This guideline will assist staff at the Royal Women's Hospital (the Women's) care for women admitted to hospital for methadone stabilization in pregnancy.
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This guideline is based on the National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. The quality of scientific evidence supporting guideline statements is indicated throughout using NHMRC levels of evidence.
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1. Methadone maintenance treatment
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Methadone maintenance treatment (MMT) is the treatment of choice for opioid dependant pregnant women 2. Methadone is a long-acting opioid that enables women to cease or reduce their heroin use and related behaviours, in accordance with a harm minimization philosophy.
MMT throughout pregnancy is associated with improved fetal development, infant birth weight, and reduces the risk of perinatal and infant mortality in heroin dependant women (level III 2, 1).
The aims of methadone maintenance treatment are to:
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- Reduce or eliminate illicit heroin and other drug use
- Improve the health and wellbeing of those in treatment
- Facilitate social rehabilitation
- Reduce the spread of blood borne diseases
- Reduce the risk of death associated with opioid use
- Reduce the level of crime associated with opioid use 2
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Withdrawal from heroin, without MMT is associated with risks to the fetus and a high risk of relapse2. Women should be informed of these risks, and if it is to be attempted it should ideally be done in the 2nd trimester, supervised in a specialist unit (Consensus,1). While inpatient supervision of withdrawal is not available at the Women's, WADS clinicians are able to provide outreach services to pregnant women undergoing withdrawal in specialist detoxification units.
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2. Methadone stabilisation program
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Heroin dependant women should have priority access to methadone treatment, which includes admission to an inpatient obstetric unit for stabilization and rapid dose titration, with respite from the external environment (Consensus,1). This service is offered at the Women's, under the supervision of WADS care coordination team inpatient stabilisation brochure, at any gestation. Admission is for 5 days (Monday to Friday). Inpatient admission is necessary as rapid induction onto methadone is required. Legislative requirements must be met, including obtaining a permit for prescribing methadone from DHS before commencing, as per the Women's CPG: Methadone and Buprenorphine Dosing Procedures.
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Care in pregnancy should be provided as per CPG: Care of Women with Alcohol and Drug Issues in Pregnancy.
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2.1 Criteria for methadone stabilisation program
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Women will be assessed as being
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- dependent on opioids
- motivated to undertake induction onto MMT
- willing to comply with the whole program and methadone regime.
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Women not suitable for treatment with methadone3:
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- Severe hepatic impairment
- Hypersensitivity to methadone
- Unable to give informed consent (eg. Major psychiatric illness) or age under 18, consider jurisdictional requirements for obtaining legal consent
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Specialist advice should be sought for clients with severe respiratory depression, acute asthma, acute alcoholism, head injury and raised intracranial pressure, ulcerative colitis, biliary and renal tract spasm, patients receiving monoamine oxidase inhibitors.
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3. Methadone induction procedure
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Women should commence on a dose of methadone that should be titrated to the woman's symptoms with rapid increases1.
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The starting dose should be 20mg, and is reviewed at 4 hourly intervals or earlier if required.
At each review, if the woman has objective signs of withdrawal (eg. Pupils dilated, restless, see short opiate withdrawal scale in appendix of National clinical guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn), then give an additional 5-10mg.
If there are no signs of withdrawal no extra dose is given until the next scheduled review.
The maximum dose in the first 24 hours should not exceed 50mg.
Extreme caution should be exercised when assessing the woman's requirements on subsequent days if a dose of over 30mg is used on day 1, in order to prevent accumulation and possible toxicity from methadone.
The same process should be repeated on day 2 (when the woman will almost certainly require less methadone), commencing again with 20mg and giving additional doses of 2.5 to 10mg as required, with a maximum dose increase of 50mg.
If at any time the woman becomes sedated (small pupils, drowsiness), increase frequency of observation and ensure no further methadone is administered until sedation is reversed.
Women should be encouraged to remain on the ward for 30-60 minutes post dose, for observation.
Women should be cautioned regarding the use of other drugs whilst on methadone.
Urine drug screening is not routine, but may sometimes be requested if there are concerns about harmful concurrent drug use.
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3.1 Vomiting
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Vomiting is a serious concern in pregnant women on methadone. Vomiting of a methadone dose may lead to withdrawal in both mother and fetus (consensus,1).
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If a methadone dose is vomited (consensus,1):
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- Within 10 minutes of dosing - consider giving a repeat dose
- Within 10-60 minutes of dosing - consider giving half a repeat dose
- More than 60 minutes after dosing - consider half a repeat dose if withdrawal occurs
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Prevention of vomiting (consensus,1):
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- Women should be discouraged from ingesting methadone on an empty stomach
- Women should be encouraged to sip their dose slowly
- If the dose consistently causes vomiting, consider splitting the dose or giving rectal prochlorperazine 30-60 minutes before dosing
- If woman vomits constantly not in relation to dose, assess and treat according to the Women's CPG: Hyperemesis Gravidarum.
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4. Discharge planning
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Discharge planning should commence from admission and include collaboration with multiple agencies.
For safety reasons, clear written information should be provided to the new prescriber and the dosing point, to comply with the pharmacotherapy regulations.
Prescriber and pharmacy provider contact details and appointments should be given in writing to the woman.
Clinic (or hospital) for ongoing pregnancy care should be discussed with the woman and appointments made prior to discharge.
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5. Restabilisation admission
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Women who have missed more than 3 doses of their methadone, will require readmission for methadone stabilisation.
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6. Further information
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Pharmacotherapy treatments
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Pharmacotherapy: Drugs and Poisons in Victoria - Victorian Government Health Information, Australia
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Methadone and pregnancy
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Women's Alcohol & Drug Service: Methadone
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Management of drug use in pregnancy and birth
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National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn.
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7. References
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1. NSW Department of Health. 2006. National Clinical Guidelines for the management of drug use during pregnancy, birth and the early development years of the newborn. Report commissioned by the Ministerial Council on Drug Strategy under the Cost Shared Funding Model.
2. Women's ADS and Turning Point Alcohol and Drug Centre. 2006. Methadone prescribing in an obstetric setting.
3. Australian Government Department of Health and Ageing. 2003. Clinical Guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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