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Joseph Shaeffer ARNP/CNM
Community Health Association of Spokane
Spokane, WA
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Braun,
R. Daniel
Sent: Friday, October 31, 2003 3:29 AM
To: Multiple recipients of list OB-GYN-L
Subject: FW: Methadone in pregnancy amended
I sent the comments about this issue to Jim Nocon who is the Director of
our Substance abuse Clinic here at the Wishard Memorial Hospital. He is
also widely known in the field of Substance abuse. The following are his
comments for your perusal. They are forwarded with his permission.
Dan
Dan,
the observations are partly true and it depends on the methadone maint
(MM) clinic.
Local Clinic A tends to be like the one mentioned - they do not want to
decrease methadone levels during pregnancy. On the other hand, they are
very supportive and cooperative in the management of our mutual
patients.
In contrast, Local Clinic B is a private MM clinic and we have
successfully decreased methadone levels in selected (motivated)
patients.
There is an article in the Canadian addiction medicine literature that
describes sudden IUFD in attempting to decrease methadone levels,
especially in the 3rd trimester. However, the IUFD appears to have
occurred in detoxification where the methadone dose was decreased
rapidly.
In my experience, methadone can be decreased 2-5 mg per week (the lower
level the better) but most patients get symptoms of withdrawal at about
22 hours when they get below 50 mg. For the large majority of patients,
levels of 70-90 mg are the norm and withdrawal symptoms do not occur
until about 26-28 hours from last dose.
There is a sub group of patients who experience withdrawal symptoms at
22 hours as the pregnancy progresses. Thus, they require an increase in
the methadone dose. There may be an antagonism between estrogen and
methadone at the mu receptors but this is poorly understood. However,
it does account for the observation that clinics increase the dose in
some pregnant patients.
In Europe, pregnant narcotic addicts are managed with buprenorphine
rather than methadone. Buprenorphine can be rapidly detoxed with
minimal withdrawal symptoms. This would allow for a baby to be virtually
narcotic free by the time of the delivery. Likewise newborns on
buprenorphine can be rapidly detoxed - 2-3 days in contrast to 3-4
weeks with methadone. Although the FDA approved the use of
Buprenorphine in the US, it has yet to approve it use in pregnancy.
James J Nocon, M.D.
-----Original Message-----
From: Braun, R. Daniel Sent: Thursday, October 30, 2003 6:15 AMTo: Nocon, James J.
Subject: FW: Methadone in pregnancy
Jim,
Any thoughts about this?
Dan
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Dr.
Ainsworth
Sent: Wednesday, October 29, 2003 7:46 PM
To: Multiple recipients of list OB-GYN-L
Subject: Methadone in pregnancy
I've seen more patients in the last couple of years on methadone
maintenance than I recall in previous years. My impression is that the
methadone clinics only incentive is to increase the number of patients
they treat and increase the amount of methadone they dispense. These
patients are told by the clinic that they cannot stop methadone during
pregnancy because they will miscarry. Rather than attempting to detox
patients during the second trimester or taper them down to a workable
level of 20-40 mg by the third trimester, most of these patients have
been increased to 120 mg or greater. It is frustrating because the
clinic gives no feedback and I've even had the experience of patients
not even informing me until late in their pregnancies that they are on
methadone - to "avoid stigmatization." I've tried to enter into a
dialogue with the physician who is in charge of the clinic, I've sent
several faxed notes about specific patients as well as my general
concerns but get no response. If you read the literature on methadone
in pregnancy, this is far from ideal! How is it working in other's
experience and areas?
