KATHERINE MARSHALL RN, BSNARIZONA STATE UNIVERSITY

DOCTOR OF NURSING PRACTICE (DNP) STUDENT

Methadone and Breastfeeding

Introduction

Current Level 3 NICU bedside nurse

Clinical in level 3 NICU’s all over the valley

Identifiable knowledge gap and inconsistent recommendations for mother’s maintained on methadone

Objectives

Quick review to the benefits of methadone Epidemiology of breastfeeding, methadone

treatment during pregnancy, and breastfeeding rates among methadone maintained mothers

Quick look at the mechanics of methadoneIt’s safety with breastfeeding The impact of breastfeeding on neonatal

outcomes Review current recommendations and

guidelines

Why Breastfeed?

According to the American Academy of Pediatrics (2012) breastfeeding decreases the risks of; respiratory tract infections, ear infections, gastrointestinal tract infections, necrotizing enterocolitis (NEC), sudden infant death syndrome and infant mortality, allergic disease, celiac disease, obesity, diabetes, childhood cancers and improves neurodevelopmental outcomes .  

Breastfeeding Statistics

Breastfeeding and use of human milk is widely considered the standard for the developing newborn. Infants that have breastfed in the United States are currently at 76.9%  (CDC).

Infants who remained breastfed at three months of age are 47.2% (Centers for Disease Control and Prevention (CDC), 2012).

What about mothers with contraindications?

Polysubstance and illicit drug abuse during pregnancy is a rising statistic in the United States. According to the U.S. Department of Health and Human Services (2011), 20.9 percent of women aged 15-17 had illicit drug use in pregnancy. Ages 18-25 had a decrease in illicit drug use at 8.2 percent and a further decline to 2.2 percent among pregnant women aged 26 to 44.

Methadone

Approximately 980,000 people are addicted to opiates in the United States alone (Centers for Disease Control and Prevention, 2002).

Methadone maintenance treatment programs provide an administration of 60-120 mg of methadone daily congruent with urine drug screens to ensure a relapse of illicit drugs has not occurred.

Methadone is a synthetic agent working to block brain receptor sites that have an affinity for opiates ( CDC, 2002). This blocking of receptor sites will reduce the euphoria given by opiates and therefore relieve the craving and symptoms of withdrawal. A minimum of 12 months of treatment is required to alleviate all symptoms and prevent relapse ( CDC, 2002).

What about when the mother is on methadone?

Research suggests breastfeeding benefits can be achieved even in the presence of concurrent maternal methadone treatment. (American Academy of Pediatrics, 2013).

However, in methadone maintained women, over three-quarters elect not to breastfeed (Abdel-Latif et al., 2006).

Among the small percentage of women who do choose to breastfeed, more than half stop within one week (Abdel-Latif et al., 2006).

Neonatal Abstinence Syndrome (NAS)

NAS symptoms include diarrhea, shrill and excessive crying, irritability, excessive sucking, fever, hyperactive reflexes, poor feeding, excessive sneezing and yawning, tremors, and in severe cases, seizures (Lim, Prasad, Samuels, Gardner & Cordero, 2009).

Neonatal Outcome

This can cause the newborn to stay in the hospital for prolonged periods of time. Newborns with NAS stay in the hospital an average of 16.4 days and costs on average of $53,400 (Pritham, 2013). Most opioid-dependent mothers are in Medicaid programs where these hospital stays are paid by the state.

This again creates a societal need for create inexpensive and efficient treatment for NAS infants.

NAS has increased nationally from 7,653 infants in 1995 to 11,937 infants in 2008 (ACOG, 2013)

The associated medical and public health cost of

in-utero drug exposure in 2009 was between $70-$112Million (ACOG, 2013)

How can we help infant’s with NAS?

Mother’s maintained on methadone that choose to breastfeed can alleviate the symptoms infants experience and also decreased the need for the pharmacological intervention (Abdel-Latif et al., 2006).

A significant positive outcome of breastfeeding in the methadone maintained mother is decreased symptoms of withdrawal and decreased the length of stay (Jansson, Velez, & Harrow, 2004).

