Running Head: METHADONE TREATMENT
Methadone Treatment during Pregnancy
Substance and Alcohol Abuse
Anna Segovia, Erin Schnurbusch, and Victoria Carter
George Warren Brown School of Social Work
April 23, 2014
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Running Head: METHADONE TREATMENT
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Introduction
According to The National Survey on Drug Use and Health (2012) 5.9% percent
of pregnant women report being current illicit drug users. However, because this
statistic is self-reported, it is believed to be much higher. Many women find
themselves pregnant while addicted opioids, scared, and without knowledge of
proper neonatal resources or clinics available. There are several treatment options;
however, Methadone Maintenance Treatment (MMT) has been the widely used and
accepted treatment option since the 1970s (Center for Substance Abuse Treatment,
2005). Since then there have been medical advancements in terms of buprenorphine
and buprenorphine-naloxone as alternatives to using methadone which will be
expound upon further.
The Overall Alcohol and Drug Problem in the US
As substance abuse becomes an issue of increasing prevalence in the United
States, more emphasis is being placed on studying both the occurrence of chemical
dependency and approaches for treatment. In recent years, substance use has
reached a worrisome high. According to the National Survey on Drug Use and Health
(2012) 9.2% of the U.S. population had used illicit drugs during the previous month.
These drugs are not only illegal, but present a significant challenge to public health
in the U.S. The same survey reported that 52.1% were current drinkers at the time
of the survey, and binge drinking and heavy drinking were reported by 23% and
6.5% of respondents, respectively. Because substance use is correlated with a
variety of health issues, these numbers are cause for concern. The National Survey
on Drug Use and Health (2012) also found that 5.9% percent of pregnant women
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reported being current illicit drug users and 8.5% reported current alcohol use.
Because substance use during pregnancy can have a variety of negative effects on
both mother and infant, it is vital that treatment is available specifically for this
population. As such, the following is a discussion of current approaches to
treatment.
Current Treatment Options
Currently, there are few programs directed specifically at treating pregnant
women, especially amongst medical treatments for withdrawal. Some experts,
including The American College for Obstetricians and Gynecologists, still
recommend the use of methadone and buprenorphine in the case of opioid
addiction (2012). These medications are frequently prescribed for pain, but with
regard to chemical dependency, they are used to control withdrawal symptoms in
opioid-dependent clients and often allow physicians to initiate a step-down process.
On the other hand, the Centers for Disease Control and Prevention (2012) also
found that roughly 5,000 people die from methadone overdose every year, and
additional concern exists regarding the safety of the medication during pregnancy.
As such, other methods of treatment, especially in the medical field, are vital.
Best Treatment Design for Women with Children
While medical treatments are necessary, some of the treatments for
addiction amongst pregnant women with the best success rates are psychosocial
therapeutic interventions rather than medical treatments. For chemical dependency
of all types, some have suggested that pregnant women benefit from
comprehensive, family-centered care for attracting and treating pregnant and
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parenting women (Finkelstein, 1993). Finkelstein (1993) argues that because
women’s biggest area of concern is often their children, centering treatment around
family concerns often attracts more women, keeps them in treatment longer, and
leads to the best outcomes.
A study by Jones, O’Grady, and Tuten (2012) indicates that pregnant women
in a Reinforcement-Based Treatment program for heroin and cocaine remained in
treatment significantly longer than those in a control program. The authors also
note that, on average, neonates also spent 1.3 fewer days in the pediatric nursery
after delivery when involved in this treatment program. This program essentially
breaks large tasks such as abstinence and obtaining jobs into small steps and, as a
strengths-based approach, offers reinforcement during every interaction with staff
and at every possible juncture. It appears to be helpful to avoid overwhelming those
with chemical dependency issues with large demands, but rather to guide them
through a series of smaller steps to reach their goals.
Research also suggests that women with children perform better in
substance abuse programs when they also receive support in multiple areas of the
social services spectrum, and that tailoring those services to the individual needs of
the client may be especially beneficial (Smith & Marsh, 2002; Marsh, D’Aunno, and
Smith, 2002). In essence, mothers with substance use problems often need help in
areas such as housing, transportation, or even putting food on the table, and when
these needs are constantly weighing on women, they have a harder time focusing on
their own recovery. Treatment programs that aim to help women in as many areas
as possible seem to have greater success than those focused solely on substance use.
