Medication-Assisted Treatment (MAT) During Pregnancy – Part II

This is the second of two articles on treating pregnant patients in MAT, clinical considerations related to their care, and outcomes for their babies.

Opioid treatment programs (OTPs) are caring for increasing numbers of pregnant patients-some who become pregnant while in methadone treatment programs, others who decide to begin methadone treatment upon learning they are pregnant. Helping these mothers-to-be through their pregnancy and to a successful outcome can be a highly rewarding experience for OTP staff.

Methadone Dose Management

Induction and Stabilization

Initial methadone doses for pregnant women are generally based on the same criteria as those for women who are not pregnant. Pregnant patients already taking methadone usually continue their existing dosage. As with all patients starting methadone treatment, induction is based on individualized dosing. Induction should be done slowly, based on the individual response to treatment. Careful observation for signs and symptoms of withdrawal or sedation is essential. Patients are considered stabilized when they are without opioid craving, and are comfortable with their dose for the full 24 hours before their next daily dose. It is important that doses for pregnant women be individualized, as they are with nonpregnant patients.

Later Stages of Pregnancy

As pregnancy progresses, many women require dose increases, especially during the third trimester. Careful monitoring to achieve a comfortable dosage in the last trimester ensures the best outcome for mother and child. Drs. Kaltenbach and Jones stress how important it is to increase the methadone dosage gradually, based on the patient’s clinical response. If single daily doses of methadone are not enough, Drs, Kaltenbach and Jones suggest dividing the daily dose into two doses, and giving them at least eight hours apart; for example, half in the morning and half in the evening. Many OTPs monitor changes in the mother’s blood methadone levels to guide dose adjustments. A useful indication of underdosing is the mother’s sense of how active her baby is within the uterus.

Just when the mother may need a higher dose of methadone, she may face increased pressure from well-meaning family or friends to take less methadone-or even to stop taking it-”for the sake of the baby.” This advice is not based on evidence or knowledge, and only adds to feelings of guilt and uncertainty the mother may have as the birth draws near. OTP staff can be very helpful to the patient by providing information, advice, and reassurance in a sympathetic and understanding way.

Labor, Delivery, and Post-Delivery

Methadone treatment continues throughout labor and delivery, and into the post-delivery period. Once the mother has given birth, the dosage needs to be re-evaluated. For patients who were already on methadone maintenance, the TIP 43 Consensus Panel recommends post-delivery doses that are usually similar to those given before pregnancy. For those who initially were not in methadone maintenance treatment, post-delivery doses should be adjusted until the patient is on a comfortable dose and is stabilized. As during pregnancy, any decrease in dosage should be based on signs of overmedication, and any increase should be based on the patient’s methadone blood levels and signs and symptoms of withdrawal.

Some patients express the desire to be medication-free after their baby is born. This is usually not an ideal time to discontinue methadone. OTP staff need to advise patients about the possibility of relapse during methadone tapering, and the increased likelihood of relapse associated with the stresses of early motherhood. The importance of continuing treatment during this time cannot be overemphasized.

Neonatal Abstinence Syndrome

Some babies born to methadone-maintained mothers develop a temporary and treatable condition called neonatal abstinence syndrome (NAS). Signs and symptoms include increased sucking on the thumb or fingers, uncoordinated feeding efforts, excessive high-pitched crying, sleeplessness, irritability, and tremors. Neonatologists use a scale such as the Neonatal Abstinence Score developed by Finnegan and colleagues to diagnose NAS, assess its severity, and determine how well the baby is responding to treatment. While not all babies born to MAT mothers need medication to treat NAS, all babies should be evaluated for NAS during the first few days after birth.

NAS may be mild or severe, and may begin just after birth or up to two weeks later. The likelihood and severity of NAS depend on many factors, but the mother’s methadone dosage or blood level has not consistently been shown to be one of them. Other drugs that may contribute to NAS include heroin, morphine, and other opioids; alcohol; nicotine; and benzodiazepines.

Newborns with NAS are treated in the hospital for several days or up to several weeks. NAS can be treated without any long-term effects on the baby. Some babies with mild symptoms of withdrawal can be soothed during stressful periods by being wrapped tightly in a blanket and gently rocked. Although evidence is limited, the severity of NAS may be reduced by breastfeeding. NAS is considered controlled when babies have rhythmic feeding and sleep cycles and optimal weight gains, and a low average score on a scale such as the Neonatal Abstinence Score.

