Bob Newman is Retiring, But You Haven’t Heard the Last From Him

BobNewmanphotoLegendary methadone treatment advocate Robert G. Newman, MD, is retiring. But, he hastens to add, he is not leaving the field. “What I’m leaving,” he told AT Forum in February, “is the office.”

Dr. Newman announced via a January 26 e-mail that he would be giving up his “formal role” as director of Beth Israel’s Baron Edmond de Rothschild Chemical Dependency Institute. He will continue to work through June, but Hindy Bernstein, his assistant of the past 25 years, will be leaving in April. “Hindy is leaving me for Florida,” he said. Although he will no longer have the financial support of Beth Israel, he will continue advocacy efforts.

An Advocate

“The challenges are at least as great today as they were 40 years ago when I started my advocacy work,” Dr. Newman said. He will continue to be a fly in the ointment, but he does want to see more “noise” from the rest of the opioid treatment program (OTP) community.

His days will continue to begin and end the way they have for years, he told AT Forum. “I go to the Internet, I get the Google alerts, which very often have some particularly horrendous feature that I’m obliged to respond to.”

There is a lot of “bad news” for Dr. Newman to blog, write letters to the editor, and send e-mails about. And he does so very articulately. For example, some states are cutting off methadone treatment arbitrarily, trying to limit it to one or two years. Regulators are confounding addiction and dependence, not recognizing that maintenance medication is treatment, not a “substitute” for heroin. Unbelievable as it is that this non-science is going on today, some 50 years after medication-assisted treatment (MAT) has been proven effective, and in the face of federal officials, Dr. Newman sees it happening. And he isn’t going to be quiet about it.

NIMBY

NIMBY—the “not in my back yard” phenomenon in which even people who claim to support MAT don’t want programs in their neighborhoods—is illegal, violating the Americans with Disabilities Act (ADA). But despite the various ADA wins that OTPs have achieved, they are never “precedent-setting,” and therefore need to be fought over and over again. “This is terribly frustrating to me,” said Dr. Newman.

Dr. Newman said the opioid-treatment field can help with this fight. “There are many reasons for NIMBY, and some of those reasons have to do with the field, how we have allowed our treatment, our patients, our services to be viewed,” he said. “It isn’t just misperception on the part of communities and politicians. Some of the anti-methadone- patient bias reflects the way the field has chosen to isolate itself and adopt and embrace unique practices that make this treatment separate.”

 Office-based Methadone

 Dr. Newman is glad that buprenorphine has been made available to OTPs and to office-based opioid treatment (OBOT) providers, as a treatment tool for caring for opioid dependence. He notes that more than 40 years ago he proposed that private physicians be permitted to offer methadone maintenance, in addition to OTPs. And now that buprenorphine can be utilized in OBOT, why not methadone, he asks rhetorically. Dr. Newman also notes the extremely limited willingness of office-based physicians to become “waivered” to prescribe buprenorphine. “I think some of the practices of programs are so foreign to what is done in every other field of medicine that medical colleagues view this as something that is from Mars and refuse to get involved in any form of opioid-dependence treatment.”

In fact, the requirement that patients go to a clinic every day is a barrier to care. Dr. Newman is skeptical about the effect of the Affordable Care Act (ACA) on OTPs in particular. “I have seen repeated references to the notion that under the ACA, there’s going to be a sudden upsurge of demand for addiction treatment,” he said. “Increased demand, maybe,” he said. “But how is that demand going to be met? You can have all the insurance you want, but an awful lot of people who need treatment will avoid OTPs because of the requirements and the stigma, and there are not that many OBOT providers.”

Nevertheless, he noted that hundreds of thousands of patients do go to OTPs for MAT, which shows how motivated these patients are. “How many people would have the motivation to deal with obesity, smoking, hypertension, or a great many other medical problems if the treatment regimen required many months of daily attendance and a host of other demands? The fact that there are 300,000 people enrolled in MAT is amazing.”

 Methadone Safety and Dosing

With an appropriate dosage schedule, methadone is an extremely safe medication, said Dr. Newman. But he warned that some OTPs give induction increments that are too great. The federal regulations state that the dose on the starting day must not be more than 40 milligrams—the first dose has to be no more than 30, and an additional dose that day can be 10, said Dr. Newman. But after that, there are some programs that raise the dose too quickly. “Some programs have induction protocols of 30, 40, 50, 60, 70,” with the dose going up daily, he said. The rule of thumb—“start low, go slow, aim high”—needs more of an emphasis on “go slow.”

 Federal Exclusions

Finally, Dr. Newman would like to see more support for methadone treatment at the federal level. The insurance plans of the federal Department of Veterans Affairs and the Department of Defense have an exclusion against methadone and buprenorphine maintenance treatment, something Dr. Newman has long railed against. “Tom McLellan (then deputy director of the federal Office of National Drug Control Policy) and other very high-level officials have said the exclusion is bad, and that they were trying to change it,” said Dr. Newman. “But it persists, and that’s inexcusable and shameful. “

What Dr. Newman wants advocates to do is to speak up. “Silence equals death,” he said, citing an oft-used slogan of AIDS activists years ago. And he is not going to be silent. “There are a lot of windmills still out there.”

