JOGC

Substance Use in Pregnancy

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      Abstract

      Objective

      To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers

      Options

      This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy.

      Outcomes

      Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation.

      Evidence

      Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

      Values

      The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1)
      Benefits, harms, and costs
      This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

      Recommendations

      1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A)
      2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B)
      3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A)
      4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B)
      5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B)
      6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A)
      7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B)
      8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B)
      9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B)
      10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B)
      11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)

      Key Words

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      REFERENCES

        • Health Canada
        Canadian perinatal health report, 2003.
        Minister of Public Works and Government Services Canada, Ottawa2003
        • Statistics Canada
        Canadian community health survey (CCHS), Cycle 1.1.
        Statistics Canada, Ottawa2002 (Available at:) (Accessed December 22, 2010)
        • Substance Abuse and Mental Health Services Administration
        Results from the 2007 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-34, DHHS Publication No. SMA 08-4343). 2008 (Rockville, MD)
        • Giles W.
        • Patterson T.
        • Sanders F.
        • Batey R.
        • Thomas D.
        • Collins J.
        Outpatient methadone programme for pregnant heroin using women.
        Aust N Z J Obstet Gynaecol. 1989; 29: 225-229
        • Lutiger B.
        • Graham K.
        • Einarson T.R.
        • Koren G.
        Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis.
        Teratology. 1991; 44: 405-411
        • DiFranza J.R.
        • Lew R.A.
        Effect of maternal cigarette smoking on pregnancy complications and sudden infant death syndrome.
        J Fam Pract. 1995; 40: 385-394
        • Little B.B.
        • Wilson G.
        • Jackson G.
        Is there a cocaine syndrome? Dysmorphic and anthropometric assessment of infants exposed to cocaine.
        Teratology. 1996; 54: 145-149
        • Makarechian N.
        • Agro K.
        • Devlin J.
        • Trepanier E.
        • Koren G.
        • Einarson T.R.
        Association between moderate alcohol consumption during pregnancy and spontaneous abortion, stillbirth and premature birth: a meta-analysis.
        Can J Clin Pharmacol. 1998; 5: 169-176
        • Kuhn L.
        • Kline J.
        • Ng S.
        • Levin B.
        • Susser M.
        Cocaine use during pregnancy and intrauterine growth retardation: new insights based on maternal hair tests.
        Am J Epidemiol. 2000; 152: 112-119
        • Ernst M.
        • Moolchan E.T.
        • Robinson M.L.
        Behavioral and neural consequences of prenatal exposure to nicotine.
        J Am Acad Child Adolesc Psychiatry. 2001; 40: 630-641
        • US Centers for Disease Control and Prevention
        The health consequences of smoking: a report of the Surgeon General. Office on Smoking and Health, 2004 ([cited 2009 April 4]. Available at:) (Accessed December 22, 2010)
        • Fajemirokun-Odudeyi O.
        • Sinha C.
        • Tutty S.
        • Pairaudeau P.
        • Armstrong D.
        • Phillips T.
        • et al.
        Pregnancy outcome in women who use opiates.
        Eur J Obstet Gynecol Reprod Biol. 2006; 126: 170-175
        • Araojo R.
        • McCune S.
        • Feibus K.
        Substance abuse in pregnant women: making improved detection a good clinical outcome.
        Clin Pharmacol Ther. 2008; 83: 520-522
        • Binder T.
        • Vavrinkova B.
        Prospective randomised comparative study of the effect of buprenorphine, methadone and heroin on the course of pregnancy, birthweight of newborns, early postpartum adaptation and course of the neonatal abstinence syndrome (NAS) in women followed up in the outpatient department.
        Neuro Endocrinol Lett. 2008; 29: 80-86
        • Delpisheh A.
        • Brabin L.
        • Drummond S.
        • Brabin B.J.
        Prenatal smoking exposure and asymmetric fetal growth restriction.
        Ann Hum Biol. 2008; 35: 573-583
        • Floyd R.L.
        • Jack B.W.
        • Cefalo R.
        • Atrash H.
        • Mahoney J.
        • Herron A.
        • et al.
        The clinical content of preconception care: alcohol, tobacco, and illicit drug exposures.
        Am J Obstet Gynecol. 2008; 199: S333-S339
        • Vucinovic M.
        • Roje D.
        • Vucinovic Z.
        • Capkun V.
        • Bucat M.
        • Banovic I.
        Maternal and neonatal effects of substance abuse during pregnancy: our ten year experience.
        Yonsei Med J. 2008; 49: 705-713
        • Edelin K.C.
        • Gurganious L.
        • Golar K.
        • Dellerich D.
        • Kyei-Aboagye K.
        • Hamid M.A.
        Methadone maintenance in pregnancy: consequences to care and outcome.
        Obstet Gynecol. 1988; 71: 399-404
        • Chang G.
        • Carroll K.M.
        • Behr H.M.
        • Kosten T.R.
        Improving treatment outcome in pregnant opiate-dependent women.
        J Subst Abuse Treat. 1992; 9: 327-330
        • Rehm J.
        • Baliunas D.
        • Brochu S.
        • Fischer B.
        • Gnam W.
        • Patra J.
        • et al.
        The costs of substance abuse in Canada 2002: highlights.
        Canadian Centre on Substance Abuse, 2006 (April 2006. Available at:) (Accessed December 27, 2010)
        • Chiu T.T.
        • Vaughn A.J.
        • Carzoli R.P.
        Hospital costs for cocaine-exposed infants.
        J Fla Med Assoc. 1990; 77: 897-900
        • Adams E.K.
        • Miller V.P.
        • Ernst C.
        • Nishimura B.K.
        • Melvin C.
        • Merritt R.
        Neonatal health care costs related to smoking during pregnancy.
        Health Econ. 2002; 11: 193-206
        • Hutson J.
        A prenatal perspective on the cost of substance abuse in Canada.
        JFAS Int. 2006; 4: 1-4
        • Lefebvre L.G.
        • Ordean A.
        • Midmer D.
        • Kahan M.
        • Tolomiczenko G.
        Physicians’ knowledge of alcohol, tobacco and folic acid in pregnancy.
        J Subst Abuse. 2007; 28: 3-9
        • Leversha A.M.
        • Marks R.E.
        Alcohol and pregnancy: doctors’ attitudes, knowledge and clinical practice.
        NZ Med J. 1995; 108: 428-430
        • Gehshan S.
        Missed opportunities for intervening in the lives of pregnant women addicted to alcohol or other drugs.
        J Am Med Womens Assoc. 1995; 50: 160-163
      1. Public Health Agency of Canada. Knowledge and attitudes of health professionals about fetal alcohol syndrome: results of a national survey. Available at: http://www.phac-aspc.gc.ca/publicat/fasd-surv-etcafenquete/index.html. Accessed November 23, 2010.

