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VOLUME 48 AUGUST 1971 NUMBER 2
COMMENTARIES
METHADONE
AND
CHILDREN
T
HE increasing use of methadone main-tenance (substitution) programs13 inthe treatment of adult heroin addiction has
created situations for children which
re-quire the attention of pediatricians.
Metha-done is an analgesic drug. In urban areas,
thousands of heroin addicts are now
receiv-ing high dosage of methadone, usually 80 to
120 mg daily. This approach to heroin ad-diction has met with greater success than
any other form of treatment. It is expected
that increasing numbers of heroin addicts
will be treated in the near future by this
method throughout the United States and
Canada.
Pediatricians should focus on three
as-pects of the problem as follows: (1)
acci-dental poisoning of children by methadone,
(2) the infants born to women who are
treated with methadone during pregnancy, and (3) the question of including adoles-cent heroin users in methadone
mainte-nance treatment programs.
Accidental methadone poisoning of
young children is increasing in incidence in urban centers.5’6 In recent months New
York City alone has experienced many of
these poisonings resulting in coma and in at least four deaths. Boston, Detroit, and
Washington, D.C. have likewise reported
accidental poisoning by methadone in chil-dren. Childproofing and labeling of
con-tainers holding methadone should be
embarked upon. