Pregnant inmate Ashley Michelle Sligh says that the methadone treatment provided by the Duval County (FL) jail will cause harm to her unborn child.  She wants to be released early so that she can switch from methadone to buprenorphine.

Medical experts have long recommended methadone treatment for pregnant women who are opiate dependent.  But a new study funded by the National Institutes of Health and recently published in the New England Journal of Medicine suggests that buprenorphine (brand names Suboxone and Subutex) may be a better choice.

“Methadone, which is the standard of care, works fine, but buprenorphine works better”

“Methadone, which is the standard of care, works fine, but buprenorphine works better,” says study co-author Dr. Peter Martin of the Vanderbilt Addiction Center in Nashville, TN.

Researchers found that babies born to mothers treated with buprenorphine during pregnancy had an average hospital stay upon birth of 10 days versus 18 days for babies born to mothers treated with methadone.

Babies born to mothers treated with buprenorphine also needed less morphine to treat withdrawal symptoms.  Babies of mothers treated with methadone needed an average of 10 milligrams of morphine versus 1 milligram of morphine for babies of mothers treated with buprenorphine.

These results suggest that babies born to mothers treated with buprenorphine during pregnancy were weaned from medication more quickly and more comfortably.

This was the study finding that became the focus of most of the media coverage of the Vanderbilt study.  But there was another finding that I think may be important to notice.

Among pregnant women in the study, 33 percent (one out of three) of those treated with buprenorphine dropped out of treatment compared to only 18 percent (less than one out of five) of those treated with methadone.

Treatment can’t work if the treatment fails to engage and retain the patient in treatment.

Some thoughts:

Both methadone and buprenorphine protect the mother and unborn child by promoting conditions of safety and stability.

Both medications help create a medically stable environment for the mother and unborn child by reducing the roller coaster effect of alternating periods of intoxication and withdrawal.  This reduces the risk of miscarriage.

But the medications also promote  recovery stability, which results in a more stable lifestyle.  Mother and child often experience better nutrition, better sleep, less risk of violence and more.

Medical stability is important during pregnancy.  But the need for medical stability, recovery stability and lifestyle stability does not end with the birth of the child.  Both mother and child need safety and stability after the birth of the baby too -perhaps even more.

Women choosing between methadone or buprenorphine treatment during pregnancy might be wise to consider which treatment is more likely to help her achieve long term stability both during pregnancy and after the birth of the child.

For the sake of both mother and baby, the primary focus should be on creating conditions of safety over the long term.  This includes during pregnancy and after the birth of the baby.

Reducing the temporary and medically manageable discomfort to the newborn from medication withdrawal should be a secondary consideration.

Treatment Effectiveness Example

Consider, for example, an opiate-dependent young woman with a long history of addiction, high tolerance for opiates, a need for a structured treatment setting, and a history of unsuccessful recovery attempts with buprenorphine.

This young woman would be more likely to stay in treatment and avoid relapse if treated with methadone through a methadone clinic than buprenorphine through a private doctor.

This fact doesn’t change just because the opiate-dependent person is a pregnant woman.  For this woman, methadone might be a better choice for both her and her unborn child simply because methadone is more likely to successfully create conditions of safety and stability.

Treatment Sustainability Example

Long-term medication-assisted treatment is more effective than short-term treatment.

This means that a pregnant woman living with opiate dependence might be wise to think about which among her medication-assisted treatment options is most likely to be available to her over the long term (2 years or more).

Methadone costs pennies a dose and is widely available in the US through methadone clinics, even to those without health insurance.  Buprenorphine is much more expensive.  State and private insurance programs often limit coverage for buprenorphine.

In Tennessee, for example, where the Vanderbilt study was conducted, state Medicaid only covers buprenorphine for three months with a possibility for six-month extensions.  This rule applies to everyone, including pregnant women and new mothers.

A pregnant woman who wants to reduce the risk of relapse after the birth of her child might choose methadone over buprenorphine in this situation, or plan to transition to methadone after the birth of the child.

The Bottom Line

Pregnant women who are opiate dependent often feel very guilty about their addiction and very much want to avoid discomfort to their newborn.  But I would suggest that it is in the best interest of mother and child to choose the treatment option that is most likely to allow that particular woman to remain in treatment, avoid relapse or withdrawal, and parent after the birth of her baby.

The Judge’s Decision

This medical decision was not made by the doctor or the patient.  In effect, this medical decision was made by Judge Elizabeth Senterfitt, who denied Ashley Sligh’s request for early release.  The judge said her decision was based in part on the fact that she was not convinced that Suboxone would be any safer for the baby.

A Note About Suboxone vs. Subutex:

Suboxone is a formulation of buprenorphine that contains naloxone.  Naloxone is included in Suboxone as a deterrent to injecting the medication.  Many doctors who treat opiate dependent women with buprenorphine during pregnancy choose to prescribe Subutex instead of Suboxone to avoid exposure to naloxone.

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