Methadone & Pregnancy “Is methadone safe for my baby?” is usually the first question we hear from women. Pregnant women have been treated with methadone for more than 25 years and neither methadone or other opiates have not been shown to directly cause birth defects. However, your baby may experience some side effects from methadone. The most common are smaller-than-normal head size, low birth weight, and withdrawal symptoms. As babies born dependent on methadone grow, they usually will fall in the normal range for size and development. Methadone is not the only thing that can cause these symptoms. Smoking cigarettes, drug use, your biological makeup, nutrition, and how well you take care of yourself are just a few examples of things that can affect the health of your baby. Whether or not you are pregnant, you only get the benefits of methadone if you are stable on your dose. There is no ‘magic number’ of milligrams to stay below. If you feel any withdrawals or cravings to use, make sure you talk to your counselor about adjusting your dose. When you feel withdrawals, so does your baby and that can lead to complications and even miscarriage.
Research does not necessarily show any connection between a mother’s dose and withdrawal symptoms in the baby.It might seem that the more milligrams a mother is taking, the worse the withdrawal symptom s will be, however this is not the case. That’s why we encourage you to focus on finding a dose that works for you and not to worry about the amount of milligrams. If you are tapering, most clinics will stop your taper and keep you at your current dose. Some women ask about tapering off methadone while they are pregnant. The Government’s Center for Substance Abuse Treatment says this: “Medical withdrawal of the pregnant women from methadone is not indicated or recommended.” and here at methadoneandpregnancy.com agree with them. Remember- If you were not ready to taper before you were pregnant, you are not ready to taper because you are pregnant. Medically, pregnant women have been safely tapered off of methadone, but it’s only been done on an inpatient basis where they can monitor the fetus for any distress. You should never try to detox yourself. This can be very dangerous to you and your baby. This can also put your recovery in jeopardy. Usually when women learn more about methadone use during pregnancy and see other healthy babies at the clinic with their moms, they decide to continue methadone treatment. It’s not uncommon to need a dose increase during your pregnancy. By the third trimester the amount of blood in your body just about doubles! Because of this your dose of methadone may need to be increased to help keep you and your baby free from withdrawal symptoms. In fact, an increase in methadone (if you need it) during this time can help improve growth and reduce risk of premature delivery. We cannot stress it enough; make sure you are stable on your dose! If for some reason you aren’t able to make it to the clinic for one day make sure you call the clinic and let them know you aren’t able to make it in. Do your best to get there the next day as early as possible. If you’re having problems with transportation, talk to your counselor. They will help you to figure out how you can get to the clinic every day. Many people wonder: does methadone use during pregnancy increase the chance of my child becoming an addict? There are not many studies that have looked at long-term effects of babies born depended on methadone. The other problem is that there are so many factors influencing drug use, it would be difficult to pinpoint methadone as the ‘cause’ if a child did start using drugs. We do know that there is a genetic component to addiction, so regardless if you are in methadone treatment or not, if you or the baby’s father has had substance abuse problems, the child may be at an increased risk of being an addict or having problems with drug use. While you are pregnant some clinics require that you meet with the Nurse Practitioner (NP) or other medical staff at least once per month. The medical staff wants to check in with you to make sure your pregnancy is going smoothly and ask about your prenatal visits. This is an excellent time to ask any medical questions. If you have any questions at anytime feel free to talk to your counselor or medical staff at the clinic. Your questions are important and deserve to be answered! Clinic staff may ask you to sign a release so we can speak with your prenatal providers. The release is needed so we can talk with your prenatal provider about your treatment at the clinic. It’s also important to have a release in place so if there are any medical concerns the clinic will be able to assist you. Medications such as Suboxone, Nubain, and Stadol could cause you to have severe withdrawal symptoms if you are taking methadone. Be cautious of medications that you are prescribed or given. You should always check with your medical providers before taking any medication. You should never take anyone else’s prescription medication. And be careful about taking any medications, even if it’s offered to you from a friend or family member. Some people store more than one type of medication in a bottle and you might be given something that could harm you, your pregnancy, or cause you to have a positive drug screen. All of your providers are here to support you and want to help you to have a healthy and safe pregnancy! Let us know what you need and how we can help. 1. Methadone maintenance treatment Methadone maintenance treatment (MMT) is the treatment of choice for opioid dependant pregnant women 2. Methadone is a long-acting opioid that enables women to cease or reduce their heroin use and related behaviours, in accordance with a harm minimization philosophy. MMT throughout pregnancy is associated with improved fetal development, infant birth weight, and reduces the risk of perinatal and infant mortality in heroin dependant women (level III 2, 1). The aims of methadone maintenance treatment are to:
- Reduce or eliminate illicit heroin and other drug use
- Improve the health and wellbeing of those in treatment
- Facilitate social rehabilitation
- Reduce the spread of blood borne diseases
- Reduce the risk of death associated with opioid use
- Reduce the level of crime associated with opioid use 2
- Withdrawal from heroin, without MMT is associated with risks to the fetus and a high risk of relapse2. Women should be informed of these risks, and if it is to be attempted it should ideally be done in the 2nd trimester, supervised in a specialist unit (Consensus,1). While inpatient supervision of withdrawal is not available at the Women's, WADS clinicians are able to provide outreach services to pregnant women undergoing withdrawal in specialist detoxification units.
