Opiate Addiction: Commentary for Breastfeeding Supportive Care

Disclaimer: Native Mothering strongly opposes the use of drugs by breastfeeding mothers unless prescribed by a physician. Please consult your healthcare provider before taking any medications or drugs while pregnant or breastfeeding. This article is not meant to replace the advice of your health care provider or traditional medicine provider. By proceeding, you agree that the contents of this article do not constitute medical or legal advice.

Drugs and Breastfeeding in the News

It is important to realize the increased danger of using street drugs while parenting. For example, there have been several articles in the news about breastfeeding mothers accidentally exposing their babies to methamphetamine in breastmilk, tragically leading to the death of their babies. Another current article describes the illegal use of drugs such as hydrocodone, fentanyl, duragesic, and morphine (opiods); taken in combination by a breastfeeding mother, resulting in her infant’s death. Yet another mother was convicted in 2011 for taking a large amount of morphine while breastfeeding, to intentionally make her baby sick.

Intentional harm of an infant is hardly the norm when reviewing general news on breastfeeding and illegal drug use. Far more commonly, there is little or no individual awareness from the mother herself, that what unauthorized prescription medication or street drugs she takes frequently ends up in varying levels in her milk.

Drugs and Breastfeeding: Laws That Apply

In many U.S. states and territories, parental substance abuse is part of the wider definition of child abuse or neglect, regardless of when it occurs—prenatally or after birth. According to the U.S. Department of Health and Human Services website (US Dept of Health, 2009):

“Specific circumstances that are considered child abuse or neglect in some States include:

  • Manufacturing a controlled substance in the presence of a child or on premises occupied by a child
  • Exposing a child to, or allowing a child to be present where, chemicals or equipment for the manufacture of controlled substances are used or stored
  • Selling, distributing, or giving drugs or alcohol to a child
  • Using a controlled substance that impairs the caregiver’s ability to adequately care for the child
  • Exposing a child to the criminal sale or distribution of drugs

Approximately 25 States and the U.S. Virgin Islands address in their criminal statutes the issue of exposing children to illegal drug activity. For example, in 14 States the manufacture or possession of methamphetamine in the presence of a child is a felony and in four States, the manufacture or possession of any controlled substance in the presence of a child is considered a felony. California, Mississippi, Montana, North Carolina, Ohio, and Washington State have enacted enhanced penalties for any conviction for the manufacture of methamphetamine when a child was on the premises where the crime occurred.

Exposing children to the manufacture, possession, or distribution of illegal drugs is considered child endangerment in seven States. The exposure of a child to drugs or drug paraphernalia is a crime in North Dakota, Utah, and the Virgin Islands. In North Carolina and Wyoming, selling or giving an illegal drug to a child by any person is a felony.”

It is prudent to read and understand the position of your individual state so that you are adequately prepared to support and help the families with whom you work.

Heroin:

Abstaining from heroin is the best choice when breastfeeding. Most street drugs are dangerous to an infant’s health; even in small quantities they can prove fatal. A baby’s liver and kidneys are not as mature as an adult’s, so the effects of the drug are often intensified. Small amounts of the drug may have stronger and longer lasting effects on infants than on adults. Drugs may also accumulate (build up) in infants’ bodies, with the effect of contributing to serious organ damage or death.

It is unethical for a healthcare professional to advise a mother that she can safely breastfeed, even if she reports that she is only using heroin once in a while. Beyond the questionable effects of the heroin itself, it is often not possible to know if the drug has been cut with other substances. The presence of “cutting” agents may allow more unknown toxic substances to pass through breastmilk to the baby. In short, the true content of street drugs are always an unknown.

Causes for Immediate Weaning

If you believe a mother may be habitually or occasionally using heroin, other street drugs, or misusing pills of any kind, it is critical to suggest that she immediately wean her baby and switch to another method of feeding. It is a protective practice to offer your client a referral to a drug treatment program that accepts children, if you do not have such a program in your area, consider compiling a list of free or low cost support groups. Narcotics Anonymous is free, and meetings may be found here: http://www.na.org/

In some rare medically supervised situations, if the mother is voluntarily getting substance misuse treatment, is not currently breastfeeding, is no longer using, and has passed into a clinically safe period when her milk is clean of all residual drugs, an experienced Lactation Consultant may be able to work with her to help her maintain her milk production and reintroduce breastfeeding later. Reintroduction would depend on whether she is considered medically stable, at low risk of using again, and is actively collaborating with a healthcare team.

The risks would be high for the infant if the mother had insufficient support systems, difficulty staying clean, was unable to test clean, or failed to meet the conditions of her drug treatment plan. In this case it would be imperative to immediately facilitate another method of feeding that did not include breastfeeding by the mother or the mother expressing breastmilk for bottle feeding.

