Methadone and Pregnancy Methadone/Buprenorphine 101 Workshop, April 1, 2017 Charissa Patricelli, MD, CCFP, ABAM Clinical Associate Professor, Dept. of Family Practice UBC American Board of Addiction Medicine Certified Original prepared by Launette Rieb, MD MSc, CCFP, FCFP Clinical Associate Professor, Dept. Family Practice UBC American Board of Addiction Medicine Certified

College of Physicians and Surgeons of British Columbia 2

Overview Opioids, fertility and pregnancy

Heroin in pregnancy

Methadone in pregnancy

Perinatal methadone management

Counselling and follow-up

College of Physicians and Surgeons of British Columbia 3

Opioids and fertility Opioid use can interfere with fertility Heroin6090% menstrual irregularities

Methadonemajority resume regular menses by six to 12 months

Beware of undiagnosed pregnancy

Always do BHCG with first UDS, then PRN

Provide contraception options

College of Physicians and Surgeons of British Columbia 4

Opioids and pregnancy Opioids are not physical teratogens This includes:

natural opioids

opium, morphine, codeine

semi-synthetics

heroin, hydromorphone

synthetics

methadone, fentanyl, oxycodone

But heroin can be cut with teratogens quinine, cocaine, amphetamine, etc.

College of Physicians and Surgeons of British Columbia 5

Opioids and pregnancy Opioid use is not what endangers in utero

Opioid withdrawal endangers the fetus

Also, illicit opioid use with all the associated risks endangers the fetus

College of Physicians and Surgeons of British Columbia 6

Disadvantages of heroin in pregnancy Withdrawal produces noradrenalin release

Increased abruption, abort/miscarriage

Increased premature labour/infant

Increased IUGR

Decreased birth weight + head circumference

Increased NAS + SIDS + feeding problems

College of Physicians and Surgeons of British Columbia 7

Disadvantages of heroin in pregnancy Illegal activity, sex trade, needle use

STDs, TB, endocarditis, UTIs, sepsis

Viremia HIV, HAV, HBV, HCV

Maternal mortality

Family disruption

College of Physicians and Surgeons of British Columbia 8

Advantages of methadone in pregnancy Fetal/newborn advantages Stops withdrawal cycle

Decreased prematurity rates

Increased birth weight + head circumference

Decreased infant mortality

Better prenatal care and nutrition

Babies have normal milestones by 18 months

College of Physicians and Surgeons of British Columbia 9

Advantages of methadone in pregnancy Maternal advantages for methadone Decreased sex trade, needle use

Decreased infections STDs, viral, bacteria

Decreased maternal mortality

Engagement in recovery training

Increased family cohesion and/or choice

College of Physicians and Surgeons of British Columbia 10

Disadvantages of methadone Maternal disadvantages sweating, constipation, libido, sleep, nausea

Infant disadvantages increased risk of more prolonged and pronounced NAS, increased risk of

SIDS

College of Physicians and Surgeons of British Columbia 11

Perinatal methadone management If on heroinconvert to methadone (or buprenorphine) Conversion in hospital is recommended faster, and other tests can be

done at the same time

Integrated care and discharge planning are vital to success

Contraindicated: clonidine, naloxone, naltrexone, pentazocine, nalbuphine, butorphanol

Many women are most stable if maintained on methadone through delivery and six months+ postpartum

College of Physicians and Surgeons of British Columbia 12

Perinatal methadone management In second and third trimester, pregnant women have increased weight and

blood volume and may need:

increase dose once daily

Or become rapid metabolizers thus may need:

split dose according to symptoms

To achieve the same methadone blood level, one patient may need 20 mg, another 120 mg

College of Physicians and Surgeons of British Columbia 13

Methadone tapering The best dose is the lowest dose that keeps a woman out of withdrawal

If she wants to taper off - explore reasons: insufficient/false information, fear of social services, partner pressure, etc.