- dependent on opioids
- motivated to undertake induction onto MMT
- willing to comply with the whole program and methadone regime.
- Severe hepatic impairment
- Hypersensitivity to methadone
- Unable to give informed consent (eg. Major psychiatric illness) or age under 18, consider jurisdictional requirements for obtaining legal consent
- Within 10 minutes of dosing - consider giving a repeat dose
- Within 10-60 minutes of dosing - consider giving half a repeat dose
- More than 60 minutes after dosing - consider half a repeat dose if withdrawal occurs
- Women should be discouraged from ingesting methadone on an empty stomach
- Women should be encouraged to sip their dose slowly
- If the dose consistently causes vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before dosing
- If woman vomits constantly not in relation to dose, assess and treat according to the Women's CPG: Hyperemesis Gravidarum.
- Unpredictable sleeping patterns
- Feeding difficulties
- Atypical social interactions
- Delayed language development
- Poor fine motor development
- Atypical social interactions
- Minimal play strategies
- Provide a calm environment: low lighting; soft voices; slow transition from one activity to another.
- Be aware of signs of escalated behavior and frantic distress states before they occur, e.g., increased yawns, hiccoughs, sneezes, increased muscle tone and flailing, irritability, disorganized sucking, and crying.
- Use calming and special care techniques on a regular basis, such as
- swaddling blankets tightly around the infant
- using a pacifier even when the infant is not organized enough to maintain a regular suck
- rocking, holding, or placing the infant in a swing, or Snuggly™ carrier
- massaging the child
- bathing in a warm bath, followed by a soothing application of lotion
- rubbing ointment on diaper area to prevent skin breakdown
- Encourage developmental abilities when the infant is calm and receptive using only one stimulus at a time. Look for signs of infant distress and discontinue the activity if this occurs.
- Gradually increase the amount and time of daily developmental activities; encourage the child to develop self-calming behaviors and self control of his own body movements.