Methadone Dosing During Pregnancy: Does Anyone Have a Clue? John J. McCarthy, MD, Guest Author


Methadone treatment of the pregnant, opioid-addicted mother is routinely cited in research studies as causing a neonatal abstinence syndrome (NAS). But this is an oversimplification of the effects on the fetus of the mother’s drug use before, and sometimes during, methadone treatment.

There are limits to what we really know about the effects of opioid abuse on the developing fetus. Even more complicated are the effects of additional use of nicotine, alcohol, stimulants, and benzodiazepines. We know something about the effects of cycles of opioid intoxication and withdrawal on the health of the fetus and newborn, but we can’t routinely identify or measure these effects.  We can only wonder if maternal addiction can truly be “without harm”—leaving only methadone withdrawal as the cause of the newborn’s ill health.

Despite all this uncertainty, methadone has become identified as “the cause” of NAS. Here’s how this chain of events typically unfolds. The mother arrives at a hospital on methadone. The baby has NAS. The doctors know nothing about what the baby has been exposed to during the pregnancy, beyond some vague drug abuse history before methadone treatment—but not what drugs, what amount, or for how long. And if doctors see a sick baby, they look for a cause: there is methadone.

It is almost as if addiction never happened. Despite exaggerated claims about how potentially deadly methadone withdrawal is,* in an ongoing study in our pregnancy program the majority of newborns experience NAS that is so mild it does not require treatment. Uncomplicated opioid withdrawal that is more severe is very treatable; only medical neglect would endanger the life of the neonate! What really was life-threatening was fetal withdrawal in the pre-methadone era, for it did result in fetal and neonatal death.*

But opioid withdrawal, when complicated by the harmful effects of poly-drug addiction and repeated episodes of withdrawal on the fetus, might not be easily treated.  It is more complicated than simple methadone withdrawal.

As for how we reduce risks for the neonatal illness called NAS, I suggest the following:  1.) treat the maternal addiction, and stop the fetal exposure to drugs and drug withdrawal; 2.) stabilize the disordered maternal and fetal brain chemistry, using the dose of methadone that will keep the mother and fetus out of withdrawal; and 3.) treat the more severe cases of NAS after birth, if needed, when the newborn’s symptoms are easy to monitor. There is evidence that avoiding neonatal intensive care units and encouraging rooming-in, with frequent skin-to-skin contact between mother and newborn, starting at birth, along with breastfeeding, can reduce NAS symptoms.*

In reality, risks aren’t always reduced by such evidence-based practices, however. We have mothers put through withdrawal during pregnancy “to prevent NAS.”* This practice shifts the burden of withdrawal onto the fetus, where we can’t see what’s happening, because our limited tools of fetal monitoring show us almost nothing of actual fetal withdrawal physiology. Because maternal withdrawal is linked to fetal withdrawal, the fetus can develop an intrauterine abstinence syndrome (IAS).* Maternal/fetal opioid withdrawal can cause restriction of placental blood flow and fetal hypoxia (reduced levels of oxygen in the brain), and fetal brain damage.  Some authors have also encouraged mothers to stay on low doses of methadone and endure withdrawal “to protect the fetus.”* I would ask  what the fetus is being protected from when it is suffering withdrawal in utero; how making the mother sick helps the pregnancy; and how fetal withdrawal helps the baby.

In summary, we have no consensus on the goals of methadone treatment in pregnancy.

Part of the confusion relates to the question of whether giving the mother high doses of methadone worsens NAS. A recent meta-analysis of 67 studies found this not to be the case.* The fetus is not exposed to the maternal dose; it is exposed to the maternal plasma level. We know that plasma levels vary significantly, depending on genetics. And pregnant women metabolize methadone more quickly, necessitating dose increases—but these increases do not necessarily increase fetal exposure to methadone.

One mother in our pregnancy program required 270 mg/day of methadone, in four divided doses. Her plasma level, before the morning dose one week before delivery, was undetectable. After birth, the baby required no treatment for NAS. We don’t know how many physicians are willing to prescribe these high, split doses to keep the mother and fetus out of withdrawal. We don’t know whether programs use maternal plasma methadone levels to monitor changes in maternal metabolism and fetal exposure.

In pregnancy, split doses of methadone protect the fetus from exposure to daily cycles of peaks and troughs, which have been shown to have negative physiologic effects on the fetus.* Even high doses, when given as single daily doses, can result in fetal withdrawal distress before the next day’s dose. That may be why high doses, at times, seem to cause more cases of NAS: The fetus may be sensitized to daily episodes of withdrawal.* Some mothers, like our patient who received 270 mg daily, are ultra-rapid metabolizers; the methadone exposure for their fetuses is far more consistent and physiologic when dosing is four times a day.