Heroin and Breastfeeding

If a mother is using heroin and breastfeeding, she should be told to wean immediately. Dr. Hale (2010, p. 500) lists heroin as an L5 lactation risk. This means it is considered unsafe, is contraindicated in breastfeeding mothers, and should be avoided while breastfeeding.

Heroin users—whether part-time or regular users—should be discouraged from breastfeeding for several reasons. Some people combine heroin use with methamphetamine, cocaine, alcohol or other drugs. Combining street drugs is unsafe for adults; it is particularly dangerous for babies who have immature livers and kidneys. A typical drug dose for a breastfeeding mother could be deadly for her infant.

Non-prescription Opiod Use in Mothers

If you are working around a population of people that use street drugs, you may have noticed the increase in misuse of opiod medications versus heroin itself. A study on toxicology reports from deceased poly-drug users (Minett, et al. 2010) stated that, “…the Boston Public Health Commission has found that deaths from drugs and alcohol have risen dramatically from 2005 to 2006 mainly because of an increase in inexpensive heroin and the growing addiction to prescription medications.” This speaks to evidence that as a population of addicts begins to use accessible pain medication for recreational purposes, the rate of overdose, and miscalculation involved with strong analgesics will increase. Unregulated opiate use, whether it is in pill, power, tar, or liquid form, combined with other drugs or by itself, can pose considerable negative effects or death on nursing children. Sadly, the rates of overdose in the adult population is higher in the childbearing years between 19-30, meaning that it is likely that the children of addicts have an increased chance of suffering the loss of a parent, living in poverty or that they may have had prenatal drug exposure during their formative period themselves.

Methadone and Breastfeeding

A 2008 study by the American Academy of Pediatrics concluded that breastfeeding women taking maintenance doses of methadone should be encouraged to breastfeed. “Results contribute to the recommendation of breastfeeding for methadone-maintained women.” (Janesson, et al. 2008)

Methadone use while breastfeeding may be acceptable if the mother is in treatment, under the care of a physician, and has given birth to a drug-dependent baby. In cases such as these, Dr. Hale (2010, p.667) recommends that the mother must be very careful and that she should observe the infant for “sedation, respiratory depression, addiction, withdrawal syndrome, neonatal abstinence syndrome.” If the mother is unclear about the signs of sedation in an infant/toddler, she must be immediately directed to contact her healthcare provider for clarification and instruction.

In a study of the effects of methadone use on breastfeeding infants, Keegan and colleagues (2010) concluded that: “…Neonates should be observed for signs of adverse effects, such as gastrointestinal side effects, sedation, and feeding pattern changes. For heavy narcotic abusers and women in methadone treatment programs, the postpartum time period is an excellent time to readdress the possibility of gradual narcotic withdrawal and continued rehabilitation.”

The small amount of methadone present in breastmilk has been reported to help with neonatal abstinence syndrome (NAS). NAS describes drug withdrawal in infants. A mother should speak with her healthcare provider about making safe and healthy breastfeeding choices for her baby.

Complications with Methadone

Serious complications may arise if a mother takes other medications or drugs in addition to methadone. Any change in medications would require close supervision of her infant for sedation and other dangerous side-effects. The first priority must always be the safety and health of the baby.

Are the Effects of Using Heroin the same as Using Methadone when a Mother is Breastfeeding?

No. Methadone is measured precisely and physicians know the exact dose a mother is taking—thus the amount of the infant’s theoretical dose through breastmilk can be estimated. This is not possible with heroin because the potency and dose may vary, and heroin may be cut with a variety of other substances of unknown quantity. If a mother has been using heroin while pregnant, it is advisable to immediately direct her to a substance use treatment clinic for evaluation. The best time to get support to quit is prenatally. A mother can talk to her physician about her desire to breastfeed, and ask for advice on how to get help for addiction.

Mothers in Recovery

The stigma of being in recovery from drug addiction is understandably difficult; it often comes with heartache and a loss of control and accountability. A mother in early recovery has a tremendous amount of work ahead of her, but it doesn’t have to prevent her from forging a strong bond with her baby. A child will benefit from a family that gets clean, stays clean, and actively parents. A mother’s choice to breastfeed should be respected and honored. Additionally, a mother should takes steps to avoid putting herself in a position of risking her recovery from drug use, because of her social circle, environment or location.

Breastfeeding after Physical Abuse

Women all over the world may have been recipients of undesired physical or sexual contact. This can especially be an issue for mothers who use drugs or are recovering from drug use. You can read more on the topic of supporting survivors of abuse here.

Recovery Resources

Directing a mother to local support groups through a methadone clinic or Narcotics Anonymous (NA) may increase her chances of successfully staying clean. Check the NA website to find an NA meeting near you: http://www.na.org/?ID=home-content-fm

References

Academy of Breastfeeding Medicine Protocol Committee. ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug-Dependent Woman.  Breastfeeding Medicine Vol. 4, No. 4, 2009. Mary Ann Liebert, Inc.

Child Welfare Information Gateway. (2011). Definitions of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau.

Fisher, Denise MMP, BN, RN, RM, IBCLC . Social Drugs and Breastfeeding. 2006 http://www.health-e-learning.com/resources/articles/40-social-drugs-and-breastfeeding

Glatstein , Miguel Marcelo, MD, Facundo Garcia-Bournissen, MD, Yaron Finkelstein, MD, and Gideon Koren, MD. Methadone Exposure During Lactation. Canadian family Physician. Dec 2008 vol 54/12 pgs1689-1690. http://www.cfp.ca/content/54/12/1689.full.pdf+html

Hale, Thomas, Ph.D. Medications and Mothers’ Milk. 2010 Hale Publishing.

Hutchison, Courtney. California Woman Claims Meth-Laced Breast Milk Not Cause of Her Baby’s Death.  ABC News. Aug 5th, 2011 http://abcnews.go.com/Health/Drugs/california-mother-charged-murder-breastfeeding-meth/story?id=14231552

Ito, Shinya M.D. Drug Therapy for Breastfeeding Women. New England Journal of Medicine 2000; 343:118-126.

Jansson, L. M., Choo, R., Velez, M. L., Schroeder, J. R., Shakleya, D. M.,
Huestis, M. A., & Harrow, C. (2008, January 1). Methadone Maintenance and
Breastfeeding in the Neonatal Period. The American Academy of Pediatrics, 
121(1), 106-114. doi:10.1542/peds.2007-1182.

Karila, l Cazas, O, Danel T, Reynaud M. Short- and long-term consequences of prenatal exposure to cannabis. Journal of Gynecol Obstet Biol Reprod (paris) 2006 Feb;35(1):62-70.

Keegan, Joan DO, Parva ,Mehdi MD, Finnegan, Mark MD, Gerson, Andrew MD, Belden Michael MD. Addiction in Pregnancy. Journal of Addictive Diseases, 29:175–191, 2010. Taylor & Francis Group, LLC,

March of Dimes. 2008. Illicit Drug Use During Pregnancy.  http://www.marchofdimes.com/pregnancy/alcohol_illicitdrug.html

Minnett, W. J., et al. (2010, April/May 28). Concentrations of Opiates and Psychotropic
Agents in Polydrug Overdoses: A Surprising Correlation Between Morphine and
Antidepressants. Journal of Forensic Sciences, 55(5), 1319-25. doi:10.1111/
j.1556-4029.2010.01408.x.

Narcotics Anonymous World Services. http://www.na.org/

Nonacs, Ruta  MD PhD. Methadone and Breastfeeding. Harvard Medical School. March 21, 2011  http://www.womensmentalhealth.org/posts/methadone-and-breastfeeding/

Riparbelli, L. (2011, June/July 27). Breastfeeding Mother Charged in Infant’s 
Death [News article]. Retrieved June/July 22, 2012, from ABC News
Internet Ventures. Yahoo! – ABC News Network website: http://abcnews.go.com/
US/morphine-womans-breast-milk-kills-infant-police/
story?id=13940659#.T-QlkbVDxhs

Schempf, Ashley H PhD,, Strobino ,Donna M. Illicit Drug use and Adverse Birth Outcomes: Is it the Drugs or the Context? Journal of Urban Health. 2008 November; 85(6): 858–873.

*In conclusion, I would like to acknowledge the assistance and support of Yvette Malamud Ozer, who devoted time editing and adding in suggestions when needed. These acts of kindnesses from our friends must be appreciated.

 

(c) 2015 Serena Meyer RN, IBCLC. All Rights Reserved


 

 

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One Response to Opiate Addiction: Commentary for Breastfeeding Supportive Care

  1. Em says:

    One of the most unfortunate things I see as a healthcare provider is expectant, new, whatever, mothers being weaned from opiates that they may have started taking for legitimate reasons but their bodies have become dependent on TO something like Methadone, particularly DURING pregnancy because it’s somehow seen as a safer (controllable) option. THEN, their OB or Pediatrician might say that they should not breastfeed as a result of the medication in their system, which is where a knowledgable healthcare provider/advocate would step in and point out the actual lactation risk and the benefit outweighing the risk to those opposed to the mother breastfeeding. I have had to produce studies for colleagues on this matter to be heard. Not everyone has compassion for pregnant or new mothers in this situation and that can be as bad as the problem itself.

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