- Email: [email protected]
Improving the management of opioid-dependent pregnancies
1806
Letters to the Editors
Improving the management of opioid-dependent pregnancies To the Editors: We read with interest the article by Berghella et al1 and share their goal of improving the management of pregnancies complicated by opioid addiction. We also recently published a study of maternal methadone dosage and neonatal withdrawal.2 Although Berghella et al found no relationship, in our series, treatment for neonatal withdrawal was necessary in 12% of women receiving less than 20 mg methadone per day, 44% receiving 20 to 39 mg/day, and 90% receiving more than 40 mg/day (P!.02). In addition, methadone dosage was associated with duration of neonatal hospitalization and neonatal abstinence score (rs = 0.70 and 0.73, respectively, both P!.001).2 Berghella et al cited work published more than 25 years ago that proposed using low doses of methadone in pregnancy, below 20 mg/day, to prevent neonatal withdrawal, exactly what our data support.2 Though Berghella et al suggested such a low dosage would promote illicit drug use, we found less heroin supplementation in women requiring less methadone: in 4% of women receiving less than 20 mg/day, 16% receiving 20 to 39 mg/day, and 25% receiving more than 40 mg/day (P!.05).2 Methadone-maintained pregnancies have many complicating factorsddrug abuse, tobacco and alcohol use, prostitution, underlying medical conditions, and limited social supports. Our studies were conducted in different parts of the United States, and the dosage range in our area may be lower than in the mid-Atlantic region. Berghella et al found no difference in neonatal withdrawal when pregnancies receiving 80 mg or more methadone per day were compared with those receiving less than 80 mg/day. Importantly, more than 70% of infants in each group experienced withdrawal.1 It is possible the investigators could not detect a dose-response relationship because fewer than 5% of women received less than 40 mg methadone per day.1 This information may be important in light of recent trends toward increasing (rather than decreasing) the dosage of methadone maintenance therapy.3
Berghella et al have clearly shown that clinicians administering high doses of methadone will find no correlation of maternal dosage with neonatal withdrawal. Indeed, they can expect the majority of infants to require several weeks of treatment for neonatal abstinence. We have previously reported that selected women can safely undergo methadone detoxification during pregnancy, when managed closely by a similar multidisciplinary team.4 We strongly believe that pregnant women who are motivated to decrease their methadone intake in a controlled environment should not be discouraged, as in many cases doing so can decrease the incidence and severity of neonatal withdrawal. Jodi S. Dashe, MD* Jeanne S. Sheffield, MD George D. Wendel, Jr, MD *Department of Obstetrices and Gynecology MCP/Hahnemann University 245 N 15th St Mailstop 495 Philadelphia, PA 19102 E-mail: [email protected]
References 1. Berghella V, Lim PJ, Hill MK, Cherpes J, Chennat J, Kaltenbach K. Maternal methadone dose and neonatal withdrawal. Am J Obstet Gynecol 2003;189:312-7. 2. Dashe JS, Sheffield JS, Olscher DA, Todd SJ, Jackson GL, Wendel GD Jr. Relationship between maternal methadone dosage and neonatal withdrawal. Obstet Gynecol 2002;100:1244-9. 3. D’Aunno T, Pollack HA. Changes in methadone treatment practices: results from a national panel study, 1988-2000. JAMA 2002;288:850-6. 4. Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD Jr. Opioid detoxification in pregnancy. Obstet Gynecol 1998;92:854-8.
0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.081
Reply To the Editors: We thank Dashe et al for their interest in our research. We have read with attention their article,1 published 4 months after we submitted ours.
As Dashe et al state in their letter, recent trends in the nonpregnant population are toward increasing the dosage of methadone maintenance therapy. As we stated in
Letters to the Editors
Improving the management of opioid-dependent pregnancies To the Editors: We read with interest the article by Berghella et al1 and share their goal of improving the management of pregnancies complicated by opioid addiction. We also recently published a study of maternal methadone dosage and neonatal withdrawal.2 Although Berghella et al found no relationship, in our series, treatment for neonatal withdrawal was necessary in 12% of women receiving less than 20 mg methadone per day, 44% receiving 20 to 39 mg/day, and 90% receiving more than 40 mg/day (P!.02). In addition, methadone dosage was associated with duration of neonatal hospitalization and neonatal abstinence score (rs = 0.70 and 0.73, respectively, both P!.001).2 Berghella et al cited work published more than 25 years ago that proposed using low doses of methadone in pregnancy, below 20 mg/day, to prevent neonatal withdrawal, exactly what our data support.2 Though Berghella et al suggested such a low dosage would promote illicit drug use, we found less heroin supplementation in women requiring less methadone: in 4% of women receiving less than 20 mg/day, 16% receiving 20 to 39 mg/day, and 25% receiving more than 40 mg/day (P!.05).2 Methadone-maintained pregnancies have many complicating factorsddrug abuse, tobacco and alcohol use, prostitution, underlying medical conditions, and limited social supports. Our studies were conducted in different parts of the United States, and the dosage range in our area may be lower than in the mid-Atlantic region. Berghella et al found no difference in neonatal withdrawal when pregnancies receiving 80 mg or more methadone per day were compared with those receiving less than 80 mg/day. Importantly, more than 70% of infants in each group experienced withdrawal.1 It is possible the investigators could not detect a dose-response relationship because fewer than 5% of women received less than 40 mg methadone per day.1 This information may be important in light of recent trends toward increasing (rather than decreasing) the dosage of methadone maintenance therapy.3
Berghella et al have clearly shown that clinicians administering high doses of methadone will find no correlation of maternal dosage with neonatal withdrawal. Indeed, they can expect the majority of infants to require several weeks of treatment for neonatal abstinence. We have previously reported that selected women can safely undergo methadone detoxification during pregnancy, when managed closely by a similar multidisciplinary team.4 We strongly believe that pregnant women who are motivated to decrease their methadone intake in a controlled environment should not be discouraged, as in many cases doing so can decrease the incidence and severity of neonatal withdrawal. Jodi S. Dashe, MD* Jeanne S. Sheffield, MD George D. Wendel, Jr, MD *Department of Obstetrices and Gynecology MCP/Hahnemann University 245 N 15th St Mailstop 495 Philadelphia, PA 19102 E-mail: [email protected]
References 1. Berghella V, Lim PJ, Hill MK, Cherpes J, Chennat J, Kaltenbach K. Maternal methadone dose and neonatal withdrawal. Am J Obstet Gynecol 2003;189:312-7. 2. Dashe JS, Sheffield JS, Olscher DA, Todd SJ, Jackson GL, Wendel GD Jr. Relationship between maternal methadone dosage and neonatal withdrawal. Obstet Gynecol 2002;100:1244-9. 3. D’Aunno T, Pollack HA. Changes in methadone treatment practices: results from a national panel study, 1988-2000. JAMA 2002;288:850-6. 4. Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD Jr. Opioid detoxification in pregnancy. Obstet Gynecol 1998;92:854-8.
0002-9378/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ajog.2004.01.081
Reply To the Editors: We thank Dashe et al for their interest in our research. We have read with attention their article,1 published 4 months after we submitted ours.
As Dashe et al state in their letter, recent trends in the nonpregnant population are toward increasing the dosage of methadone maintenance therapy. As we stated in