        • Nevin A.C.
        • Christopher P.
        • Nulman I.
        • Koren G.
        • Einarson A.
        A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS.
        BMC Fam Pract. 2002; 3: 2-6
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Publishing Inc, Arlington2000 (Text Revision (DSM-IV-TR))
      2. Brands B. Kahan M. Selby P. Wilson L. Management of alcohol, tobacco and other drug problems: a physician’s manual. Centre for Addiction and Mental Health, Toronto2000
      3. Office of Maternal and Child Health (2008 A). Substance abuse during pregnancy: guidelines for screening. Washington State Department of Health. Available at: http://www.doh.wa.gov/cfh/mch/documents/ScreenGuideline.pdf. Accessed April 2, 2009.

        • Hinderliter S.A.
        • Zelenak J.P.
        A simple method to identify alcohol and other drug use in pregnant adults in a prenatal care setting.
        J Perinatol. 1993; 13: 93-102
        • Chang G.
        • Wilkins-Haug L.
        • Berman S.
        • Goetz M.A.
        • Behr H.
        • Hiley A.
        Alcohol use and pregnancy: improving identification.
        Obstet Gynecol. 1998; 91: 892-898
        • Chang G.
        • Wilins-Halig L.
        • Berman S.
        • Goetz M.A.
        The TWEAK: Application in a prenatal setting.
        J Stud Alcohol. 1999; 60: 306-309
        • Carroll J.C.
        • Reid A.J.
        • Biringer A.
        • Midmer D.
        • Glazier R.H.
        • Wilson L.
        • et al.
        Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: a randomized controlled trial.
        CMAJ. 2005; 173: 253-259
        • Reid A.J.
        • Biringer A.
        • Carroll J.D.
        • Midmer D.
        • Wilson L.M.
        • Chalmers B.
        • et al.
        Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial health assessment.
        CMAJ. 1998; 159: 677-684
        • Office of Maternal and Child Health (2008 B)
        Guidelines for Testing and Reporting Drug Exposed Newborns. Washington State Department of Health, 2008 (Available at:) (Accessed April 2, 2009)
        • Ostrea E.M.
        • Knapp D.K.
        • Tannenbaum L.
        • Ostrea A.R.
        • Romero A.
        • Salari V.
        • et al.
        Estimates of illicit drug use during pregnancy by maternal interview, hair analysis, and meconium analysis.
        J Pediatr. 2001; 138: 344-348
        • Gourlay D.
        • Heit H.A.
        • Caplan Y.H.
        Urine drug testing in primary care.
        PharmaCom Group Inc., USA2002
        • Callahan C.M.
        • Grant T.M.
        • Phipps P.
        • Clark G.
        • Novack A.H.
        • Streissguth A.P.
        • et al.
        Measurement of gestational cocaine exposure: sensitivity of infants’ hair, meconium, and urine.
        J Pediatr. 1992; 120: 763-768
        • Vinner E.
        • Vignau J.
        • Thibault D.
        • Codaccioni X.
        • Brassart C.
        • Humbert L.
        • et al.
        Neonatal hair analysis contribution to establishing a gestational drug exposure profile and predicting a withdrawal syndrome.
        Ther Drug Monit. 2003; 25: 421-432
        • Christmas J.T.
        • Knisely J.S.
        • Dawson K.S.
        • Dinsmoor M.J.
        • Weber S.E.
        • Schnoll S.H.
        Comparison of questionnaire screening and urine toxicology for detection of pregnancy complicated by substance use.
        Obstet Gynecol. 1992; 80: 750-754
        • Kwong T.C.
        • Shearer D.
        Detection of drug use during pregnancy.
        Obstet Gynecol Clin North Am. 1998; 25: 43-64
        • Gehringer K.
        Informed consent: hospitals must obtain informed consent prior to drug testing pregnant patients.
        J Law Med Ethics. 2003; 31: 455-457
        • Mikhail B.I.
        Perceived impediments to prenatal care among low-income women.
        West J Nurs Res. 1999; 21 (discussion 351–5): 335-350
        • Milligan R.
        • Wingrove B.K.
        • Richards L.
        • Rodan M.
        • Monroe-Lord L.
        • Jackson V.
        • et al.
        Perceptions about prenatal care: views of urban vulnerable groups.
        BMC Public Health. 2002; 2: 25
      4. Currie JC. Best practices treatment and rehabilitation for women with substance use problems. 2001, Ottawa: Minister of Public Works and Government Services Canada. Available at: http://www.cds-sca.com. Accessed November 23,2010.