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In the end, this has been just a summary of the treatments commonly used
for pregnant women with chemical dependency problems. However, we will now
provide a deeper understanding of methadone and buprenorphine specifically to
understand the best way to treat opioid-dependent mothers and their infants.
Methadone and its Use for Other Addiction Issues
According to Maxwell and McCance-Katz, methadone is a “pharmaceutical
opioid used in the treatment of opioid dependence…” (pg.73). Methadone comes in
various forms such as a “tablet, a dispersible tablet, a solution, and a concentrated
solution” that can be taken by mouth (The American Society of Health-System
Pharmacists, 2009). According to the Bay Area Addiction Research and Treatment
(BAART) program (2004), “methadone blocks the receptors in the brain that are affected
by opiates, such as oxycontin and other prescription drugs, enabling users to experience a
more gradual detox process rather than a more extreme and painful withdrawal process”.
Additionally, Methadone has other characteristics to aid persons addicted to
opiates. Methadone “reduces the drug cravings and harsh withdrawal symptoms that are
often associated with a patient's relapse, without creating the sense of euphoria associated
with the abuse of heroin and other opiates” (BAART, 2004). The therapeutic effects of
Methadone have the ability to last “ between 24 and 36 hours, and therefore most patients
benefit from a single daily dose” (BAART, 2004).
Methadone is not useful for all addiction issues. The drug is not used to treat
“other non-opioid drug addictions to substances like alcohol, marijuana or cocaine”
(BAART, 2004). There are other factors that can contribute to the success of Methadone
Maintenance Treatment (MMT). “Methadone maintenance treatment (MMT) can help
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injection drug users (IDUs) reduce or stop injecting and return to productive lives” (CDC,
2002). According to Doukas (2011) the population of older women (age 50+) in
particular might have a complicated transition in MMT (p.239). She points to studies that
indicate a high rate of women in MMT having HIV, a group that experiences higher rates
of depression, and anxiety disorder than women who are not HIV positive (p.239).
Benefits and Risks for Addicted Women who are Pregnant
Risks
In a pilot study conducted by Tomedi, Bogen, Hanusa, Wisner, & Bodnar (2012),
researchers compared methadone maintained pregnant women and nondrug-using
pregnant women. The researchers found that “methadone-treated women were
significantly leaner when entering pregnancy than control women and may be more likely
to be underweight” (Tomedi et al., 2012, p. 290). Through an extensive literature review
conducted by the researchers, it was found that current research was lacking information
that described the nutritional needs of opiate users entering treatment. However, the
literature did yield that the American Drug Association (ADA) believes that the drug
abuse accelerates the “nutritional needs beyond normal, so that even a well balanced diet
may be inadequate” for pregnant women (Tomedi et al., 2012, p. 291). Other previous
studies found that opiate users specifically have a “high intake of carbohydrates,
especially sweets” (Tomedi et al., 2012, p. 291).
In this particular study conducted by Tomedi et al., the sample of methadonetreated women had a less iron deficiency than control women (p.291). The “pregnancies
exposed to methadone are considered “high risk” and may be screened more carefully for
iron deficiency and treated earlier” as opposed to non-methadone using mothers (Tomedi
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et al., 2012, p. 291). According to the research poor nutrition is a high concern for all
opiate users entering treatment, especially pregnant women (Tomedi et al., 2012, p. 292).
Pregnant women that maintain the methadone maintenance treatment are at an increased
risk of entering pregnancy underweight and with a nutritional deficiency (Tomedi et al.,
2012, p. 292).
In another study conducted by Holbrook, Baxter, Jones, Heil, Coyle, Martin,
Stine, & Kaltenbach (2012) that focused on obstetric complications in opioid-dependent
women, researchers discovered that opioid-dependent women had similar complications
that occurs win women who did not receive prenatal care. Those complications included
“increased risk of spontaneous abortion, placental insufficiency, intrauterine growth
restriction, premature labor/delivery, premature rupture of membranes, anemia, and preeclampsia and abruptio placentae” (Holbrook et al., 2012, p. 84) However, despite all of
these risks Holbrook et al. (2012) found that “comprehensive care received by the
participants helped to reduce obstetric and neonatal morbidity” (Holbrook et al., 2012, p.
87).
Benefits
Concurrently, there are benefits of taking methadone as a pregnant woman.
Methadone maintenance treatment “reduces many of these negative outcomes through
substitution of an illicit substance of uncertain composition and dose (heroin) with a pure
substitute at a stable dose (methadone)” (Burns, Mattick, Lim, & Wallace, 2007, p. 264).
The research conducted by Burns et al. (2007) suggests that early commencement on
methadone increases prenatal care and reduces prematurity (p. 268). By coupling the use
of methadone with adequate prenatal care it promotes the fetal stability and growth of the
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fetus (p.268). The research advocates for strategies to be put in place that encourages
pregnant “ opioid-dependent women to enter treatment as early as feasible in their
pregnancies” (Burns et al., 2007, p. 268). Previous research has shown, however, that
injecting drug use quadruples the risk of amenorrhoea (stopping of menstrual cycle) and
it may therefore be that a number of heroin using women confuse their pregnancy status
with amenorrhoea and subsequently come into treatment later on in their pregnancy”
(Burns et al., 2007, p. 268).
These results lead to the need of developing models of care
that “emphasize the education of drug dependent women about pregnancy planning,
identifying early signs of pregnancy as well as engaging them in services as early on in
their pregnancies as possible”(Burns et al., 2007, p. 268).
Concerns for the Newborn
In a study by Brown et al. (1998) birth outcomes were not significantly different
between women using methadone and women using cocaine. In addition, women
receiving methadone maintenance were likely to be using other illicit drugs (Brown et al,
1998). Additionally, “single daily-dosing of methadone has been associated with a
suppression of fetal heart rate variability and reactivity at peak levels in human fetuses”
(Salisbury, Coyle, O'Grady, Heil, Martin, Stine, Kaltenbach, Weninger, & Jones, 2012, p.
41). It was also found that newborns who were exposed to “methadone treatment in utero
were found to have more active sleep and less quiet sleep than control infants in the first
week after delivery” (Salisbury et al., 2012, p. 41). Quiet sleep was characterized by low
fetal heart rate variability and few body movements (p.41).
In a study conducted by Dinges, Davis, & Glass (1980) that focused on fetal
exposure to narcotics found that newborns were likely to display symptoms of opiate
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withdrawal, including agitated behavioral states, hypertonicity, tremors, and irritability
(p. 619).Overall, there was a lack in research that studied the post exposure of newborns
addicted to methadone.
Should mothers detox from methadone before giving birth?
Methadone maintenance treatment has been the norm in treating pregnant women
with opioid addiction since the 1970s (Center for Substance Abuse Treatment, 2005). In
1998 it was recommended as the standard of care for pregnant women with opioid
addiction (Center for Substance Abuse Treatment, 2005). Sixteen years later, methadone
maintenance is still the standard of treatment with little research on other alternatives
such as buprenorphine and buprenorphine-naloxone. Both methadone and buprenorphine
are categorized as schedule C drugs by the Food and Drug Administration in the United
States (Center for Substance Abuse Treatment, 2005). Although buprenorphine is a
schedule C drug studies have found it to be a safer alternative than methadone, which will
be discussed later.
