawal syndromes are less for the addicts and as this article suggest the baby. As of last publication there isn’t sufficient research to declare buprenorphine safe for fetes consumption. I hope that one day buprenorphine will be found to be safe, as of recently research I do not believe we have sufficient data on buprenorphine while methadone has been shown to be substantially safe.

    The National Alliance of Methadone Advocates with a large female membership and a good number of women who have been pregnant, have a number of professional experts who have made it their business to find out everything there is to know about methadone. I suggest anyone interested to contact NAMA by email and have them give the email of their experts. I was specially impressed by this female nurse who had a family member on methadone and she had taken a substantial amount of her time to research this issues. If I remember correctly (her name I do not remember) she was also a midwife, but I might be incorrect about the latter information. It was my impression that her level of committment on this issue was rather high and if there is a person who has kept with research that has come on the treatment of Opiodic Preganta patients she is an important expert to contact.

  7. Avatar of Anonymous
    Anonymous / January 20, 2014 at 8:47 pm

    Please tell me the place you went to. I am in this position and am so depressed I cannot function until I get off these. I am pregnant and can’t do another week like this. I pray you respond ASAP

  8. haley / March 25, 2014 at 11:46 pm

    Sadly the program i was in was shut down shortly after my stay due to funding becuse they were not getting enough patients i am not sure of your where a bouts but if it is possible you could call gratitude house (561) 833-6826 and/or susan b anthony (954) 733-6068. I am truly upset that this program was shut down they have been around for years! praying this can help you in some way and that i am not to late and that you see this! good luck with everything! pleae write back let me know how things go!

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