Addiction is a complex medical and social reality. Discussions of addiction often center around one of three different conversations: sale of illegal drugs and trafficking, long-term drug addiction in adults (whether illegal drugs like heroin or alcoholism), or teenage drug use. However, within medical ethics, the the ethics of long-term pain management and addiction to prescribed pain killers is a growing concern. Treating a patient addicted to medically prescribed-prescription drugs is always ethically complex for medical professionals. Nowhere is this question more acute or more ambiguous then in the case of a pregnant patient.
What should a doctor or nurse do when faced with a pregnant patient addicted to prescribed pain medication like Oxycontin or in a program for Methadone maintenance? A recent NY Times Article, Newly Born and Addicted to Painkillers,
The mother got the call in the middle of the night: her 3-day-old baby was going through opiate withdrawal in a hospital here and had to start taking methadone, a drug best known for treating heroin addiction, to ease his suffering. . . .
As prescription drug abuse ravages communities across the country, doctors are confronting an emerging challenge: newborns dependent on painkillers. While methadone may have saved Tonya’s pregnancy, her son, Matthew, needed to be painstakingly weaned from it.”
Focusing on a hospital in Maine, the article examines the difficult choices the few doctors who agree to treat pregnant women with opiate dependency face: how do they continue to treat their patients suffering from addiction while also taking into consideration the effects on the baby?
Before she was pregnant, Tonya said, she quickly became addicted, spending all of her money on pills bought on the street. She and her boyfriend, Josh, needed to stave off withdrawal and get through the day, she said.Now that she is in treatment, Tonya, who like most mothers interviewed for this article did not want her last name used, said her focus was on Matthew. “We put him in this situation,” she said, “and we have to help him out of it.”
Medicine and medical ethics often rely heavily on the guidelines of a tested standard of care. In the case of methodone maintenance, there is little comprehensive research done and as a result, no clear medical guidelines.
There is growing debate over treatment for pregnant women addicted to prescription drugs, in light of concerns over the effects on their babies. Many are slowly weaned from their dependence with methadone, the standard of care for decades. Methadone, when taken in prescribed doses, keeps a steady amount of opiate in the body, preventing withdrawal and drug cravings that occur when levels dip. But it, too, can be addictive and cause nagging side effects like drowsiness.
A recent study in the New England Journal of Medicine highlighted the positive alternative of buprenorphine; however, as the article notes, this drug does not work for all. In particular, reincidence of drug use on buprenophrine was noted to be higher than on methadone maintenance. This is currently being followed up in Henree Jones of Johns Hopkins “Mother Study” following infant outcomes to age three.
The uncertainty of medical research and need for greater attention on the effects of withdrawal or Neonatal Abstinence Syndrome (for example recent studies by Lisa Clark MS, DNP(c), CPNP-AC and Carolyn Milana MD of Stony Brook Medical Center (NY), BUPRENORPHINE EXPOSURE AND THE NEONATE. WHAT DO WE REALLY KNOW? A CASE PRESENTATION.) In all cases, the focus of the research is on developing better guidelines to prevent maternal relapse and to identify, treat and minimize withdrawal effects on newborns.
From the perspective of medical ethics: How do you determine the best course of treatment when you are treating two patients? If the doctor simply withdraws all addiction treatment (whether methadone maintenance or buprenophine) from the mother, the effects can be disastrous. Aside from the obvious risk of unmonitored drug use, research is showing that withdrawal during pregnancy causes greater harm to the fetus. At the same time, treatment plans must be adjusted to account for different stages of pregnancy – as the pregnancy progresses, questions emerge concerning proper dosing of methadone and corresponding infant outcomes (ie. less is not always best).
In studying the ethics of addiction, it is important to consider this growing and acutely vulnerable population. How do we treat pregnant women under medical care for opiate addiction? How do we protect both their recovery and the future health of their child? To protect the dignity of both mother and child, greater research is needed.