Standard of Care
Despite the controversy associated with methadone use, methadone remains the standard of care for treatment of the narcotic addict during pregnancy.3, 11 Alternatives such as long acting, slow release morphine preparations appear to have no distinct advantage over methadone maintenance.6 Buprenorphine, a newer agent, appears promising, although further controlled, clinical trials in pregnant women are needed before a recommendation for its use as standard therapy can be made. (ref 12, 13 14)
UCMC Perinatal Substance Abuse Program
The University of Cincinnati Medical Center has developed a Perinatal Substance Abuse Program that works in conjunction with a variety of methadone-maintenance programs throughout the greater Cincinnati area. The goal of the program is to provide care that will optimize the outcome of pregnancy. The program offers comprehensive prenatal care that extends through labor and delivery and supports the woman during her postpartum period as well. As a part of the prenatal care provided, women are counseled regarding the outcome possibilities for their infants. 15 Counseling regarding methadone use is offered during the second or third trimester of pregnancy, and is given in part by a nurse practitioner and in part by a neonatologist. These mothers typically worry that their infants will experience severe withdrawal symptoms and will be treated with a variety of drugs over a prolonged period of time. It is helpful to allow these patients to express their concerns openly and to give them some indication as to what symptoms to expect and how these will be managed.
Information is given to the mother regarding how the baby will be observed for signs and symptoms of the neonatal abstinence syndrome, using the Neonatal Abstinence Scoring System developed by Loretta Finnegan. 16 This scale offers a semi-quantitative measurement of central nervous system, metabolic, vasomotor, cardio-respiratory, and gastro-intestinal symptoms. The mothers are advised that points will be assigned for severity and significance of symptoms, so that a high score indicates a greater intensity of withdrawal. It is explained that the infant will be followed closely and treated according to the severity of his or her symptoms. Mild or subtle symptoms will be treated with supportive comfort measures; moderate symptoms will be treated with medications if comfort measures are not effective; and severe symptoms will be treated with either oral methadone or morphine, using a standard tapering protocol (Tables 1 and 2).
Breastfeeding and Methadone Management
Breastfeeding is also discussed with these women. Until recently, breast-feeding has not been recommended for women who are using illicit drugs, or who are taking more than 20 mg. of methadone per day. 17 However, a recent study suggests that breast-feeding during methadone maintenance is an acceptable practice for women who choose to breast-feed their infants after delivery. 18 The results of this study and our own clinical observations are encouraging. Mothers who prefer to breast-feed are advised to take the baby to the breast as soon a possible after delivery in order to initiate lactation as early as possible. Mothers are also advised that they must abstain from any and all non-prescribed drugs, if they plan to breast feed their infants. They are given weekly urine toxicology tests as long as they remain on their methadone maintenance program.