Maintenance agonist treatments for opiate dependent pregnant women

ASL RM E, Department of Epidemiology, via Pellicone 5, Fosdinovo, Italy, 54035.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 02/2008; 12(2):CD006318. DOI: 10.1002/14651858.CD006318.pub2
Source: PubMed


The prevalence of opiate use among pregnant women ranges from 1% to 2% to as much as 21%. Heroin crosses the placenta and pregnant opiate dependent women experience a six fold increase in maternal obstetric complications such as low birth weight, toxaemia, 3rd trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neurobehavioral problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome.
To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions on child health status, neonatal mortality, retaining pregnant women in treatment, and reducing use of substances
We searched Cochrane Drugs and Alcohol Group' Register of Trials (June 2007), PubMed (1966 - June 2007), CINAHL (1982- June 2007), reference lists of relevant papers, sources of ongoing trials, conference proceedings, National focal points for drug research. Authors of included studies and experts in the field were contacted.
Randomised controlled trials enrolling opiate dependent pregnant women
The authors assessed independently the studies for inclusion and methodological quality. Doubts were solved by discussion.
We found three trials with 96 pregnant women. Two compared methadone with buprenorphine and one methadone with oral slow morphine. For the women there was no difference in drop out rate RR 1.00 (95% CI 0.41 to 2.44) and use of primary substance RR 2.50 (95% CI 0.11 to 54.87) between methadone and buprenorphine, whereas oral slow morphine seemed superior to methadone in abstaining women from the use of heroin RR 2.40 (95% CI 1.00 to 5.77)For the newborns in one trial buprenorphine performed better than methadone for birth weight WMD -530 gr (95% CI -662 to -397), this result is not confirmed in the other trial. For the APGAR score both studies didn't find significant difference . No differences for NAS measures used. Comparing methadone with oral slow morphine no differences for birth weight and mean duration of NAS. The APGAR score wasn't considered.
We didn't find any significant difference between the drugs compared both for mother and for child outcomes; the trials retrieved were too few and the sample size too small to make firm conclusion about the superiority of one treatment over another. There is an urgent need of big randomized controlled trials.

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    • "Variables infl uencing fetal growth and gestational age at delivery include smoking, multiple drug use and low socioeconomic status: all factors being prevalent in SMMs in the present and previous studies (Cleary et al. 2011; Fischer and Kopf, 2007; Simpson, 1957). While heroin has been associated with retarded fetal growth (Bada et al 2002; Minnes et al. 2011; Minozzi et al. 2008), the use of methadone has been shown to be associated with higher birth weights when compared with women who continued to use heroin. It has further been shown to prevent premature labour so that fetuses exposed to methadone had a higher birth weight and less morbidity than heroin-exposed babies (Finnegan et al. 2010). "
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    ABSTRACT: In this ten-year retrospective study we were able to show that Maltese substance-misusing mothers (SMMs) have significantly different socio-biological characteristics from mothers in the general population which seem to impact on neonatal outcomes. Significant differences from the general population were noted in the SMM's age, age at first pregnancy, marital status, educational background, number of cigarettes smoked, number of offspring and weight gained in pregnancy. SMMs booked their pregnancy in hospital later than the general population. On the other hand their infants had a lower mean birth weight and head circumference, had lower Apgar scores, were of lesser gestational age and premature. They were less breast-fed and stayed longer in hospital after their birth.
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    • "Accordingly, there are risks associated with prenatal exposure to methadone or buprenorphine [33]. A recent Cochrane systematic review identified four trials comparing methadone in pregnancy with buprenorphine in three studies and oral slow-release morphine in the other [34]. Patients using methadone had lower dropout rates than for the other treatment options but there were no differences in neo-natal abstinence syndrome in the trials. "
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    ABSTRACT: It is assumed within the accumulated literature that children born of pregnant opioid dependent mothers have impaired neurobehavioral function as a consequence of chronic intrauterine opioid use. Quantitative and systematic review of the literature on the consequences of chronic maternal opioid use during pregnancy on neurobehavioral function of children was conducted using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched Cinahl, EMBASE, PsychINFO and MEDLINE between the periods of January 1995 to January 2012. There were only 5 studies out of the 200 identified that quantitatively reported on neurobehavioral function of children after maternal opioid use during pregnancy. All 5 were case control studies with the number of exposed subjects within the studies ranging from 33-143 and 45-85 for the controls. This meta-analysis showed no significant impairments, at a non-conservative significance level of p < 0.05, for cognitive, psychomotor or observed behavioural outcomes for chronic intra-uterine exposed infants and pre-school children compared to non-exposed infants and children. However, all domains suggested a trend to poor outcomes in infants/children of opioid using mothers. The magnitude of all possible effects was small according to Cohen's benchmark criteria. Chronic intra-uterine opioid exposed infants and pre-school children experienced no significant impairment in neurobehavioral outcomes when compared to non-exposed peers, although in all domains there was a trend to poorer outcomes. The findings of this review are limited by the small number of studies analysed, the heterogenous populations and small numbers within the individual studies. Longitudinal studies are needed to determine if any neuropsychological impairments appear after the age of 5 years and to help investigate further the role of environmental risk factors on the effect of 'core' phenotypes.
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    • "Clinical data suggests that heroin use during pregnancy contributes to poor maternal and child outcomes and causes an increase in obstetric complications [17] as well as neonatal complications [18,19]. However, meta-analyses have shown that social disadvantage and tobacco use are often not considered in analyses [20,21]. "
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    ABSTRACT: In light of the recent debate on the use of financial incentives to promote long-acting contraception and sterilisation among women who use illicit drugs we discuss attitudes to contraception, pregnancy and parenting among Australian women who inject drugs. Qualitative interviews were conducted with 90 women of reproductive age about contraceptive use, preferences, reproductive histories, attitudes to and experiences of parenting. All women were either currently, or had previously injected drugs. The in-depth, semi-structured interviews were compared and contrasted for themes relating to drug use, contraception, pregnancy and parenting. Participants aspired to control their fertility, expressed individual contraceptive preferences and concerns for their children (both born and unborn). Most had tried a number of contraceptive methods interspersed by periods of non-use related to experiences of side-effects, being single or abstinent, believing that they were infertile and trying to conceive. Attitudes varied from woman to woman and in the same individual over their life course. Some believed that they were not likely to be capable, but most aspired to be successful mothers. Women's drug use should not automatically be associated with an inability to make informed health care choices or to care for children. Evidence suggests that women who use drugs do not need to be paid to limit or end their fertility. Rather, programs that aim to reduce barriers to obtaining free, non-discriminating reproductive advice and parenting assistance would better utilise women's agency to improve their own reproductive health.
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