Approximately every 3 months at least one baby is born in Annapolis Valley Health District that needs to be detoxed from opiates.
Pregnant women who are dependent on opioids are at high risk for many different medical complications. A review by Jones, et al. (1999, 260) provides a valuable overview of these issues (See Table 10)
Table 10: Obstetric Problems Associated with Opioid Use (based on Jones et al., 1999, 260)
- Issues with Opioid Use:
- Spontaneous abortion
- Intrauterine death
- Abruptio placentae
- Septic thrombophlebitis
- Placental insufficiency
- Premature rupture of membranes
- Gestational diabetes
- Postpartum haemorrhage
- Increased hospitalization
- Intrauterine growth retardation
- Premature labour
The extent to which these problems result directly from drug use, or from the poor nutrition, high-risk lifestyle and lack of prenatal care experienced by pregnant women who are dependent on opioids is not clear. (Robins & Mills, as cited in Jones et al., 1999, 256-257) In addition, Jones et al. (1999, 257) point out that drug-related complications vary depending on: drug(s) used; stage of pregnancy when drugs were used; route of drug administration; withdrawal, or cycles of intoxification and withdrawal; lack of prenatal care; and failure to diagnose and treat drug-related problems.
Since the 1970s, methadone maintenance has been the “treatment of choice” for the opioid-dependent pregnant woman (Finnegan; Finnegan; Kaltenbach et al., as cited in Ward et al., 1998d, 397). Kandall, Doberczak, Jantunen and Stein (1999, 180) conclude that: “General agreement exists that pregnancy offers a unique opportunity to bring women into medical, obstetric, and drug treatment.” Ward et al. (1998d, 413) summarize the benefits of providing methadone maintenance treatment which have been demonstrated in the research, including:
- providing a pharmaceutical grade opioid under medical supervision rather than using an illicit opioid of “unknown quality and uncertain supply”
- avoiding the “peaks and troughs” in blood levels when a shorter-acting opioid such as heroin is used
- avoiding exposure to contaminants including those that may be teratogenic; and
- creating an opportunity to provide adequate antenatal care.
Ward et al. (1998d, 413) also conclude, based on their review of the evidence, that compared to women not in treatment, providing methadone maintenance treatment results in increased likelihood of carrying pregnancy to term; fewer birth complications; and larger infants (for their gestational age).
Like other women who are dependent on opioids, pregnant opioid-dependent women may experience significant barriers to accessing treatment (see Section 7.2). In addition, Ward et al. (1998d, 413) note that the research indicates that women who are pregnant may also experience conditions that are not conducive to a successful pregnancy, such as inadequate nutrition and rest; inadequate antenatal care, including poor access to obstetrical care; and exposure of themselves and their fetuses to fluctuating blood levels of heroin, unknown drugs and contaminants and infections with HIV, HCV and other blood-borne pathogens associated with injection drug use.
Other barriers to care include fear of involvement with the criminal justice system; fear that their children will be removed from their care; lack of transportation; lack of child care for other children; lack of access to obstetrical care; social stigma/attitudes of medical personnel; and lack of women’s treatment services (Janson et al., as cited in Jones et al, 1999, 259).
Ward et al.(1998d, 398) suggest that the key clinical issues in providing methadone maintenance treatment for pregnant women who are dependent on opioids include selecting an appropriate dose; providing appropriate antenatal care; making counselling available during treatment; and managing the abstinence syndrome in the neonate.
Based on their review of the literature, Jones et al., (1999, 259-260) note that providing comprehensive care can improve pregnancy outcomes. A comprehensive approach to treatment which addresses the unique needs of pregnant women who are opioid dependent includes:
- primary medical care to address the range of problems related to opioid dependence including tuberculosis
- treatment and management of infection (with HIV, HCV or other blood-borne pathogens) for mothers, and possibly for infants
- intensive perinatal management for high-risk pregnancy
- psycho social counselling (including nutrition, parenting and money management education; social services advocacy for assistance with unstable living conditions, unemployment, and literacy)
- prenatal/parenting education classes
- mental health assessment and therapy, and
- methadone maintenance.
Based on their review, Ward et al. (1998d, 414) also suggest the following:
- women-only group sessions which also function as antenatal and parenting classes, and which address other relevant issues for opioid-dependent women
- non-judgmental antenatal care including special clinic times, access to analgesia or anaesthesia during labour or birth
- proper assessment of the severity of the neonatal abstinence syndrome using specially designed instruments
- provision of morphine, phenobarbital or paregoric, as needed, and
- encouragement of breastfeeding by mothers receiving methadone maintenance treatment.
Careful monitoring and adjustment of methadone dose and regimen is required throughout the pregnancy, especially during the third trimester, when the metabolism of methadone increases (Kreek, Schecter and Gutjar; Kreek; Pond et al; Gazaway, Bigelow and Brooner, as cited in Jones et al., 1999, 262). If unexpected withdrawal symptoms develop during this period, increased or split doses may be required (Ward et al., 1998d, 414). Jones et al. (1999, 272) conclude that detoxification from methadone during pregnancy is not recommended, except under “the most dire circumstances.” According to Ward et al.’s summary (1998d, 413): “Few…women…can achieve total abstinence without relapse or obstetrical complications intervening. Therefore, the treatment of choice for most opioid dependent women is methadone maintenance throughout their pregnancy.” In their review, Kaltenbach, Berghella and Finnegan (1998, 147-148), point out that, although prenatal exposure to heroin or methadone often results in neonatal abstinence syndrome, this syndrome can be treated with pharmacotherapy without negative effects. They conclude that: “There is no compelling evidence to reduce maternal methadone dose to avoid neonatal abstinence.”
Comprehensive methadone maintenance treatment is widely considered the standard of care for pregnant women who are dependent on opioids. The benefits – compared to heroin use – include better prenatal care; increased fetal growth; reduced fetal mortality; decreased risk of HIV infection; decreased cases of preeclampsia and neonatal withdrawal; increased likelihood that infant will be discharged to his or her parents; and increased retention in treatment (Kandall et al., Finnegan; Svikis et al., as cited in Jones et al., 1999, 258).
Jones et al. (1999, 272) conclude that: “Overall it appears that when the physical, psychologic, and economic issues of the pregnant opioid abuser are addressed concurrently with methadone treatment, the benefits far outweigh the risks for the mother, the fetus and the infant.”