Rather than detoxing from methadone, it is more common for pregnant women to
increase their dosage of methadone in the third trimester because metabolism and volume
of distribution increase rapidly during this time (Monika, 2014). Generally, detoxing
from methadone or reducing dosage is not recommended, medically supervised
withdrawal (MSW), as it may lead to withdrawal symptoms and street drug abuse, with
potential of harming both mother and fetus (Center for Substance Abuse and Treatment,
2005; Monika, 2014). Pregnant women wishing to detox from methadone should consult
a physician experienced in perinatal addiction treatment and do so under close medical
supervision (Center for Substance Abuse and Treatment, 2005). According to the Center
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for Substance Abuse and Treatment (2005) “MSW is appropriate only for patients who
live where methadone maintenance is unavailable, have been stable in methadone
maintenance treatment and request MSW before delivery, refuse methadone maintenance
treatment, or plan to undergo MSW through a structured treatment program.” Typically
through MSW, methadone is decreased by 1.0 to 2.5 mg per day for individuals in
inpatient treatment and 2.5 to 10.0 mg per week for those in outpatient treatment (Center
for Substance Abuse and Treatment, 2005). Since MSW may place additional stress on
the fetus, fetal movement should be examined twice a day and stress tests should be
conducted at least twice a week (Center for Substance Abuse and Treatment, 2005).
Additionally, the Center for Substance Abuse and Treatment (2005) suggests that if these
tests and examinations conclude that there is additional stress on the fetus or possibility
for preterm labor, MSW should be discontinued immediately.
Should newborns be detoxed off methadone?
Neonatal abstinence syndrome (NAS) describes the withdrawal symptoms of infants
who are exposed to substance abuse in the utero and become physically dependent upon
them (Kassin & Greenough, 2006). Newborns experiencing NAS are essentially detoxing
from methadone and may require treatment from a physician (Center for Substance
Abuse and Addiction, 2005). Withdrawal symptoms may last several weeks and
commonly include symptoms similar to adults doing through opioid withdraw such as
fussiness/restlessness, not eating or sleeping well, fever, vomiting, and trembling.
Intensive research has been conducted on the effects of methadone on newborns and NAS
(Kassin & Greenough, 2006). For example, Dashe et al (2002) concluded that increased
methadone dosage was associated with duration of infant hospitalization, neonatal
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abstinence score, and treatment for withdrawal. Additionally, lowering the mother’s
methadone dosage was associated with both incidence and severity of neonatal
withdrawal in some pregnancies.
A study in 2005 sought to compare pregnancy outcomes for individuals receiving
high and low doses of methadone maintenance treatment. For this study, high dose was
defined as above or equal to 100mg and low dose was defined as below 100 mg of
methadone (McCarthy, Leamon, Parr, & Anania, 2005). In addition to dosage of
methadone, researchers examined both maternal and neonatal outcomes. There were a
total of 81 babies born during the study, however, because of custody issues there was not
data available for 10 of the infants. Of the remaining 71 infants the median length of
hospital stay was 10 days with a range of one to 105 days of hospitalization (McCarthy,
Leamon, Parr, & Anania, 2005). Nearly half of the newborns, 37, required neonatal
abstinence syndrome treatment and spent a median of 25 days in the hospital with the
range being between 8 to 105 days (McCarthy, Leamon, Parr, & Anania, 2005). Despite
the high amount of neonatal abstinence syndrome treatment required, there were no
differences between the two groups in rate of treatment for neonatal abstinence syndrome
or days of infant hospitalization. However, in this study there was a difference in
maternal drug abuse, with high doses of methadone being associated with increased
maternal drug abuse (McCarthy, Leamon, Parr, & Anania, 2005).
A study by Wouldes and Woodward in 2010 found conflicting results when compared
to the 2005 study. Similarly to the previous study, this one assessed maternal methadone
dose during pregnancy and its correlation with infant outcomes. Whereas the previous
study (McCarthy, Leamon, Parr, & Anania, 2005) defined high dosages as greater than
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100mg, this study characterized higher dosages as 46mg or greater of methadone daily
(Wouldes & Woodward, 2010). For the 42 women involved in this study, increased
methadone dose was corresponded with an increase in an infant’s risk of being born
preterm, being symmetrically smaller, spending longer periods of time in the hospital,
and the need for treatment of neonatal abstinence syndrome (Wouldes & Woodward,
2010).