        • Roberts G.
        • Nanson J.
        Best practices: fetal alcohol syndrome/fetal alcohol effects and the effects of other substance use during pregnancy.
        Minister of Public Works and Government Services Canada, Ottawa2001
        • Ellwood D.A.
        • Sutherland P.
        • Kent C.
        • O’Connor M.
        Maternal narcotic addiction: pregnancy outcome in patients managed by a specialized drug- dependency antenatal clinic.
        Aust NZ J Obstet Gynaecol. 1987; 27: 92-98
        • Kandall S.R.
        • Albin S.
        • Lowinson J.
        • Berle B.
        • Eidelman A.I.
        • Gartner L.M.
        The narcotic-dependent mother: fetal and neonatal consequences.
        Early Hum Dev. 1977; 1: 159-169
        • Lee M.I.
        • Stryker J.C.
        • Sokol R.J.
        Perinatal care for narcotic-dependent gravidas.
        Perinatol Neonatol. 1985; 9: 35-40
        • Burkett G.
        • Gomez-Marin O.
        • Yashin S.Y.
        • Martinez M.
        Prenatal care in cocaine-exposed pregnancies.
        Obstet Gynecol. 1998; 92: 193-200
        • Jansson L.M.
        • Svikis D.
        • Lee J.
        • Paluzzi P.
        • Rutiglioano P.
        • Hackerman F.
        Pregnancy and Addiction. A comprehensive care model.
        J Subst Abuse Treat. 1996; 13: 321-329
        • Sweeney P.J.
        • Schwartz R.M.
        • Mattis N.G.
        • Vohr B.
        The effect of integrating substance abuse treatment with prenatal care on birth outcome.
        J Perinatol. 2000; 20: 219-224
        • Reece E.A.
        • Leguizamon G.
        • Silva J.
        • Whiteman V.
        • Smith D.
        Intensive interventional maternity care reduces infant morbidity and hospital costs.
        J Matern Fetal Neonatal Med. 2002; 11: 204-210
        • Suffet F.
        • Brotman R.
        A comprehensive care program for pregnant addicts: obstetrical, neonatal, and child development outcomes.
        Int J Addict. 1984; 19: 199-219
        • McLaughlin F.J.
        • Altemeier W.A.
        • Christensen M.J.
        • Sherrod K.B.
        • Dietrich M.S.
        • Stern D.T.
        Randomized trial of comprehensive prenatal care for low- income women: effect on infant birth weight.
        Pediatrics. 1992; 89: 128-132
        • Scholl T.O.
        • Hediger M.L.
        • Belsky D.H.
        Prenatal care and maternal health during adolescent pregnancy: a review and meta-analysis.
        J Adolesc Health. 1994; 15: 444-456
        • Wong T.
        • Lee S.S.
        Hepatitis C: a review for primary care physicians.
        CMAJ. 2006; 174: 649-659
        • Robinson J.L.
        Vertical transmission of the hepatitis C virus: current knowledge and issues.
        Paediatr Child Health. 2008; 13: 529-536
        • Substance Abuse and Mental Health Services Administration, Office of Applied Studies
        The NSDUH report: sexually transmitted diseases and substance use. 2007 (Rockville, MD)
        • Fichtner R.
        • Carson D.
        • Brackbill R.
        Behavioural risks for HIV/STD and birth outcomes among pregnant women who abuse substances: evidence from intensive outreach—Atlanta, Georgia.
        Int Conf AIDS. 1996; 11 (abstract): 362
        • Bolnick J.M.
        • Rayborn J.M.
        • Rayborn W.F.
        Substance use disorders in women: special considerations during pregnancy.
        Obstet Gynecol Clin North Am. 2003; 30: 545-558
        • Schempf A.H.
        • Strobino D.M.
        Illicit drug use and adverse birth outcomes: is it drugs or context?.
        J Urban Health. 2008; 85: 858-873
        • Bailey B.A.
        • Daugherty R.A.
        Intimate partner violence during pregnancy: incidence and associated health behaviors in a rural population.
        Matern Child Health J. 2007; 11: 495-503
        • Liston R.
        • Sawchuck D.
        • Young D.
        SOGC Fetal Health Surveillance Consensus Committee. Fetal health surveillance: antepartum and intrapartum consensus guideline. SOGC Clinical Practice Guideline No. 197, September 2007.
        J Obstet Gynaecol Can. 2007; 29: S1-S56
        • Chang G.
        • Goetz M.A.
        • Wilkins-Haug L.
        • Berman S.
        A brief intervention for prenatal alcohol use: an in-depth look.
        J Subst Abuse Treat. 2000; 18: 365-369
        • The Project CHOICES Intervention Research Group
        Reducing the risk of alcohol-exposed pregnancies: a study of a motivational intervention in community settings.
        Pediatrics. 2003; 111: 1131-1135
        • Nordstrom B.R.
        • Levin F.R.
        Treatment of cannabis disorders: a review of the literature.
        Am J Addict. 2007; 16: 331-342
        • Dutra L.
        • Stathopolou G.
        • Basden S.L.
        • Leyro T.M.
        • Powers M.B.
        • Otto M.W.
        A meta-analytic review of psychosocial interventions for substance use disorders.
        Am J Psychiatry. 2008; 165: 179-187
        • Carroll K.M.
        • Chang G.
        • Behr H.
        • Clinton B.
        • Kosten T.R.
        Improving treatment outcome in pregnant, methadone-maintained women: results from a randomized clinical trial.
        Am J Addict. 1995; 4: 56-59
        • Davis M.M.
        • Brown B.S.
        • Glendinning S.T.
        Neonatal effects of heroin addiction and methadone-treated pregnancies. Preliminary report on 70 live births.
        Proc Natl Conf Methadone Treat. 1973; 2: 1153-1164
        • Harper R.G.
        • Solish G.I.
        • Sang E.
        • Purow H.
        The effect of a methadone treatment program upon pregnant addicts and their infants.
        Proc Natl Conf Methadone Treat. 1973; 2: 1133-1137
      5. Johnson H. Measuring violence against women: statistical trends 2006. Statistics Canada catalogue no. 85-570-XWE, Ottawa.

