THE DRUGS-PREGNANCY EQUATION

Subtracting Methadone Maintenance Does Not Equal Improved Outcomes

"Methadone complicates pregnancy" pronounced the Medical Post
headline summarizing a study from Duke University. Oh, really? So if
you're pregnant and polydrug using, better stay away from methadone?

I chased down the original article, and to my dismay, this whole
research project (never mind the terrible, impenetrable scientific
prose), seemed too bizarre to merit publication in a journal.

To start with, the patients on methadone--and by extrapolation and
documentation, these were heavy drug users--were matched with women
who had no history of illicit drug use and were not on methadone. And
guess which group did better?! The authors concluded, by
"dichotimising" methadone doses (whatever that means) that a lower
methadone dose was better as there appeared to be a correlation to
improved birth weight.

So what would this lead the average family physician or obstetrician
to conclude? Get pregnant women off methadone, outcomes will improve,
birth weights will go up and everything will end happily ever after--right?

Think again.

For some reason, the authors of this study reached the simplistic
conclusion that poor pregnancy outcomes in substance-dependent women
are the result of methadone maintenance. On the contrary, extensive
research has indicated greatly improved pregnancy outcomes in women
who can be properly maintained on adequate doses of methadone,
especially if, at the same time, they receive broad-based social
support, which is the expectation in any methadone maintenance
program of excellence.

What happens to pregnant women who continue polysubstance use during
pregnancy? They lack the basic necessities of life: food, shelter and
safety. They work the streets to pay for their next fix. They don't
eat. They are at the mercy of their pimps or other so-called
"protectors" and physical abuse is part of their daily experience.
They are at risk of getting or transmitting terrible diseases.

And what are the pregnancy outcomes? These women have a low incidence
of prenatal care. Prematurity, low birth weights and perinatal
infections are common. Heroin has a short half-life, so there is a
high incidence of abruption, for mother and baby experience recurrent
withdrawal and consequent smooth muscle contractions. At the time of
delivery, most infants born to actively drug using mothers are
apprehended. Many will spend their childhood in and out of foster
homes. These youngsters' long-term outcomes are predictably poor.

But let's suppose a pregnant woman on heroin manages to consult a
physician knowledgeable in addiction medicine. That physician will
recommend initiation and stabilization on methadone, which in turn
opens the door for her to get proper prenatal care and regular
medical intervention. Her physician will work with social services to
ensure adequate shelter and food. She will be referred to an
obstetrician, for these are high-risk pregnancies.

What about methadone dosage? One of the great truths about methadone
in pregnancy is that inadequate or tapered doses are responsible for
virtually 100% relapse, which, of course, confirms the irrational
convictions of those determined to implicate methadone as the
villain. Every woman who "fails on methadone," thanks to poor
prescribing, becomes another statistic to prove their point.

Are there any downsides to methadone maintenance in pregnancy? Yes.
In spite of best medical interventions, some women continue to
polysubstance use. Neonatal abstinence from methadone and heroin is
equally challenging. There have been studies to show that sudden
infant death syndrome is more common in babies born to
methadone-maintained mothers. Management of labour and delivery can
be difficult.

So, is it methadone that complicates pregnancy, as this study
implies? No. Substance abuse during pregnancy leads to terrible
outcomes for mother and baby. Outcomes are predictably better for
those women properly supported and maintained on methadone. It is
ridiculous to compare such a cohort of patients with those who have
no drug use history.

The study also has disturbing judgmental undertones, reflective of
times past when less analgesic for pain control was better; when
blaming the patient was easier than working with her to help her
survive physical and emotional illness compounded by desperate social
circumstances.

If this study leads physicians to refuse methadone maintenance to
pregnant, opiate-abusing women, the authors will have done a terrible
disservice to all those needy and marginalized women suffering from
the illness we call addiction.