Similar to the previous studies discussed, a European retrospective cohort study
conducted between January 2004 to December 2006 in the United Kingdom analyzed the
extent to which children born from mothers using methadone experienced neonatal
abstinence syndrome. Dryden, Young, Hepburn, and Mactier (2009) had a sample size of
450 pregnant women who received methadone maintenance treatment at an inner-city
hospital. The average methadone dosage at birth was 63.8 mg per day with a range of
four to 125 mg per day. Methadone dosage was increased for 56% of the women and
decreased for 6% of women. High dosages of methadone were defined as being greater
than 58 mg per day. Of the 450 newborns, 40% required treatment for neonatal
abstinence syndrome. The researchers found that higher dosages of methadone
significantly increased the likelihood of NAS requiring treatment. In addition, this study
revealed that women on higher dosages of methadone were more likely to be using illicit
drugs as well (Dryden, Young, Hepburn, & Mactier, 2009). The median hospital stay was
ten days for all infants with a range of 7 to 17 days of hospitalization.
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Is suboxone/subutex for pregnant substance abusing women a beneficial alternative
to methadone?
Buprenophine has a long half-life and less abuse potential than methadone
(Ducharme, 2012). In 2003 buprenophine-naloxone, suboxone, was approved by the
Food and Drug Administration in the United States as maintenance treatment that could
be used by primary care physicians (Ducharme, 2012). This means that Suboxone can be
written as a prescription and given to the patients to take home with them. Suboxone has
been called the “son of methadone” (Austin Addiction Medicine Associates, 2014).
Although there is a potential for suboxone to replace methadone, there is little research in
regards to pregnant women and newborn outcomes.
The Maternal Opioid Treatment: Human Experimental Research (MOTHER) study
found promising results for treating opioid dependence during pregnancy using
buprenorphine (Whitten, 2006). The researchers found buprenorphine to be both a safe
and effective alternative to methadone maintenance for the pregnant women with opioid
dependence in their study (Whitten, 2006). “Women who received either medication
experienced similar rates of pregnancy complications and gave birth to infants who were
comparable on key indicators of neonatal health and development” (Whitten, 2006).
When compared to infants born to women whose mother received methadone, those born
to women who received buprenorphine had milder symptoms of neonatal opioid
withdrawal (Whitten, 2006).
Jones et al. (2010) used a double-blind randomized-control trial study to compare
methadone and buprenorphine usage in pregnant women in regards to the likelihood and
intensity of neonatal abstinence syndrome. The study started with 175 women, however,
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many dropped out before delivery. In the methadone group 16 dropped out, 18%, and 28
in the buprenorphine group ended the study. It should be noted that 71% of women in the
buprenorphine group that discontinued the study did so based on “dissatisfaction with the
medication” compared to the 13% of women in the methadone group (Jones et al., 2010).
The conclusions are based on the results and evidence collected from 131 newborns. For
the group born from women receiving buprenorphine less morphine was required,
significantly shorter hospitalization was needed with 10 days compared to 17 required
from the methadone group, and there was less duration of neonatal abstinence syndrome,
four compared to 10 of methadone group (Jones et al., 2010).
Conclusion
We have demonstrated that alcohol and drug abuse is a continuing problem both
in the United States and abroad. As discovered, more evidence based models involving
psychoeducation are vital to inform mothers the benefits and risks of MMT, detoxing
while pregnant, and the possible Neonatal Abstinence Syndrome symptoms their
newborn may experience. While there are some effective psychosocial interventions,
more research is needed in medical interventions to adequately treat this population.
Buprenorphine and Suboxone appear to be a promising alternative to methadone
treatment. However, more research is required to transition pregnant mothers from using
methadone with the FDA’s approval.
Further Readings
Other readings that have been helpful to this research study are: The MOTHER
Study, researching forums for women who were addicted to opioids in order to gain
another perspective of potential clients’ experiences, questions they had, and current
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knowledge. The Center for Disease Control and other statistical data provided insight as
the current data that has been collected on substance and alcohol users, pregnant users,
and mothers using methods to detox from substances. It is also encouraged to research
methadone clinics in the area of research to view their methods and services that are
provided. It would be beneficial to gather materials that compare and contrast the
benefits and risks of Buprenorphine and Suboxone vs. Methadone. Furthermore, we
encourage researchers to observe various documentaries that follow substance addicted
mothers through their pregnancy and postpartum.
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