Breastfeeding

Breastfeeding should be encouraged in OTP patients unless the mother is HIV positive, is using illicit drugs or alcohol, or has another contraindicating condition. The well-known benefits of breastfeeding include transferring protective antibodies to the baby, providing optimal nutrition, promoting attachment between mother and child, and lessening the mother’s stress. Methadone levels in breast milk are very low, and are unrelated to the mother’s blood methadone concentrations. The American Academy of Pediatrics considers methadone compatible with breastfeeding at any maternal dose.

Unfortunately, some caregivers still discourage breastfeeding, due to prejudice or lack of knowledge. “You’d be surprised how many people still counsel women not to breastfeed” Dr. Kaltenbach said. “Or they put a limit on the mother’s dose,” Dr. Jones added.

Outcomes for Infants

Short-term. Birthweight is a major factor in infant health. Studies have consistently found that infants born to methadone-maintained mothers have higher birthweights than infants born to heroin-dependent women. Dr. Kaltenbach noted, “Pregnant women who enter methadone maintenance treatment late in their pregnancy have increased obstetrical risk, because they have not had the longer-term benefit of preventative health care. They have a higher risk of having a premature baby, and once you have a premature baby, you have all the problems associated with prematurity that are not necessarily a direct result of drug exposure.”

Long-term. Few recent studies have focused on the long-term outlook for babies born to methadone-maintained mothers, but available data have not indicated any severe developmental delay during the early years of life. Dr. Kaltenbach pointed out that babies exposed to methadone before birth develop well within the normal range through age two. No significant developmental differences have been found between children of mothers maintained on methadone and a comparison group of non-drug-exposed children, when various social, biological, and health factors were considered. “Drug exposure was one risk factor,” she said, “but the environment the child was raised in was the most important, in terms of developmental outcome.”

Suggestions for Managing Pregnant Patients in OTPs

Drs. Kaltenbach and Jones offer the following suggestions for managing the complex needs of pregnant patients on methadone maintenance:

Continued Opioid and Poly-Substance Abuse. Pregnant women who relapse to opioid use, or abuse alcohol, nicotine, benzodiazepines, or other drugs, increase their risk of medical complications. They need to be educated about how these drugs can increase the severity of NAS, or can cause fetal alcohol spectrum disorder, premature labor, or other complications. Weekly drug testing and more intensive counseling is recommended.

Co-Occurring Disorders. Mood disorders during pregnancy have been associated with adverse maternal health behaviors, a high risk of postpartum depression, and undesirable behavior of the offspring. According to Dr. Jones, “Opioid-dependent pregnant patients should be screened for disorders and given appropriate medication and behavioral treatments.”

Methadone-Drug Interactions. OTP staff need to pay special attention to the potential for drug interactions in pregnant patients. Factors such as the physiological changes that accompany pregnancy can change the way drugs interact and are metabolized in the body.

OTP staff need to check all medications the patient is taking, including over-the-counter drugs, dietary supplements, and medications prescribed by other health care providers. It may be necessary to adjust either the methadone dose or the dose of other medications being given.

Patients’ Questions. Pregnant patients will have many questions that OTP staff will be called upon to answer, especially about what to expect at the hospital.

• How will I get my methadone in the hospital?
• How long will my baby be in the hospital?
• Will I be able to get something for my pain when I’m in labor and giving birth?
• Will my baby have withdrawal? What will it be like? When will I be able to take my baby home?

Patients find it very helpful to visit the hospital before their delivery date so they can meet the hospital staff, visit the nursery, and have a chance to ask questions.

Dedicated Staff Can Make a Difference

A woman who elects to combine pregnancy and methadone maintenance will face challenges in the months ahead. She will most likely have special concerns about balancing her own physical and emotional needs with the welfare of the baby she is carrying. With the help of dedicated medical, nursing, and counseling staff throughout her pregnancy, this can be a happy and rewarding time for her. The chances of a positive outcome for her and her baby can be excellent.

Jones, Martin. “Medication-Assisted Treatment (MAT) During Pregnancy – Part II.” Center for Substance Abuse Treatment. U.S. Department of Health and Human Services, 19 July 2009. Web. 5 Nov. 2009. <http://csat.samhsa.gov/>.