        • Messer K.
        • Clarke K.A.
        • Martin S.L.
        Characteristics associated with pregnant women’s utilization of substance abuse treatment services.
        Am J Drug Alcohol Abuse. 1996; 22: 403-422
        • Martin S.L.
        • Beaumont J.L.
        • Kuper L.L.
        Substance use before and during pregnancy: links to intimate partner violence.
        Am J Drug Alcohol Abuse. 2003; 29: 599-617
        • Tuten M.
        • Jones H.E.
        A partner’s drug-using status impacts women’s drug treatment outcome.
        Drug Alcohol Depend. 2003; 70: 327-330
        • Kissin W.B.
        • Svikis D.S.
        • Morgan G.D.
        • Haug N.A.
        Characterizing pregnant drug-dependent women in treatment and their children.
        J Subst Abuse Treat. 2001; 21: 27-34
        • Kissin W.B.
        • Svikis D.S.
        • Moylan P.
        • Haug N.A.
        • Stitzer M.L.
        Identifying pregnant women at risk for early attrition from substance abuse treatment.
        J Subst Abuse Treat. 2004; 27: 31-38
        • Tough S.C.
        • Siever J.E.
        • Johnston D.W.
        Retaining women in a prenatal care randomized controlled trial in Canada: implications for program planning.
        BMC Public Health. 2007; 7: 148
        • Ontario Ministry of Children and Youth Services. Reporting child abuse and neglect: it’s your duty. Queen’s Printer for Ontario
        (Available at:) (Accessed December 22, 2010)
        • Rore C.
        • Brace V.
        • Danielian P.
        • Williams D.
        Smoking cessation in pregnancy.
        Expert Opin Drug Saf. 2008; 7: 727-737
        • Crawford J.T.
        • Tolosa J.E.
        • Goldenberg R.L.
        Smoking cessation in pregnancy: why, how, and what next.
        Clin Obstet Gynecol. 2008; 51: 419-435
        • Lumley J.
        • Oliver S.
        • Chamberlain C.
        • Oakley L.
        Interventions for promoting smoking cessation during pregnancy.
        Cochrane Database System Rev. 2004; (Issue 4. Art No.: CD001055. DOI:10.1002/14651858. CD001055. pub2)
        • McBride C.M.
        • Baucom D.H.
        • Peterson B.L.
        • Pollak K.I.
        • Palmer C.
        • Westman E.
        • et al.
        Prenatal and postpartum smoking abstinence a partner-assisted approach.
        Am J Prev Med. 2004; 27: 232-238
        • Rigotti N.A.
        • Park E.R.
        • Regan S.
        • Chang Y.
        • Perry K.
        • Loudin B.
        • et al.
        Efficacy of telephone counseling for pregnant smokers: a randomized controlled trial.
        Obstet Gynecol. 2006; 108: 83-92
        • Melvin C.L.
        • Dolan-Mullen P.
        • Windsor R.A.
        • Whiteside Jr., H.P.
        • Goldenberg R.L.
        Recommended cessation counselling for pregnant women who smoke: a review of the evidence.
        Tob Control. 2000; 9: 1180-1184
        • Ruger J.P.
        • Emmons K.M.
        Economic evaluations of smoking cessation and relapse prevention programs for pregnant women: a systematic review.
        Value Health. 2008; 11: 180-190
        • Hajek P.
        • Stead L.F.
        • West R.
        • Jarvis M.
        • Lancaster T.
        Relapse prevention interventions for smoking cessation (Review).
        Cochrane Database System Rev. 2009; (Issue 1. Art No.: CD003999. DOI: 10.1002/14651858. CD003999.pub3)
        • Oncken C.
        • Dornelas E.
        • Greene J.
        • Sankey H.
        • Glasmann A.
        • Feinn R.
        • et al.
        Nicotine gum for pregnant smokers: a randomized controlled trial.
        Obstet Gynecol. 2008; 112: 859-867
        • Kapur B.
        • Hackman R.
        • Selby P.
        • Klein J.
        • Koren G.
        Randomized, doubleblind, placebo-controlled trial of nicotine replacement therapy in pregnancy.