Evidence Synopsis

Some studies state that it is unclear if the act of breastfeeding itself, or the small amounts of methadone crossing into breast milk, that aids in decreasing withdrawal symptoms (Glatstein, Garcia-Bournissen, Finklestein & Koren, 2008).

Even at high doses of methadone in the mother, the actual amount of methadone transferred to breast milk is minimal regardless of maternal dosing (Bogen et al., 2011).

Evidence Synopsis

Breastfeeding should be encouraged for methadone maintained mothers regardless of their methadone dosing. (Jansson et al., 2007)

Breastfeeding directly decreased the severity of NAS, pharmacological intervention and length of stay in hospital compared to those infant formula fed (McQueen et. al, 2011).

American Academy of Pediatrics (AAP) Recommendation

As of 2001, AAP has eliminated the dose restriction to mother’s on methadone that choose to breastfeed. Their guideline has required healthcare facilities and providers to revise policies, provide new recommendations, and revise approach to the complex, disconcerting issue of drug-abusing mothers and NAS infants.

American College Obstetricians and Gynecologists Recommendations (ACOG)

Women should be counseled that minimal levels of methadone and buprenorphine are found in breast milk regardless of the maternal dose. Breastfeeding should be encouraged in patients without HIV who are not using additional drugs and who have no other contraindications (ACOG, 2012.)

Status Quo

It has been widely encouraged to accept the maternal decision to not breastfeed and not provide education to the mother regarding breastfeeding benefits to the infant in the presence of ongoing methadone therapy.

It is important to change this standard of care, and as healthcare providers to educate encourage and support breastfeeding mothers prescribed methadone (Jansson, Velez, & Harrow, 2004).

Why not?

The low rate of breastfeeding among mother’s maintained on methadone has been contributed to several factors including the stigma attached to mothers on methadone during pregnancy, a lack of knowledge about the safety of breastfeeding and methadone and the impact breastfeeding can have on the withdrawal the infant experiences.

Next Steps

Initiate conversations among colleagues and co-workers about the recommendation of mother’s maintained on methadone to breastfeed

Open the dialogue among the mother, if she desires to breastfeed support and encourage this decision. Emphasize the importance of adhering to the methadone program rules and guidelines

The ultimate goal is to improve the outcome of infant’s that experience withdrawal. If we keep this goal in mind, perhaps we can decrease the withdrawal they experience and decrease their length of stay in the hospital

References

Abdel-Latif, M. E., Pinner, J., Clews, S., Cooke, F., Lui, K., & Oei, J. (2006). Effects of breast milk on the severity and outcome of neonatal abstinence syndrome among infants of drug-dependent mothers. Official Journal of the American Academy of Pediatrics, 117(6), 1162-1169.Arlettaz, R., Kashiwagi, M., Das-Kundu, S., Fauchère, J., Lang, A., & Bucher, H. (2005). Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources. Acta Obstetricia et Gynecologica Scandinavica, 84(2), 145-150.American Academy of Pediatrics. (2012). Breastfeeding and the Use of Human Milk. 129(3), 827-841. doi: 10.1542/peds.2011-3552. American College of Obstetrics and Gynecology (2012). Opioid abuse, dependence, and addiction in pregnancy. Women’s Health Physicians Committee Opinion. http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Opioid_Abuse_Dependence_and_Addiction_in_PregnancyBogen, D. L., Perel, J. M., Helsel, J. C., Hanusa, B. H., Thompson, M., & Wisner, K. L. (2011). Estimated infant exposure to enantiomer-specific methadone levels in breast milk. Breastfeeding Medicine: the Official journal of the Academy of Breastfeeding Medicine, 6(6), 377-384. doi:10.1089/bfm.2010.0060.Centers for Disease Control and Prevention . (2012). Breastfeeding Report Card-United States-2012. National Immunization Survey, Provisional Data, 2009 births. Retrieved from: http://www.cdc.gov/breastfeeding/data/reportcard.htmCenters for Disease Control and Prevention. (2002). Methadone Maintenance Treatment.http://www.cdc.gov/idu/facts/methadonefin.pdf

