Posts Tagged ‘methadone during pregnancy’

Difficulties Getting Treatment While Pregnant

Ukrainian Art Bought off ETSY by Anastasiia Grygorieva

I read an interesting and depressing article in the Journal of Addiction Medicine (May/June 2022) by Davis et al. It was about access to treatment for pregnant women in states with laws preventing discrimination against them. The study sought to find out if such laws made a difference and assured more access to care than in states without such laws.

As my readers know, using medications for opioid use disorder (MOUD) is the standard of care for people with opioid use disorder, and is particularly recommended for pregnant patients with opioid use disorder. This is because of proven benefits not only to the mom, but also to the infant. Moms on MOUD are less likely to have complications and more likely to have heathy full-term babies.

There’s no evidence that avoiding MOUD during pregnancy decreases the risk of withdrawal in newborns, as some have falsely claimed. This sentence is directed to the backward obstetricians in Tennessee, except apparently, they don’t do much reading, or they’d already know this by now.

Anyway, back to the study. This was a “secret shopper” type of study, where the study’s authors called treatment programs, posing as prospective patients. These simulated patients said either that they were not pregnant or were four months pregnant. They made calls to programs in states that have laws forbidding providers from refusing to treat pregnant patients, and in states without such laws. The study sought to see if treatment is more accessible to pregnant women in states with laws forbidding discrimination.

They called opioid treatment programs and office-based buprenorphine programs in ten states. Four states had laws preventing discrimination due to pregnancy: Kentucky. Missouri, Tennessee, and West Virginia. Study authers also called providers in six other states: Florida, Massachusetts, Michigan, North Carolina, Virginia, and Washington, where there are no such laws.

All callers said they had either Medicaid or private insurance.

In both groups of states, non-pregnant callers were significantly more likely to get appointments than pregnant callers.

 In states with a law mandating treatment access for pregnant patients, the non-pregnant callers got appointments 75% of the time, and pregnant patients only 60% of the time. In states without a law mandating treatment access for pregnant patients, 73% of non-pregnant patients and 62% of pregnant patients were able to get an appointment.

The study was done in 2019, so COVID wasn’t a confounding factor.

Office-based buprenorphine prescribers were significantly more likely to turn down pregnant patients than opioid treatment programs. In fact, at opioid treatment programs, pregnant and non-pregnant patients got appointments at the same rate.

So why don’t laws prohibiting pregnancy discrimination work?

I have some ideas, and so do the authors of this study.

The authors think providers might not know about these laws prohibiting discrimination, or if they do know, have never seen the laws enforced. These providers may not think they will get into any trouble for turning down a pregnant patient.

They also point out that the relevant laws only apply to providers who accept Medicaid for payment. Many OBOT (office-based opioid treatment) programs don’t participate in the Medicaid. I think this is because of low reimbursement rates and administrative hassles.

I also think most providers don’t like to treat pregnant women. They make us nervous. The actual physical treatment is more complicated, and more ethical issues arise. What if we precipitate withdrawal with the first dose of buprenorphine and the patient has a miscarriage?  It takes more time and energy to coordinate with an obstetrician, who may disapprove of buprenorphine use in pregnant women. For example, in Tennessee, buprenorphine providers say many OBs don’t want their pregnant patients on buprenorphine OR methadone. Will that lead to a contentious relationship between the OB and the OBOT physician?

And what if the pregnant woman refuses to go to the OB once she’s started on buprenorphine? Will the buprenorphine prescriber be blamed for a bad outcome if there’s no prenatal care except what she gets in the OBOT office?

I think these thoughts enter the average OBOT provider’s brain when faced with a new pregnant patient.

Things get even more complicated when we consider that some of these states have laws against drug use during pregnancy. In these states, instead of approaching drug use in pregnancy as a public health issue, they view it as a crime.

According to Guttmacher Institute ( ), at present twenty-four states and the District of Columbia consider drug use during pregnancy to be child abuse, and three consider it grounds for civil commitment. Twenty-five states and D.C. require healthcare professionals to report suspected prenatal drug use.

Lawmakers sometimes say the reasons they pass these laws is to push pregnant women into getting help and getting treatment for their substance use disorders. Except that, as this study shows, it’s harder for pregnant women to get into treatment than non-pregnant, even with laws meant to increase their access.

Opioid use disorder treatment providers might not want to get in a situation where they are mandated to report a pregnant patient who isn’t doing well in treatment.

Imagine you are a woman with a substance use disorder and you just found out you’re pregnant. If you live in a state with laws criminalizing drug use during pregnancy, you might fear your doctor will report you if you seek medical care, assuming the doctor detects your drug use. Would you go to the doctor for prenatal care? Would you try to get treatment assistance? If you tried to get help and were turned down repeatedly, what would you do?

With abortion becoming far more difficult to obtain in many states, I suspect most pregnant women in these states will try to carry on as best they can during the pregnancy, without prenatal care, and hope for the best at delivery.

Medically, this is the worst option.