        Curr Ther Res Clin Exp. 2001; 62: 274-278
        • Pollak K.I.
        • Oncken C.A.
        • Lipkus I.M.
        • Lyna P.
        • Swamy G.K.
        • Pletsch P.K.
        • et al.
        Nicotine replacement and behavioral therapy for smoking cessation in pregnancy.
        Am J Prev Med. 2007; 33: 297-305
        • Dwyer J.B.
        • Broide R.S.
        • Leskie F.M.
        Nicotine and brain development.
        Birth Defects Res C Embryo Today. 2008; 84: 30-44
        • Slotkin T.A.
        If nicotine is a developmental neurotoxicant in animal studies, dare we recommend nicotine replacement therapy in pregnant women and adolescents?.
        Neurotoxicol Teratol. 2008; 30: 1-19
        • Gaither K.H.
        • Huber L.R.
        • Thompson M.E.
        • Huet-Hudson Y.M.
        Does the use of nicotine replacement therapy during pregnancy affect pregnancy outcomes?.
        Matern Child Health J. 2008; 13: 497-504
        • Morales-Suarez-Valera M.M.
        • Bille C.
        • Christensen K.
        • Olsen J.
        Smoking habits, nicotine use, and congenital malformations.
        Obstet Gynecol. 2006; 107: 51-57
        • Pauley J.R.
        • Slotkin T.A.
        Maternal tobacco smoking, nicotine replacement and neuro-behavioural development.
        Acta Pediatr. 2008; 97: 1331-1337
        • Coleman T.
        Recommendations for the use of pharmacological smoking cessation strategies in pregnant women.
        CNS Drugs. 2007; 21: 983-993
        • Chun-Fai-Chan B.
        • Koren G.
        • Fayez I.
        • Kalra S.
        • Voyer-Lavigne S.
        • Boshier A.
        • et al.
        Pregnancy outcome of women exposed to bupropion during pregnancy: a prospective comparative study.
        Am J Obstet Gynecol. 2005; 192: 932-936
        • Chan B.
        • Einarson A.
        • Koren G.
        Effectiveness of bupropion for smoking cessation during pregnancy.
        J Addict Dis. 2005; 24: 19-23
        • Luty J.
        • Nikolaou V.
        • Bearn J.
        Is opiate detoxification unsafe in pregnancy?.
        J Subst Abuse Treat. 2003; 24: 363-367
        • Kashiwagi M.
        • Arlettaz R.
        • Lauper U.
        • Zimmermann R.
        • Hebisch G.
        Methadone maintenance program in a Swiss perinatal center: (I): management and outcome of 89 pregnancies.
        Acta Obstet Gynecol Scand. 2005; 84: 140-144
        • Dashe J.S.
        • Jackson G.L.
        • Olscher D.A.
        • Zane E.H.
        • Wenderl Jr., G.D.
        Opioid detoxification in pregnancy.
        Obstet Gynecol. 1998; 92: 854-858
        • Maas U.
        • Katner E.
        • Weingart-Jesse B.
        • Schafer A.
        • Obladen M.
        Infrequent neonatal opiate withdrawal following maternal methadone detoxification during pregnancy.
        J Perinat Med. 1990; 18: 111-118
        • Allen M.H.
        Detoxification consideration in the medical management of substance abuse in pregnancy.
        Bull N Y Acad Med. 1991; 67: 270-276
        • Blinick G.
        • Inturrisi C.E.
        • Jerez E.
        • Wallach R.C.
        Methadone assays in pregnant women and progeny.
        Am J Obstet Gynecol. 1975; 121: 617-621
        • Stern R.
        The pregnant addict. A study of 66 case histories, 1950-1959.
        Am J Obstet Gynecol. 1966; 94: 253-257
        • Wilson G.S.
        • Desmond M.M.
        • Wait R.B.
        Follow-up of methadone-treated and untreated narcotic-dependent women and their infants: health, developmental, and social implications.
        J Pediatr. 1981; 98: 716-722
        • Jones H.E.
        • O’Grady K.E.
        • Malfi D.
        • Tuten M.
        Methadone maintenance vs. methadone taper during pregnancy: maternal and neonatal outcomes.
