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Managing Opiate Addiction During Pregnancy

By Lisa Simpson

According to figures from the National Survey on Drug Use and Health, 5% of pregnant women in the US use illicit drugs, which rises to just over 20% in the under 18 age group. While heroin is used by only around 0.1% of women during pregnancy, a further 1% admit to using opiate based medications for purposes other than pain relief; prescribed opiates include codeine, fentanyl, hydrocodone, meperidine, morphine and oxycodone. Women are usually asked about their use of drugs early in their obstetric care to identify those who, along with their developing baby, are at risk from this habit. Displaying erratic behavior, signs of intoxication or withdrawal are easy to spot, but waiting till later in pregnancy to seek obstetric care, poor attendance at appointments and below expected weight gain are also indicators that a woman may be using opiates.

Risks from opiate use

Women who continue to use heroin during pregnancy risk reduced growth of their developing baby, fetal death, separation of the placenta from the uterus and premature labor. While birth defects have rarely been observed in babies born to women using opiates during pregnancy, a number of studies have demonstrated codeine use during the first trimester is linked to heart abnormalities; though this has not been seen with other prescribed opiates that have also been studied.

Methadone program during pregnancy

As well as treating pregnant women addicted to heroin with methadone, a similar maintenance plan is starting to be used with addiction to other opiates; there is also evidence that buprenorphine may be used as a safe alternative for management of opioid use, so this option may be presented to women. The dosage of methadone is determined by addiction specialists, who adjust the dose as required throughout pregnancy to avoid withdrawal; symptoms of this include cravings, anxiety, difficulty sleeping, feeling irritable and nauseous. Not only does this prevent these unpleasant symptoms for the mother, but protects her unborn baby; while withdrawal from opiates is rarely fatal for adults who are in good health, fetal death may occur in women who do not seek help with their addiction and try to withdraw on their own.

However, as with others who access help with opiate addiction, therapy goes beyond the prescription of methadone for pregnant women; she will also receive dependency counseling and have access to other medical and psychological interventions, as well as any other services deemed necessary. This ensures that by engaging in a program for therapy, women are more likely to receive prenatal care, which reduces the likelihood that complications will arise during their pregnancy. It is possible for most pregnant women to attend a methadone program on an outpatient basis, though in some cases it may be advisable to initiate methadone during a short stay at an opiate treatment center. While maintenance with methadone is preferred to withdrawal during pregnancy – even when medically supervised – due to the high risk of relapse, if participation within a methadone program is refused by a woman, the second trimester is the safest time for her to withdraw under the guidance of a specialist.

Neonatal Abstinence Syndrome

Although treatment with methadone is more likely to lead to a healthy pregnancy than if illicit opiate use was to continue, her newborn baby is at risk of developing a condition known as neonatal abstinence syndrome, which affects the nervous syndrome. As a result a baby’s sucking reflexes are uncoordinated, which interferes with feeding, and they are also more prone to be irritable. Babies who were exposed to methadone in the uterus usually develop withdrawal symptoms within their first three days after birth and while in some cases this may only last for a matter of days, in other infants they may remain for weeks. It is protocol for babies born to women who took opiates during pregnancy to be monitored for this syndrome so that treatment can be initiated as necessary; the obstetric and pediatric team work closely to ensure that the newborn receives optimal care to achieve normal feeding, weight gain and sleep patterns. As neonatal abstinence syndrome can be successfully managed and does not appear to have any lasting adverse consequences to physical or mental health, the advantages of initiating methadone in pregnancy far outweighs the risks.

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