The maternal mortality rate in the U.S. is 17 deaths per 100,000 live births, which isn’t as good as all other high-income countries, but at least we have fewer maternal deaths than Turkey, Chile, and Mexico. This dismal data isn’t due to drug use alone, but to lack of available health care, among other factors. [1]

Infant mortality rates in the U.S. aren’t anything to brag about either, with most recent data showing we have 5 deaths per 1000 live births. That’s far worse that countries like Norway, Japan, and Singapore, but on par with countries such as Uruguay, Serbia, and the Slovak Republic. Even the Russian Federation and Cuba had better infant mortality rates than the U.S. did in 2020. [2]

Maybe it’s time we re-thought our healthcare system and our drug laws for pregnant women. And maybe if laws are passed to improve access for pregnant women, they should be implemented with the kind of support that makes providers eager to treat them.


Opioid Addiction in Pregnancy: More Information about the Use of Methadone Versus Buprenorphine


The MOTHER (Maternal Opioid Treatment: Human Experimental Research) trial of 2012 (Jones et al) gave us much-needed information about how buprenorphine compares to methadone when used to treat opioid-addicted pregnant women. This landmark study showed us buprenorphine can be just as effective as methadone. Babies born to moms on buprenorphine had the same incidence of opioid withdrawal (called neonatal abstinence syndrome, or NAS) at 50%, but the withdrawal was significantly less severe, the babies required about half the medication as the babies born to moms on methadone. Also, buprenorphine-exposed babies spent significantly less time in the hospital – about half as long as methadone-exposed infants.

Some doctors point out that more women on buprenorphine dropped out of that study than women on methadone, and say that proves buprenorphine is less effective. However, the majority of those women didn’t leave treatment; they just left the buprenorphine arm of the study.

This week I read another study, by Meyer et al, soon to be published in the Journal of Addiction Medicine. This study also looked at pregnant patients being treated for opioid addiction.

The authors of this new study pointed out that the MOTHER trial was a placebo- controlled, double- blind study comparing buprenorphine with methadone, but in real life, the decision to start an opioid-addicted pregnant woman on buprenorphine versus methadone is more complex, and determined by other factors. So the study by Meyer et al did a retrospective analysis. They looked at cases where the choice of buprenorphine versus methadone was made by the patient and physician, as happens in real life, then studied the outcomes. The authors of the new study believed findings will be more pertinent to what happens in everyday clinical practice.

In this retrospective cohort study, 609 pregnant patients were started on either buprenorphine (361) or methadone (248). This study took place over the years from 2000 to 2012 at a single site, University of Vermont.

The study collected various data about the newborns: their sex, estimate gestational age at delivery, birth weight, head circumference, length of stay in the hospital, whether the baby received breast milk, and if the child was sent home with the mother. The study also looked at if the newborn has NAS and if the baby needed medication, and length NAS treatment.

In the results, first-time mothers were significantly more likely to start buprenorphine than methadone. Mothers positive for Hepatitis C were more likely to be started on methadone. In both groups, more than 80% of the moms were smokers. About 30% of both groups had to have a C-section at delivery.

Both groups had similar prenatal care; more than 65% of the mother in both groups initiated care within the first trimester. However, women in the buprenorphine group were significantly more likely to get what the authors defined as “adequate” prenatal care. Women on buprenorphine were also more likely to already be in treatment when they became pregnant, compared to the women in the methadone group.

Nineteen women switched from buprenorphine to methadone, out of the three-hundred and sixty-one women who started on buprenorphine. Only five of those patients switched because buprenorphine was not strong enough for them, or other medication side effects. Most were switched to methadone because they needed more intensive monitoring at an opioid treatment program due to continued positive urine drug screens. Only three women out of the three-hundred and sixty-one started on buprenorphine dropped out and were lost from treatment.

No women were switched from methadone to buprenorphine, as one would expect. That’s because in order to switch from a full opioid, methadone, to a partial opioid, buprenorphine, the pregnant opioid addict would have to go into at least mild withdrawal, thus putting her at risk for adverse events. That’s not a risk most doctors are willing to consider.

Babies born to moms on buprenorphine, as compared to methadone, were significantly more likely to have longer gestational age. This is a good thing, because it means there were significantly fewer preterm deliveries on buprenorphine compared to methadone. The babies born to moms on buprenorphine were significantly more likely to have higher birth weights and bigger head circumference.

Just like what we saw in the MOTHER trial, this study also showed that the infants born to moms on buprenorphine required significantly less medication to treat neonatal abstinence syndrome. The buprenorphine-exposed babies required medication for a significantly shorter time than methadone-exposed newborns.

More than 95% of the infants were sent home in the care of the mother or family, which makes me think this study was done on women with fairly good stability at the time of delivery.

The authors of the study concluded that this evidence suggests that buprenorphine gives outcomes that are at least as good as with methadone.

I’d take that conclusion one step farther and say we now have several studies that show less neonatal withdrawal in babies exposed prenatally to buprenorphine compared to methadone. I have to ask myself: knowing what I do from these studies, which medication would I want to take during pregnancy? I’d prefer buprenorphine, and if it didn’t work for any reason, I’d switch to methadone.

I explain all of this to pregnant patients with opioid addiction upon admission, though I’m careful to also point out that methadone is still officially the gold standard in many places.

I think that will change soon. We are getting more information that shows outcomes equal to methadone with less severe neonatal withdrawal.