        Am J Addict. 2008; 17: 372-386
        • Hagopian G.S.
        • Wolfe H.M.
        • Sokol R.J.
        • Ager J.W.
        • Wardell J.N.
        • Cepeda E.E.
        Neonatal outcome following methadone exposure in utero.
        J Matern Fetal Med. 1996; 5: 348-354
        • Kandall S.R.
        • Albin S.
        • Lowinson J.
        • Berle B.
        • Eidelman A.I.
        • Gartner L.M.
        Differential effects of maternal heroin and methadone use on birthweight.
        Pediatrics. 1976; 58: 681-685
        • Hulse G.K.
        • Milne E.
        • English D.R.
        • Holman C.D.J.
        The relationship between maternal use of heroin and methadone and infant birth weight.
        Addiction. 1997; 92: 1571-1579
        • Zelson C.
        • Lee S.J.
        • Casalino M.
        Neonatal narcotic addiction. Comparative effects of maternal intake of heroin and methadone.
        N Eng J Med. 1973; 289: 1216-1220
        • Rahbar F.
        Observations on methadone withdrawal in 16 neonates.
        Clin Pediatr (Phila). 1975; 14: 369-371
        • Malpas T.J.
        • Darlow B.A.
        • Lennox R.
        • Horwood L.J.
        Maternal methadone dosage and neonatal withdrawal.
        A NZ J Obstet Gynaecol. 1995; 35: 175-177
        • Brown H.L.
        • Britton K.A.
        • Mahaffey D.
        • Brizendine E.
        • Hiett A.K.
        • Turnquest M.A.
        Methadone maintenance in pregnancy: a reappraisal.
        Am J Obstet Gynecol. 1998; 179: 459-463
        • Arlettaz R.
        • Kashiwagi M.
        • Das-Kundu S.
        • Fauchere J.C.
        • Lang A.
        • Bucher H.U.
        Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources.
        Acta Obstet Gynecol Scand. 2005; 84: 145-150
        • Hunt R.W.
        • Tzioumi D.
        • Collins E.
        • Jeffery H.E.
        Adverse neurodevelopmental outcome of infants exposed to opiate in-utero.
        Early Hum Dev. 2008; 84: 29-35
        • Vance J.C.
        • Chant D.C.
        • Tudehope D.I.
        • Gray P.H.
        • Hayes A.J.
        Infants born to narcotic dependent mothers: physical growth patterns in the first 12 months of life.
        J Paediatr Child Health. 1997; 33: 504-508
        • Lifshitz M.
        • Gavrilov V.
        • Galil A.
        • Landau D.
        A four-year survey of neonatal narcotic withdrawal: evaluation and treatment.
        Isr Med Assoc J. 2001; 3: 17-20
        • McCarthy J.J.
        • Leamon M.H.
        • Parr M.S.
        • Anania B.
        High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes.
        Am J Obstet Gynecol. 2005; 193: 606-610
        • Jansson L.M.
        • Velez M.
        • Harrow C.
        The opioid-exposed newborn: assessment and pharmacologic management.
        J Opioid Manag. 2009; 5: 47-55
        • Marcellus L.
        Care of the substance-exposed infants: the current state of practice in Canadian hospitals.
        J Perinat Neonatal Nurs. 2002; 16: 51-68
        • Velez M.
        • Jansson L.M.
        The opioid dependent mother and newborn dyad: nonpharmacologic care.
        J Addict Med. 2008; 2: 113-120
        • Osborn D.A.
        • Jeffery H.E.
        • Cole M.
        Opiate treatment for opiate withdrawal in newborn infants.
        Cochrane Database System Rev. 2005; (Issue 3. Art No.: CD002059. DOI: 10.1002/14651858.CD002059.pub2)
        • Abrahams R.
        • Kelly S.A.
        • Payne S.
        • Thiessen P.N.
        • Mackintosh J.
        • Janssen P.A.
        Rooming-in compared with standard care for newborns of mothers using methadone or heroin.
        Can Fam Physician. 2007; 53: 1722-1730
        • Srivastava A.
        • Kahan M.
        Buprenorphine: a potential new treatment option for opioid dependence.
