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Postpartum changes in methadone dose among women in methadone maintenance treatment Leah B. 1 Kaminetzky , Christine A. 1,2 Pace , Debbie M. 3 Cheng , Michael 3 Winter , Jeffrey H. 1,2,3,4 Samet , Alexander Y. 1,2,4 Walley Boston University School of Medicine1, Boston Medical Center2, Boston University School of Public Health3, Boston Public Health Commission4 Background • Methadone maintenance for opioid dependence in pregnant women improves pregnancy and neonatal outcomes.1 • Higher methadone doses are associated with longer retention in treatment and less illicit drug use2,3, yet doses that are too high may cause oversedation. • Pregnant women often require higher doses of methadone than non-pregnant women due to increased metabolism of methadone during pregnancy.4 • The optimal approach to dosing during the postpartum period is unclear. While national guidelines recommend postpartum dosing be similar to pre-pregnancy dose or half of the third trimester dose5, there are no data to support this.6 Objectives 1. Describe changes made to methadone dose postpartum in a clinic where there is no automatic dose reduction for postpartum women 2. Compare the number of women who had doses held due to oversedation in the pregnant vs. postpartum period Methods Population: 100 pregnant women who enrolled in the Boston Public Health Commission Opioid Treatment Program (BPHC OTP), a methadone maintenance treatment program Inclusion criteria: Remained in OTP until at least 12 weeks postpartum; remained non-pregnant until discharge or 18 months after delivery Data Sources: Electronic medical records from OTP and hospital delivery discharge summaries Variables of Interest: • Average methadone dose while pregnant • Methadone dose on delivery • Methadone dose at 2, 6, and 12 weeks postpartum • Number of women who had doses held for oversedation during pregnancy and postpartum Results Analysis • Examine change in dose between delivery and 2, 6, and 12 weeks postpartum using paired t tests • Compare the proportion of women who had doses held during pregnancy or postpartum using McNemar test (exact version) Conclusion • At this OTP, where postpartum dosing changes are based on clinical signs and symptoms, women generally received a small but statistically significant dose decrease over the first 12 weeks of the postpartum period. • The proportion of women with any dose hold days appears higher during postpartum compared to pregnancy, but the results were not significant (p=0.092) and the total number of days when doses were held was small. • Since an adequate methadone dose is needed for ongoing recovery, the current recommendation for a large empiric dose reduction merits further evaluation. For now, given our finding that more postpartum women had doses held, it is reasonable to formally assess all postpartum women for dose safety and adequacy at intervals up to 12 weeks after delivery. Such a protocol has now been instituted at the BPHC OTP. Limitations • Observational data, relatively small sample size • Only one methadone clinic • Dose hold is an insensitive marker of oversedation References 1. Sinha C, Ohadike P, Carrick P, Pairaudeau P, Armstrong D. Neonatal outcome following maternal opiate use in late pregnancy. International Journal of Gynecology & Obstetrics. 2001; 74: 241-246. 2. Peles E, Schreiber S, Adelson M. Factors predicting retention in treatment: 10year experience of a methadone maintenance treatment (MMT) clinic in Israel. Drug and Alcohol Dependence. 2006; 82: 211-217. 3. Liu E, Liang T, Shen L, et al. Correlates of methadone client retention: A prospective cohort study in Guizhou province, China. International Journal of Drug Policy. 2009; 20: 304-308. 4. Jarvis MAE, Wu-Pong S, Kniseley JS, Schnoll SH. Alterations in Methadone Metabolism During Late Pregnancy. Journal of Addictive Diseases. 1999; 18: 51-61. 5. Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005. 6. Jones HE, Johnson RE, O’Grady KE, et al. Dosing Adjustments in Postpartum Patients Maintained on Buprenorphine or Methadone. Journal of Addiction Medicine. 2008; 2: 103-107.
