The following approaches are used to manage the pregnant, opioid-addicted woman. The first approach is methadone maintenance combined with psychosocial counseling.
This is a well-documented approach to improve outcomes for both the woman and her fetus.
The second approach is slow medical withdrawal with methadone.
The safety of this second approach has not been documented.
Opioid Withdrawal Signs and Symptoms
Mild withdrawal signs and symptoms include
Generalized anxiety
Opioid craving
Restlessness
Slight aching of muscles, joints, and bones
Lower back pain
Mild to moderate withdrawal signs and symptoms include
Tension
Yen sleep (mild insomnia)
Mydriasis (pupils dilated)
Lethargy
Diaphoresis (increased perspiration)
Moderate withdrawal signs and symptoms include
Chills alternating with flushing and diaphoresis (sweating)
Nausea and/or stomach cramps
Rhinorrhea (runny nose)
Moderate aching of muscles, joints, and bones
Lower back pain
Anorexia
Nausea and/or stomach cramps
Yawning
Lacrimation (tearing)
Goose flesh (earlier if client is in a cold, drafty room)
Elevated pulse and blood pressure
Moderate to severe withdrawal signs and symptoms include
Diarrhea
Vomiting
Tremors
Tachycardia (pulse over 100 BPM)
Increased respiratory rate and depth
Severe withdrawal signs and symptoms include
Doubling over with stomach cramps
Kicking movements
Elevated temperature (usually low grade, less than 100° F)
Note: Withdrawal signs and symptoms differ in their order of appearance from one individual to another.
Some individuals may not exhibit certain withdrawal signs and symptoms.
Signs may also include uterine irritability, increased fetal activity, or rarely, hypotension.
Despite its dramatic appearance, the opioid withdrawal syndrome is rarely life-threatening or permanently disabling to an adult.
However, there is good evidence that the fetus may be more susceptible to withdrawal symptoms than the mother.
In the mother, the initial signs of opioid withdrawal progress to increasingly painful physical symptoms.
In addition to these signs, patients show compelling psychological cravings for drugs, as well as drug-seeking behavior.
Methadone substitution is the standard treatment for heroin addiction.
Methadone treatment alternatives consist of (1) high-dose blockage; (2) low-dose maintenance; and (3) medical withdrawal.
Medical withdrawal of the opioid-dependent woman is not recommended in pregnancy because of the increased risk to the fetus of intrauterine death.
Methadone maintenance is the treatment of choice.
In addition to methadone maintenance, a comprehensive approach is needed that will provide the patient with counseling and other services.
The administration of methadone, combined with any opioid agonist/antagonist such as pentazocine (Talwin), will precipitate withdrawal.15 Any pregnant woman receiving methadone should be advised against taking opioid agonist/antagonists under all circumstances.
Neonatal abstinence syndrome (NAS) may or may not be related to maternal dose of methadone; NAS may also be related to fetal gestational age and infant weight.
However, studies in both pregnant women and other adults have shown that larger doses of methadone result in a decreased use of other drugs.
These effects may be the result of concomitant maternal lifestyle factors rather than the direct result of drug use.
1 Possible effects on the pregnancy:
Toxemia
Intrauterine growth retardation
Miscarriage
Premature rupture of membranes
Infections
Breech presentation (abnormal presentation due to premature delivery)
Preterm labor
No effect
2 Possible effects on the mother:
Poor nourishment, with vitamin deficiencies, iron deficiency anemia, and folic acid deficiency anemia
Medical complications from frequent use of dirty needles (abscesses, ulcers, thrombophlebitis, bacterial endocarditis, hepatitis, and urinary tract infection)
Sexually transmitted diseases (gonorrhea, chlamydia, syphilis, herpes, and HIV infection)
Hypertensive disorder
No effect
3 Possible effects on the fetus and newborn infant:
Determine the amount of drug being used and follow the dosing strategy listed below.
1 Evaluate the pattern of drug use, route of administration, and frequency and amount of drug use. Know something about the purity of the street product and the other substances, such as quinine or Valium, with which the product may be cut or diluted.
2 Obtain a detailed history of drug use within the past 24 hours.
3 Give an initial oral methadone dose of 10 to 40 mg.
Because it is imperative to reverse any opioid abstinence symptoms as quickly as possible, an additional dose of methadone may be required in the range of 5 to 10 mg if objective signs of withdrawal persist after 3 to 4 hours (time to allow the methadone to reach a peak blood level).
This 5- to 10-mg dose can be repeated at 3 to 4 hour intervals until objective signs of withdrawal are no longer present.
4 Adjust the dosage by 5 to 10 mg daily based on physical signs and symptoms of opioid withdrawal (see table) and patient comfort.
Even minimal symptoms in the mother may indicate stress in the fetus.
5 After the stabilization dose has been established, keep the patient at this level for several days.
6 If there is simultaneous dependence on other drugs such as alcohol, cocaine, and sedatives, methadone induction should proceed as outlined in items 1 through 5, while concurrent medical withdrawal procedures are initiated.
The other drug withdrawals can be managed as usual against the background of methadone maintenance.
Ideally, this is an inpatient procedure.
Important Warning: NARCAN (or any narcotic antagonist) should never be given to a pregnant, substance-using woman except as a last resort to reverse severe narcotic overdose. Administration of a narcotic antagonist to a pregnant, substance-using woman could result in spontaneous abortion, premature labor, and/or stillbirth.16
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