Home > Clinical practice guidelines for prescribing methadone in pregnancy

Lyons, Suzi (2013) Clinical practice guidelines for prescribing methadone in pregnancy. Drugnet Ireland , Issue 47, Autumn 2013 , pp. 23-24.

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New clinical practice guidelines on safe and effective prescribing of methadone for pregnant women in maternity hospitals were jointly published in April 2013 by the Institute of Obstetricians and Gynaecologists and the Health Service Executive. Based on an earlier document used by the three Dublin maternity hospitals, these new guidelines were developed after a wide-ranging review of the literature and consultation with key stakeholders.  

The document recommends that all pregnant women with problem opiate use should attend a specialist or high-risk antenatal clinic. If this is not possible, the woman should attend the same clinic throughout her pregnancy to ensure continuity of care.
 
The guidelines work through various common clinical scenarios and issues around admission and discharge. They are designed to guide clinical judgment, not replace it. 
 
Clinical Scenario 1: Pregnant women admitted and known to be on prescribed methadone from medical record or verbal history.
·         Their methadone provider should be contacted to confirm details. The hospital medical team should ensure that methadone is prescribed in a timely manner.
 
Clinical Scenario 2: Pregnant women admitted with a take–away methadone supply.
·         Women should be advised not to bring supplies of take-away methadone into hospital. If they do, the methadone must be sent to the pharmacy to be destroyed.
 
Clinical Scenario 3: Pregnant women admitted to hospital self-reporting heroin use but not registered with the addiction services or a prescribing GP.
·         This group of women need to be assessed and treated in a timely manner, given that opiate withdrawal carries the risk of pre-term delivery and foetal death. It is advisable to seek guidance from the local addiction services and also to confirm that the woman is opiate dependent. The management of initiation of any methadone treatment should be closely monitored.
 
Clinical Scenario 4: Pregnant women admitted looking for a prescribed dose of methadone out of hours and known to be on prescribed methadone from medical record or verbal history.
·         As methadone cannot be administered on an out-patient basis, the woman must be admitted, then up to a maximum of half her current dose prescribed.
 
Intoxicated pregnant women
·         Because of the risk of overdose, methadone must not be dispensed to a woman who may be intoxicated until they have been medically assessed.
 
Vomiting in pregnant women on methadone-maintenance treatment
·         Vomiting may not be related to the methadone, so other possible causes should be investigated, e.g. hyperemesis gravidarum. Depending on the time lines and amount vomited, a proportion of, or all of the dose may be re-administering.
 
Discharge of methadone- maintained women
·         All details of the woman’s methadone prescription should be sent to the prescriber in the community (either clinic or GP). Women should not be discharged with supplies of methadone from hospital stock or a prescription for methadone or benzodiazepines.
 
Peripartum pain management
·         Women on methadone treatment should be offered, if required, the same pain relief options as other women for labour or post-partum pain, as maintenance doses of methadone do not provide adequate pain relief. They should be reassured that there is no evidence that the administration of opiates for pain relief leads to relapse, however they may require higher doses to provide effective relief.
 
Breastfeeding
·         Women who are stable on methadone and have no contra-indications  should be encouraged to breastfeed if they wish. However if the woman is on other medication, e.g. benzodiazepines, advice should be sought.
 
Methadone dosing in pregnancy
·         This can be a difficult area to manage, particularly because of the complexities of pregnancy-associated pharmacokinetic changes which have been shown to reduce the concentration of methadone in the blood. Some women may wish to reduce their dose in order to reduce the risk of neonatal abstinence syndrome in their infant; however, there is no evidence to support this theory. Each woman’s dose, her tolerance and its effectiveness should be monitored and titrated closely during the pregnancy. Because of the risk of relapse and the subsequent risk to the foetus, detoxification from methadone is not recommended during pregnancy.
 
 
Key recommendations (reproduced from p.3 of Clinical practice guideline)
 
 
1. Methadone maintenance treatment is the treatment of choice for opioid-dependent pregnant women. In adequate doses, methadone provides stability for the woman during pregnancy, avoiding repeated cycles of intoxication and withdrawal that may adversely affect the foetus.
 
2. Withdrawal from opioids can cause foetal death and preterm delivery. It is important that women who report illicit opiate use are assessed and treated in a timely manner.
 
3. Clear communication between maternity hospitals and local addiction services is required, particularly in relation to methadone doses and admission/discharge of methadone-maintained women.
 
4. Initiation of methadone may be required in a maternity hospital to avoid obstetric complications of opioid withdrawal. Careful initiation is required, as the highest risk of overdose mortality is in the first two weeks on methadone treatment.
 
5. A validated scoring tool should be used to assess signs of opioid withdrawal in opioid-dependent pregnant women.
 
6. Opioid-dependent pregnant women are at risk of under-treatment of peripartum pain.
 
7. Breastfeeding should be encouraged in women who are stable on methadone maintenance treatment unless there are other medical contraindications.
 
8. The maternal methadone dose should be individually adjusted to control maternal craving or withdrawal symptoms.
 
 
 
1. Institute of Obstetricians and Gynaecologists and Health Service Executive (2013) Clinical practice guideline: methadone prescribing and administration in pregnancy. Dublin: Institute of Obstetricians and Gynaecologists and Health Service Executive www.drugsandalcohol.ie/20188 
Item Type:Article
Issue Title:Issue 47, Autumn 2013
Date:October 2013
Page Range:pp. 23-24
Publisher:Health Research Board
Volume:Issue 47, Autumn 2013
EndNote:View
Accession Number:HRB (Electronic Only)
Subjects:B Substances > Opioids (opiates) > Opioid product > Methadone
E Concepts in biomedical areas > Pregnancy
HJ Treatment method > Substance disorder treatment method > Substance replacement method (substitution) > Methadone maintenance
J Health care, prevention and rehabilitation > Patient care management
T Demographic characteristics > Pregnant woman
T Demographic characteristics > Doctor
VA Geographic area > Europe > Ireland

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