References

Cleary, B. J., Donnelly, J., Strawbridge, J., Gallagher, P. J., Fahey, T., Clarke, M., & Murphy, D. J. (2010). Methadone dose and neonatal abstinence syndrome-systematic review and meta-analysis. Society for the Study of Addiction, 105, 2071-2084.De Castro, A., Jones, H. E., Johnson, R. E., Gray, T. R., Shakleya, D. M., & Huestis1, M. A. (2011). Maternal methadone dose, placental methadone. Clinical Chemistry, 57(3), 449-458.Dryden, C., Young, D., Hepburn, M., & Mactier, H. (2009). Maternal methadone use in pregnancy: factors Associated with the development of neonatal abstinence syndrome and implications for healthcare resources. BJOG: An International Journal of Obstetrics & Gynaecology, 116(5), 665-671.Glatstein, M., Garcia-Bournissen, F., Finklestein, Y., & Koren, G. (2008). Methadone exposure during lactation. Official Publication of the College of Family Physicians of Canada, 54(12), 1689-1690. http://www-ncbi-nlm nihgov.ezproxy1.lib.asu.edu/pmc/articles/PMC2602642/Jansson, L. M., Choo, R. E., Harrow, C., Velez, M., Schroeder, J. R., Lowe, R., & Huestis, M. A. (2007).Concentrations of methadone in breast milk and plasma. Journal of Human Lactation, 23(2), 184-190.Jansson, L. M., Velez, M., & Harrow, C. (2004). Methadone maintenance and lactation: a review of the literature and current management guidelines. Journal of Human Lactation, 20(1), 62-71.Jansson, L. M., Choo, R., Velez, M. L., Harrow, C., Schroeder, J. R., Shakleya, D. M., & Huestis, M. A. (2008). Methadone maintenance and breastfeeding in the neonatal period. Official Journal of the American Academy of Pediatrics, 121(1), 106-114.

References

Jambert-Gray, R., Lucas, K., & Hall, V. (2009). Methadone-treated mothers: pregnancy and breastfeeding. British Journal of Midwifery, 17(10), 654-657.

Kaltenbach, K., Holbrook, A. M., Coyle, M. G., Heil, S. H., Salisbury, A. L., Stine, S. M., & Martin, P. R. (2012). Predicting treatment for neonatal abstinence syndrome in infants born to women maintained on opioid agonist medication. Society for the Study of Addiction, 107, 45-52.

Kuschel, C., Austerberry, L., Cornwell, M., Couch, R., & Rowley, R. (2003). Can methadone concentrations predict the severity of withdrawal in infants at risk of neonatal abstinence syndrome? ADC Fetal and Neonatal Edition, 89(5), 390-393.

Lim, S., Prasad, M. R., Samuels, P., Gardner, D. K., & Cordero, L. (2009). High-dose methadone

in pregnant women and its effect on duration of neonatal abstinence syndrome. American Journal of Obstetrics and Gynecology, 200(1), 70-75.

McQueen, K. A., Murphy-Oikonen, J., Gerlach, K., & Montelpare, W. (2011). The impact of infant feeding method on neonatal abstinence scores of methadone-exposed infants. Advances in Neonatal Care, 11(4), 282-290.

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-based Practice in Nursing and Healthcare: A Guide to Best Practice. Lippincott, Williams & Wilkins.

Peltokorpi, A., Alho, A., Kujala, J., Aitamurto, J., & Parvinen, P. (2008). Stakeholder approach for evaluating organizational change projects. International journal of healthcare quality assurance, 21(5), 418-434.

Unger, A., Jagsch, R., Jones, H., Arria, A., Leitich, H., Rohrmeister, K., & Aschauer, C. (2011).

Randomized controlled trials in pregnancy: scientific and ethical aspects . Exposure to different opioid medications during pregnancy in an intra-individual comparison. Society for the Study of Addiction, 106, 1355-1362.

United States Department of Health and Human Services (2011). Results from the 2011 National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k11resu

Wouldes, T. A., & Woodward, L. J. (2010). Maternal methadone dose during pregnancy and infant clinical outcome. Neurotoxicology and Teratology, 32, 406-413.