Re: Methadone in pregnancy amended
From: Dr. Ainsworth (ainsron@sbcglobal.net)
Fri Oct 31 14:53:19 2003
the other important issue is blinding of the doses - the patient should
not know when her dosing is decreased or the total amount she is taking.
>As the dose decreases, she will begin to developa symptoms at 22-23
>hours. When that happens, you add 2.5-5 mg back to her dose and continue
>that dose. As pregnancy progresses, She may start toi have symptoms at
>about 22-23 hrs after a dose again. Then you might need to add a little
>more, etc.
>If as you decrease the dose, she starts to have symptoms at 22-23 hours
>and you don't want to go back up, keep her on that dose for a while. If
>her symptoms get to where they are not coming back in less than 24
>hours, then you can lower the dose again and keep on doing that until
>she is completely withdrawn. Few patients really achieve that though.
>
>Dan
>
>-----Original Message-----
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Joseph
>Shaeffer
>Sent: Friday, October 31, 2003 10:50 AM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: Methadone in pregnancy amended
>
>Thanks for the information Dan and all who have responded. I will share
>what's been discussed with my MFM consultant and my patient. I hope that
>her motivation to decrease her dose will continue once she starts having
>to deal with the sx of withdrawal. The plan so far is to do frequent
>NST's as the dose decreases if we can get the clinic to work with us.
>
>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?
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