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Dear Sir,
Re: Devarajah S, Sullivan JV, Purcell A et al. Citation2012. Methadone use in pregnancy: evidence of progression in the severity of addiction. Journal of Obstetrics and Gynaecology 32:753–755
Methadone maintenance treatment (MMT), integrated in a comprehensive care for opioid-dependent pregnant women, has been shown to improve maternal, fetal and neonatal outcomes, when compared with no treatment and with medication-assisted detoxification (Winklbaur et al. Citation2008; Young and Martin Citation2012).
The paper by Devarajah et al. (Citation2012) provides important data on trends in doses of methadone prescribed to opioid-dependent pregnant women from a North of England hospital over nearly a decade. The authors describe an increase in the mean dose of methadone prescribed at the time of booking (from 33.6 ml/day in 2001 to 56.0 ml/day in 2008) and at delivery (from 28.2 to 57.9 ml/day), interpreting these results as evidence of progression in the severity of addiction. Although this interpretation can certainly be a valid and even cogent conclusion, the observed increases can be accounted for by two other alternative factors (not mutually exclusive).
A first possible explanation is based on the fact that MMT clinical practice guidelines have had a positive, albeit limited, affect on methadone-prescribing practices, as it seems to have been the case in all of England (Strang et al. Citation2007) and abroad (e.g. Pollack and D’Aunno Citation2008).
The other possibility stems from a partial shift of the clinic orientation, from a more abstinence-oriented approach to a more maintenance-oriented philosophy, quoting Caplehorn et al.' s (Citation1996) terms. In fact, the clinic orientation has been shown to be associated with methadone dosage levels (Willenbring et al. Citation2004).
Independently of the cause(s) underlying the observed increase in the average dose of methadone, there is a striking result of the referred study that deserves an additional comment. Even in the latest year studied (2008), the mean daily doses of methadone fall below the lower bound of the commonly recommended dose range (i.e. 60–120 mg/day). Note that this range was already encouraged by empirically-established national standards for best practice care before the beginning of the study period (e.g. Department of Health et al. Citation1999).
Unfortunately, the tradition of prescribing lower doses to pregnant women, based on the belief that this practice minimises the severity of neonatal abstinence syndrome (NAS), has yielded sub-optimal care for opioid-dependent pregnant women. A recent meta-analysis concludes that the severity of the NAS does not differ according to whether methadone-maintained pregnant women are treated with higher or lower doses (Cleary et al. Citation2010).
A more evidence-based, best practice care of opioid-dependent pregnant women will surely improve the quality of life of these patients and their offspring.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
- Caplehorn JR, Irwig L, Saunders JB. 1996. Attitudes and beliefs of staff working in methadone maintenance clinics. Substance Use and Misuse 31:437–452.
- Cleary BJ, Donnelly J, Strawbridge J et al. 2010. Methadone dose and neonatal abstinence syndrome – systematic review and meta-analysis. Addiction 105:2071–2084.
- Department of Health, Scottish Office Department of Health, Welsh Office et al. 1999. Drug misuse and dependence – Clinical guidelines on clinical management. London: HMSO. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4078198.pdf (Accessed 15 November 2012).
- Devarajah S, Sullivan JV, Purcell A et al. 2012. Methadone use in pregnancy: evidence of progression in the severity of addiction. Journal of Obstetrics and Gynaecology 32:753–755.
- Pollack HA, D’Aunno T. 2008. Dosage patterns in methadone treatment: results from a national survey, 1988–2005. Health Services Research 43:2143–2163.
- Strang J, Manning V, Mayet S et al. 2007. Does prescribing for opiate addiction change after national guidelines? Methadone and buprenorphine prescribing to opiate addicts by general practitioners and hospital doctors in England, 1995–2005. Addiction 102:761–770.
- Willenbring ML, Hagedorn HJ, Postier AC et al. 2004. Variations in evidence-based clinical practices in nine United States Veterans Administration opioid agonist therapy clinics. Drug and Alcohol Dependence 75:97–106.
- Winklbaur B, Kopf N, Ebner N et al. 2008. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates. Addiction 103:1429–1440.
- Young JL, Martin PR. 2012. Treatment of opioid dependence in the setting of pregnancy. Psychiatric Clinics of North America 35:441–460.