Explain that with tapering, risk of relapse is highand with it, child apprehension

Even so tapering is possible

College of Physicians and Surgeons of British Columbia 14

Methadone tapering Very slow methadone taper in pregnancy recommended only if in stable

recovery

Outpatient: Taper methadone by 12 mg on any given day, and not more than 25 mg/week

In-patient: Can taper 12 mg/day, RNs monitor

Stop if signs or symptoms of withdrawal

Monitor pregnancy: SFH, U/S, +/- NSTs

Increase frequency of visits and UDSs

Ideal if addictions and perinatal care is provided together

College of Physicians and Surgeons of British Columbia 15

Intrapartum methadone management In labour Continue methadone

Avoid fentanyl, cannot give Narcan to baby due to seizure risk

Offer entonox or epidural if appropriate

Postpartum May gradually lower methadone dose, administer once daily

Neonate Observe for NAS, prescribe morphine if needed

College of Physicians and Surgeons of British Columbia 16

MOTHER study Compared methadone to buprenorphine perinatally and observed infant

outcomes RCT Buprenorphine and methadone were safe and effective in pregnancy and for the

infant Buprenorphine use led to less morphine needed to treat baby (though same

peak NAS scoring) and shorter length of stay in hospital Methadone provided greater retention in treatment (more dropped out of the

buprenorphine group largely dropouts were methadone pts switched to buprenorphine for the study; those switched from heroin to buprenorphine did as well as methadone patients)

Methadone is still gold standard do not change a pregnant patient from methadone to buprenorphine; however if she is on heroin (or other opioid) you can offer her the choice (buprenorphine vs. methadone), beware precipitated withdrawal

If patient is on Suboxone when she gets pregnant, change to pure buprenorphine (special access needed)

College of Physicians and Surgeons of British Columbia 17

Rooming-in If possible and baby and mom are stable Rooming-in decreases withdrawal

Increases bonding, increases breastfeeding rates

Increases moms ability to care for baby

Decreases hospitalization time (likely cost)

Breastfeeding Not contraindicated with methadone

Is contraindicated if HIV+, or active drug use

College of Physicians and Surgeons of British Columbia 18

Probability Methadone/Morphine Tx JOGC May 2012

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 25 50 75 100 125 150 175 200 225 250

Mother's methadone dose (mg)

Pred

icte

d Pr

obab

ility

of i

nfan

t rec

eivi

ng

mor

phin

e No breastfeeding and other opiatesBreastfed and other opiatesNo breastfeeding and no other opiatesBreastfed and no other opiates

Chart1

0.520.180.150.03

0.660.290.230.06

0.780.420.350.1

0.860.560.50.17

0.920.70.640.27

0.950.810.760.4

0.970.880.850.54

0.980.930.910.68

0.990.960.950.79

10.980.970.87

10.990.980.92

No breastfeeding and other opiates

Breastfed and other opiates

No breastfeeding and no other opiates

Breastfed and no other opiates

Mother's methadone dose (mg)

Predicted Probability of infant receiving morphine

Sheet1

0255075100125150175200225250

No breastfeeding and other opiates0.520.660.780.860.920.950.970.980.9911

Breastfed and other opiates0.180.290.420.560.70.810.880.930.960.980.99

No breastfeeding and no other opiates0.150.230.350.50.640.760.850.910.950.970.98

Breastfed and no other opiates0.030.060.10.170.270.40.540.680.790.870.92

Sheet1

11

No breastfeeding and no other opiates

Breastfed and no other opiates

#REF!

#REF!

Mother's methadone dose (mg)

Predicted probablility of an infant receiving morphine

Sheet2

No breastfeeding and no other opiates

Breastfed and no other opiates

#REF!

#REF!

Mother's methadone dose (mg)

Predicted probablility of an infant receiving morphine

1

1

No breastfeeding and other opiates

Breastfed and other opiates

No breastfeeding and no other opiates

Breastfed and no other opiates

Mother's methadone dose (mg)

Predicted Probability of infant receiving morphine

Sheet3

College of Physicians and Surgeons of British Columbia 19

Counselling and follow-up Essential: access to food, shelter, safety

Adding counselling lessens drug use, legal, family, and psychiatric problems

Prenatal care/education, meals, daycareall improve compliance and outcome

Drug and lifestyle stability along with early voluntary MCF referral make apprehension less likely

College of Physicians and Surgeons of British Columbia 20

Key points If on methadone, maintenance is suggested, unless extremely stable and

lots of support