While the MOTHER study showed that hospitalization stays were shorter and NAS less severe for the newborns when the mother was on buprenorphine, compared to methadone, this doesn’t answer the question about induction on buprenorphine, which itself raises medical concerns. Maternal treatment with buprenorphine is complicated by buprenorphine’s narcotic antagonist properties, which require mother and fetus to be in withdrawal before the first dose is given. If they are not, buprenorphine may cause acute withdrawal, a threat to the safety of the pregnancy. Methadone inductions are far safer for the fetus.

The MOTHER study did not use split doses of methadone, introducing a potential bias in the methadone arm. Furthermore, the study used comparatively low doses of methadone, averaging 79 mg/day. If the goal of treatment is to use doses high enough to keep the mother and fetus out of withdrawal, our experience is that the average daily dose must be much higher. The average in our ongoing study is 140 mg/day, always split, given two to four times a day. With this approach, only 28 percent of our current cohort of babies (N=53) have required treatment for NAS. The MOTHER study found about a 50 percent treatment rate for both methadone and buprenorphine.

As far as buprenorphine’s having a less severe withdrawal, a Norwegian study found a treatment rate of 67 percent in neonates undergoing buprenorphine withdrawal.* And a study from Finland reported “severe” NAS with a 57 percent rate of morphine treatment, as well as a high number of sudden infant  deaths, in buprenorphine-exposed neonates!* These ”real world” studies  must temper  conclusions about any proposed superiority of buprenorphine over methadone. The etiology of NAS is likely more complicated than a simple choice of one medication or others.

The low treatment rate and relative mildness of NAS in the majority of our babies certainly is not conclusive evidence for the use of our protocol. Ours is one approach that has good theoretical support, and seems to be associated with reduced risk of NAS. It may not be widely used, but we have no true idea of current practices.

Dr. McCarthy, a specialist in addiction medicine, is the Executive/Medical Director of the Bi-Valley Medical Clinic in Sacramento, CA. He is a diplomate of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine, and an assistant professor of psychiatry at the University of California, Davis. His research publications have focused on opioid addiction in pregnancy.

Dr. McCarthy and AT Forum would deeply appreciate feedback from you, our readers, about your program’s current practices and guidelines for mothers taking methadone during pregnancy.
Please take our survey.

For a list of Dr. McCarthy’s publications and presentations, go to:

http://www.bivalley.com/articles.html

*References

1.  Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363:2320–2331. DOI: 10.1056/NEJMoa1005359.

2.  Zuspan FP, Gumpel JA, Mejia-Zelaya A, et al. Fetal stress from methadone withdrawal.  Am J Obstet Gynecol. 1975;122(1):43-46. PMID 1130446.

3.  Hodgson ZG, Abrahams, RR. A rooming-in program to mitigate the need to treat for opiate withdrawal in the newborn. J Obstet Gynaecol Can. 2012;34(5):475–481. PMID 22555142.

4.  Dashe JS, Jackson GL, Olscher DA, et al.  Opioid detoxification in pregnancy. Obstet Gynecol. 1998;92(5):854-858. PMID 9794682.

5.  McCarthy JJ. Intrauterine abstinence syndrome (IAS) during buprenorphine inductions and methadone tapers: can we assure the safety of the fetus? J Matern Fetal Neonatal Med. 2012;25(2):109–112. PMID 21867403.

6.  Lim S, Prasad MR, Samuels P, et al. High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome. Am J Obstet Gynecol. 2009;200:70.el-5. PMID 18976737.

7.  Cleary BJ, Donnelly J, Strawbridge J, et al. Methadone dose and neonatal abstinence syndrome—systematic review and meta-analysis. Addiction. 2010;105(12):2071–2084. PMID 20840198.

8.  Wittmann BK, Segal S. A comparison of the effects of single- and split-dose methadone administration on the fetus: ultrasound evaluation. Int J Addict. 1991;26(2):213–218. PMID 1889920.

9.  Rothwell PE, Gewirtz JC, Thomas MJ. Episodic withdrawal promotes psychomotor sensitization to morphine. Neuropsychopharmacology. 2010;35(13):2579–2589. doi:  10.1038/npp.2010.134.

10.  Bakstad B, Sarfi M, Welle-Strand GK, et al. Opioid maintenance treatment during pregnancy: occurrence and severity of neonatal abstinence syndrome. A national prospective study. Eur Addict Res. 2009;15(3):128–134. PMID 19332991.

11. Kahila H, Saisto T, Kivitie-Kallio S, et al. A prospective study on buprenorphine use during pregnancy: effects on maternal and neonatal outcome. Acta Obstet Gynecol Scand. 2007;86(2):185-190. PMID 17364281.

 

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