        CMAJ. 2006; 174: 1835-1836
        • Johnson R.
        • Jones H.
        • Fischer G.
        Use of buprenorphine in pregnancy: patient management and effects on the neonate.
        Drug Alcohol Depend. 2003; 70: S87-S101
        • Lacroix I.
        • Berrebi C.
        • Chaumerliac C.
        • Lapeyre-Mestre M.
        • Montastruc J.L.
        • Damase-Michel C.
        Buprenorphine in pregnant opioid dependent women: first results of a prospective study.
        Addiction. 2004; 99: 209-214
        • Lejeune C.
        • Simmat Durand L.
        • Gourarier L.
        • Aubisson S.
        • the Groupe d’Etudes Grossesse et Addictions (GEGA)
        Prospective multicenter observational study of 260 infants born to 259 opiate dependent mothers on methadone or high dose buprenorphine substitution.
        Drug Alcohol Depend. 2006; 82: 250-257
        • Jones H.
        • Johnson R.
        • Jasinski D.R.
        • O’Grady K.E.
        • Chisholm C.A.
        • Choo R.E.
        • et al.
        Buprenorphine versus methadone in the treatment of pregnant opioid dependent patients: effects on the neonatal abstinence syndrome.
        Drug Alcohol Depend. 2005; 79: 1-10
        • Reisinger M.
        Use of buprenorphine during pregnancy.
        Research and Clinical Forums. 1997; 19: 43-45
        • Schindler S.D.
        • Eder H.
        • Ortner R.
        • Rohrmeister K.
        • Langer M.
        • Fischer G.
        Neonatal outcome following buprenorphine maintenance during conception and throughout pregnancy.
        Addiction. 2003; 98: 103-110
        • National Opioid Use Guideline Group (NOUGG)
        Canadian guideline for safe and effective use of opioids for chronic non-cancer pain.
        2010 (Accessed November 23, 2010. Available at: April)
        • College of Physicians and Surgeons of Ontario
        Methadone for pain guidelines. 2004 (Accessed January 21, 2011. Avialable at: Nov)
        • Hadi I.
        • da Silva O.
        • Natale R.
        • Boyd D.
        • Morley-Foster P.K.
        Opioids in the parturient with chronic nonmalignant pain: a retrospective review.
        J Opioid Manag. 2006; 2: 31-34
        • Sharpe C.
        • Kuschel C.
        Outcomes of infants born to mothers receiving methadone for pain management in pregnancy.
        Arch Dis Child Fetal Neonatal Ed. 2004; 89: F33-F36
        • Cassidy B.
        • Cyna A.M.
        Challenges that opioid-dependent women present to the obstetric anaesthetist.
        Anaesth Intensive Care. 2004; 32: 494-501
        • May J.A.
        • White H.C.
        • Leonard-White A.
        • Warltier D.C.
        • Pagel P.S.
        The patient recovering from alcohol or drug addiction: special issues for the anesthesiologist.
        Anesth Analg. 2001; 92: 1601-1608
        • Mao J.
        Opioid-induced abnormal pain sensitivity: implications in clinical opioid therapy.
        Pain. 2002; 100: 213-217
        • Rapp S.E.
        • Ready L.B.
        • Nessly M.L.
        Acute pain management in patients with prior opioid consumption: a case-controlled retrospective review.
        Pain. 1995; 6: 195-201
        • Mehta V.
        • Langford R.M.
        Acute pain management for opioid dependent patients.
        Anaesthesia. 2006; 61: 269-276
        • Meyer M.
        • Wagner K.
        • Benvenuto A.
        • Plante D.
        • Howard D.
        Intrapartum and postpartum analgesia for women maintained on methadone during pregnancy.
        Obstet Gynecol. 2007; 110: 261-266
      6. Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment improvement protocol (TIP) 43. DHHS Publication No. (SMA) 05-4048. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. Available at: http://store.samhsa.gov/product/SMA09-4341. Accessed January 5, 2011