May have poor inner controls/frequent temper tantrums
Use books, pictures, doll play, and conversation to help the child explore and express a range of feelings. Ignores verbal/gestural limit setting Talk the child through to the consequence of the action. Shows decreased compliance with simple, routine commands Provide the child with explicitly consistent limits of behavior. Exhibits tremors when stacking or reaching Observe the child and note the onset of tremors, their duration, and how the child compensates for them; provide a variety of materials to enhance development and refinement of small motor skills, e.g., blocks, stacking toys, large Leggos™, and puzzles with large pieces. Sand and water play are soothing and appropriate. Unable to end or let go of preferred object or activity Provide attention and time to children who are behaving appropriately; provide child with an opportunity to take turns with peers and adults. Delayed receptive and expressive language Create a stable environment where the child feels safe to express feelings, wants, and needs; use stories/records/songs; use hands-on activities to reinforce the child’s language abilities. Expresses wants, needs, and fears by having frequent temper tantrums Remove and help calm the child; redirect the child’s attention; verbalize the expected behavior; reflect the child’s feelings. Praise attempts toward adaptive behavior. Set consistent limits. Difficulty with gross motor skills (e.g. swinging, climbing, throwing, catching, jumping, running, and balancing) Provide appropriate motor activities through play, songs, and equipment. Offer guidance, modeling, and verbal cues as needed. Over-reacts to separation of primary caregiver Offer verbal reassurance; be consistent, and help the child learn to trust adults. Withdraws and seems to daydream or not be there Provide opportunities for contact; move close to the child, make eye contact, use verbal reassurance; allow, identify, and react to the child’s expressions of emotions. Frequent temper tantrums Understand that a tantrum is usually a healthy release of rage and frustration; protect the child from harm; remove objects from the child’s path if he is rolling on floor. Some children do not want to be held during a tantrum and doing so can cause more frustration. Remain calm, using a soothing voice; anger will only escalate the child’s frustration. Do not shout or threaten to spank the child–the adult needs to be in control. Help the child to use words to describe emotions. Read stories about feelings. Help the child gain control by making eye contact, sitting next to the child, giving verbal reassurance, and offering physical comfort (rubbing back, etc.). Note the circumstances that provoked the tantrum, and try to avoid such confrontations when possible. Provide a neutral area for the child to work through the tantrum, (e.g., a large cushion or bean bag chair). Some children want to work through a tantrum alone; keep the child in sight, but do not interact until he is calm. Parent Involvement It is critical to the success of the drug-exposed infant that the eventual caregiver (parent, relative, foster parent, respite provider, adoptive parent) learn the care routine, control techniques, and background of the children for whom they will be providing care. Understanding the etiology of drug-exposure, the types of medical problems that arise, the developmental patterns, and the techniques for handling drug-exposed infants and toddlers is imperative. Program social workers, case managers, child care staff, and nursing staff must all work together with the caregiver to offer parent education ("hands-on" opportunities to provide care under the guidance of professionals), and encouragement for families who undertake the care of a drug-exposed infant. The caregiver’s understanding of the child’s behavior, physical "cues," and developmental problems, goes a long way in helping the drug-exposed infant, toddler, and teen succeed. It also assists the caregiver in setting realistic expectations for children who enter the world battling the the effects of their parent’s addiction. Many children who were prenatally exposed to drugs will grow and develop without unusual problems. However, for those infants who have physical indicators, the respite and crisis care provider can make a difference by providing, perhaps, the first stable, nurturing environment. Here, the child can be observed, positive routines for care can be established, and parents can receive the critically necessary education and support to enable them to care for an alcohol or drug-exposed child. Summary Staff training, caregiver training, and parent education are all critical elements of any program that will be successful with these children. Physical elements of the environment (lighting, noise, and space) may need to be adjusted to accommodate their care. The inclusion of medical support, i.e., nurses and physicians who are familiar with the problems of these children, is essential. In summary, the care of alcohol and drug-exposed children is a team effort that requires coordination, case management, special care techniques, and education to be successful in any respite or crisis care situation. With these components in place, agencies and families can witness the positive growth and development of children who have been greatly at risk. About the Author: Jeanne Landdeck-Sisco, MSW, is the Executive Director of Casa de los Niños in Tucson, Arizona, which was the first crisis nursery in the U.S., established in 1973. Ms. Landdeck-Sisco served as the first President of the ARCH National Advisory Committee for Respite and Crisis Care Programs from 1991-93 and remained on the committee until 1996. Resources Center for Substance Abuse Prevention National Resource Center for the Prevention of Perinatal Abuse of Alcohol and Other Drugs, 9302 Lee Highway, Fairfax, VA 22031, (800) 354-8824. National Organization on Fetal Alcohol Syndrome, 1815 H Street, N.W., Suite 710, Washington, DC 20006, (202) 785-4585. References Besharov, Douglas J. When Drug Addicts Have Children. Washington, DC: Child Welfare League of America, 1994. Hargrove, Elisabeth, et al. Resources Related to Children and Their Families Affected by Alcohol and Other Drugs. Chapel Hill, NC: NEC*TAS, 1995. Special acknowledgment is given to Rosemarie Dyer, R.N., Nursing Supervisor at Casa de los Niños, who has developed the agency’s program for drug- and alcohol-exposed infants and from whose training material many of the techniques and caregiver responses have been drawn; and to Anna Binkiewicz, M.D., Casa de los Niños Board Member and Medical Director, who has provided on-site medical treatment of Casa’s medically fragile children.