Doctor's Column

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Our Medical Advisory Board includes Dr. Vincent Dole, Rockefeller University; Herman Joseph, Ph. D., Research Scientist for the New York State Office of Alcoholism and Substance Abuse Services; Dr. Charles Schuster, Director of the University Psychiatric Center (UPC) and former head of NIDA, and his associate, Dr. John Hopper, Medical Director of UPC; Dr. Marc Shinderman, Director/Owner of Center for Addictive Problems (CAP) in Chicago; and Dr. Andrew Byrne, Australia, who has written two books about methadone.

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Methadone & Pregnancy in Detroit, Michigan - (November 1998, Vol. III, No. XI)
 

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 Methadone & Pregnancy in Detroit, Michigan

Dear Doctor:

 I am a pregnant methadone patient, on 120 mg, and my urines have been clean for the past seven years.

 I live in Detroit, Michigan, and I have been hiding my pregnancy at my clinic.   They and, as far as I know, every other clinic in the Detroit area MAKES their patients go to "Hospital X" when their pregnancy is discovered.  I had my first baby eight years ago through this hospital and had a horrible experience!

 Every pregnant patient I have talked to tells me that this hospital has not changed their practice from that of what I experienced eight years ago.  They decrease patients' doses whether they like it or not or start using again! "X" makes every patient come in seven days a week; they allow NO takehomes no matter what your status was at your previous clinic. They don't open until 9 am, and I have been used to dosing at 5:30 to 6 am for the past 7 years.

 When I was pregnant with my daughter 8 years ago and forced to go to Hospital "X", I had been clean for several months.  But, "X" forced me to detox to a VERY low dose (it was all BLIND dosing).  I couldn't handle the detox.  I began buying "street" methadone, and when that got too expensive, I started buying heroin.  Hospital "X" doesn't seem to care if the women can't deal with the detox and start using again! They just keep on dropping that dose, claiming its best for the baby.  How can it be better for the baby if the mother starts using heroin again!?

 Luckily, my daughter was born healthy, although she was one month premature and only weighed 4 lbs. I think it's a miracle, since I was using heroin EVERY day in my 7th & 8th months.  I HAD TO, doctor, because I was so sick from withdrawals, I just couldn't stand it!  I hope you understand.

 Over the past 20 years I have been an addict, I have had many girlfriends and known other women who were pregnant and hid it from their clinics as long as they could because they were absolutely TERRIFIED about going to "Hospital X!"  After buying a subscription to Methadone Today, I learned that addictionologists, including the ones who write the TIP and TAP books, recommend completely the opposite of what "Hospital X" is doing to women.  Can't someone make them stop!? Or why can't the other methadone clinics in the Detroit area give pregnant patients a choice whether to stay at their clinic or to go to "X"?  -  A Very Worried Patient (With Not Much Time Left Before I Start Showing)

Dear Worried:

 The mistreatment which you suffered eight years ago that resulted in your child's low birth weight and premature birth is now subject to a claim of malpractice due to the clinical research and practice guidelines that attest to the following:

 Methadone should be increased, commonly as much as 30 percent, during pregnancy.  Failure to medicate adequately increases fetal distress, prematurity and spontaneous abortion.  Methadone maintenance, when adequate to suppress the need for illicit drug abuse, results in healthier, higher birth weight newborns compared with mothers who continue to use heroin.  Infants born to methadone-maintained mothers do not over time differ significantly from those born to non-dependent mothers in ways that can be attributed to methadone.

 Management of neonatal opioid withdrawal is a safe procedure and not to be feared, especially compared to the risks of underdosing pregnant patients who relapse as a result.  Many of the infants of methadone maintained mothers may not require much in the way of management of neonatal abstinence, but it is almost impossible to predict for an individual case (at CAP clinics, there was at least one infant whose mother delivered at a maintenance dose of 180 mg/d whose abstinence syndrome was easily managed).

 "Blind" dosage should never be practiced when not requested by the patient.  It is demeaning, unsafe, anxiety provoking, and encourages diversion among nursing staff.  It is a sign of a punitive and non-medically oriented program where administration has little understanding of the disease of addiction and even less empathy for the patients whom they serve.  Run, do not walk, from such a facility.

 I have no idea why pregnant patients should be banned from MMT programs and will not comment on this bizarre practice, which you describe, of herding them all into a single clinic.  It is not done anywhere else in the world in my experience.

 There are guidelines about monitoring prenatal care that all clinics must observe in the federal regulations.  This implies that pregnant women should be served.  Depriving women of the option of attending the clinic of their choice should be addressed with the State of Michigan or with the agencies who license or fund these no-service clinics.

 Providing care to pregnant women should be a primary requirement for licensing or funding in my opinion.  It is one of the truly critical health care interventions that MMT clinics can do better than any other facility.  The federal rule regarding admission criteria for pregnant addicts is minimal compared with those for others and reflects the government's expectation that licensed clinics should serve this population ahead of everyone else and certainly not have the option of excluding it.

Dr. Marc Shinderman

Center for Addictive  Problems (CAP)

Chicago, Illinois

 Editor's Note: After receiving this letter, DONT's secretary, Nancy Rose, called "Hospital X" and spoke with the head nurse for about 20 minutes. The head nurse admitted that they begin dropping the women's doses immediately upon admission to the program. She said they do not completely detox them off but to a "very low dose" by the time the birth is imminent.

 Nancy asked the head nurse, "What dose would that be?"

 The nurse wouldn't tell Nancy, but her response was very "telling", "Well, we HAVE to drop their doses! Some of these women come in here on high doses, like 50 mg!"

  Nancy then asked if the nurse and/or medical director had read the TIP/TAP books. The nurse said that they had, but they had to do "what was best for the baby".

 Nancy asked, "But isn't it better for the baby to be born on methadone than on HEROIN?"  and the head nurse indignantly replied, "Well, these women have to take SOME responsibility!"

 We, at DONT, believe that pregnant patients should have a choice of where to go for treatment just like any other patient.  We find it appalling that this hospital's program goes against the treatment protocols well known in the field of addiction medicine and that pregnant patients have no alternatives.

NOTE:  PREGNANT PATIENTS IN SOUTHEASTERN MICHIGAN WHO WANT AN ALTERNATIVE TO "HOSPITAL X" FOR METHADONE TREATMENT, PLEASE CALL DONT AT (810) 658-9064.

 For further information, read the TIP/TAP column in the September 1998 issue of Methadone Today, "Treating Pregnant MMT Patients" or order  (1-800-SAY-NOTO) a FREE copy of TIP 2, "Pregnant, Substance-Using Women" and TIP 5, "Improving Treatment for Drug-Exposed Infants .
 

See also:

 Mitchell JL, Treatment of the addicted woman in pregnancy. In: Miller NS, ed. Principles of addiction medicine. Section 16, Women, children and addiction. Chevy Chase (MD): American Society of Addiction Medicine; c1994. Chapter 4; [4 p.].

 Mitchell JL, Brown G., Physiological effects of cocaine, heroin and methadone. In: Engs RC, ed. Women: alcohol and other drugs. Dubuque (IA): Kendall/Hunt; c1990. p. 53-60.

 Finnegan LP, Hagan T, Kaltenbach KA. Scientific foundation of clinical practice: opiate use in pregnant women.  Bull N Y Acad Med 1991 May-Jun;  67(3):223-39.

 Finnegan LP, Kaltenbach K. Neonatal abstinence syndrome. In: Hoekelman RA, ed. Primary pediatric care. 2nd ed.  St. Louis:  Mosby-Year Book; c1992. p. 1367-78.

 
 
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