Management of Addiction Disorders in Pregnancy

Abstract

In this article, we will review the prevalence of addiction disorders in pregnancy and the impact that it has on perinatal morbidity and mortality. We will then review effective screening techniques and propose a management scheme for achieving short-term abstinence leading to the ultimate goal of long-term recovery. The various medical and obstetric complications unique to this patient population will be discussed as well as the specific adverse effects of substance abuse on placentation and the developing fetus. Finally, medications proven efficacious in the treatment of addiction disorders will be reviewed in the context of their use in the pregnant population.

Changes in methadone maintenance therapy during and after pregnancy

“…This contrasts with pharmacokinetic changes after delivery in which intravascular volume declines and trough plasma concentrations of methadone are significantly higher than during pregnancy Table 2 Sample sizes, adjusted mean daily doses, and CIs for points on the graph (Drozdick et al, 2002). As a result of the rapid decline in intravascular volume after delivery and increased methadone plasma trough concentrations, some clinics decrease doses by 20%-40% or to prepregnancy doses in the postpartum period (Helmbrecht & Thiagarajah, 2008;Jones, Johnson, Jasinski, & Milio, 2005). No empirical data support this decrease in doses to prepregnancy levels, and any dose reduction should be based on signs or symptoms of overmedication or withdrawal as we did in our clinic rather than on measuring blood plasma levels (Helmbrecht & Thiagarajah, 2008;McCarthy et al, 2005).…”

“…Certain physicians wish to lower the methadone doses during pregnancy because of their concern about the risk and severity of subsequent neonatal abstinence syndrome (NAS; Helmbrecht & Thiagarajah, 2008). Tapering methadone during pregnancy is not recommended because it increases the probability of undesired maternal events (Helmbrecht & Thiagarajah, 2008).…”

“…Methadone doses should be assessed individually based on objective and self-reported opioid craving and withdrawal symptoms (Helmbrecht & Thiagarajah, 2008). Significant increases in methadone doses are expected throughout pregnancy because maternal weight, intravascular volume, and renal elimination increase during the second and third trimesters (Drozdick, Berghella, Hill, & Kaltenbach, 2002;Pond, Kreek, Tong, Raghunath, & Benowitz, 1985;Seligman et al, 2009Seligman et al, , 2010Swift, Dudley, DePetrillo, Camara, & Griffiths, 1989;Wolff, Boys, Rostami-Hodjegan, Hay, & Raistrick, 2005).…”

“…Much has been reported about the many advantages of treating opioid-dependent gravid women with methadone, such as improved access to comprehensive prenatal care, reduced use of illicit drugs, less exposure to infections associated with intravenous drug use, and improved maternal nutrition and infant birth weight (Helmbrecht & Thiagarajah, 2008;Jones, Johnson, et al, 2008;Jones, Martin, et al, 2008;Katenbach, Berghella, & Finnegan, 1998;Lim et al, 2009;Mattick et al, 2003;Rettig & Yarmolinsky, 1995;Seligman, Weiner, Berghella, 2009;Winklbaur et al, 2008). A less-preferred alternative is complete abstinence, which may lead to episodes of illicit opioid use with acute withdrawal.…”

“…An appropriate methadone dose during pregnancy is critical to foster treatment compliance, decrease maternal polysubstance abuse, and reduce rates of low-birth-weight infants (Helmbrecht & Thiagarajah, 2008). Methadone doses should be assessed individually based on objective and self-reported opioid craving and withdrawal symptoms (Helmbrecht & Thiagarajah, 2008).…”