        • Perez-Reyes M.
        • Wall M.E.
        Presence of delta9-tetrahydrocannabinol in human milk.
        N Engl J Med. 1982; 307: 819-820
        • Astley S.J.
        • Little R.E.
        Maternal marijuana use during lactation and infant development at one year.
        Neurotoxicol Teratol. 1990; 12: 161-168
        • Chasnoff I.J.
        • Lewis D.E.
        • Squires L.
        Cocaine intoxication in a breast-fed infant.
        Pediatrics. 1987; 80: 836-838
        • Steiner E.
        • Villen T.
        • Hallberg M.
        • Rane A.
        Amphetamine secretion in breast milk.
        Eur J Clin Pharmacol. 1984; 27: 123-124
        • Chaney N.E.
        • Franke J.
        • Wadlington W.B.
        Cocaine convulsions in a breastfeeding baby.
        J Pediatr. 1988; 112: 134-135
        • Hopkinson J.M.
        • Schanler R.J.
        • Fraley J.K.
        • Garza C.
        Milk production by mothers of premature infants: influence of cigarette smoking.
        Pediatrics. 1992; 90: 934-938
        • Robieux I.
        • Koren G.
        • Vanderbergh H.
        • Schneiderman J.
        Morphine excretion in breast milk and resultant exposure of a nursing infant.
        J Toxicol Clin Toxicol. 1990; 28: 365-370
        • Kreek M.J.
        • Schecter A.
        • Gutjahr C.L.
        • Bowen D.
        • Field F.
        • Queenan J.
        • et al.
        Analyses of methadone and other drugs in maternal and neonatal body fluids: use in evaluation of symptoms in a neonate of mother maintained on methadone.
        Am J Drug Alcohol Abuse. 1974; 1: 409-419
        • Pond S.M.
        • Kreek M.J.
        • Tong T.G.
        • Raghunath J.
        • Benowitz N.
        Altered methadone pharmacokinetics in methadone-maintained pregnant women.
        J Pharmacol Exp Ther. 1985; 233: 1-6
        • Geraghty B.
        • Graham E.A.
        • Logan B.
        • Weiss E.L.
        Methadone levels in breast milk.
        J Hum Lact. 1997; 13: 227-230
        • Johnson R.E.
        • Jones H.E.
        • Jasinki D.R.
        • Svikis D.S.
        • Haug N.A.
        • Jansson L.M.
        • et al.
        Buprenorphine treatment of pregnant opioid-dependent women: maternal and neonatal outcomes.
        Drug Alcohol Depend. 2001; 63: 97-103
        • Marquet P.
        • Chevrel J.
        • Lavignasse P.
        • Merle L.
        • Lacatre G.
        Buprenorphine withdrawal syndrome in a newborn.
        Clin Pharmacol Ther. 1997; 62: 569-571
        • McCarthy J.J.
        • Posey B.L.
        Methadone levels in human milk.
        J Hum Lact. 2000; 16: 115-120
        • Madadi P.
        • Koren G.
        Pharmacogenetic insights into codeine analgesia: implications to pediatric codeine use.
        Pharmacogenomics. 2008; 9: 1267-1284
        • Madadi P.
        • Ross C.J.
        • Hayden M.R.
        • Carleton B.C.
        • Gaedigk A.
        • Leeder J.S.
        • et al.
        Pharmacogenetics of neonatal opioid toxicity following maternal use of codeine during breastfeeding: a case-control study.
        Clin Pharmacol Ther. 2009; 85: 31-35
        • Madadi P.
        • Moretti M.
        • Djokanovic N.
        • Bozzo P.
        • Nulman I.
        • Ito S.
        • et al.
        Guidelines for maternal codeine use during breastfeeding.
        Can Fam Physician. 2009; 55: 1077-1078
        • Woolf S.H.
        • Battista R.N.
        • Angerson G.M.
        • Logan A.G.
        • Eel W.
        Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care.
        CMAJ. 2003; 169: 207-208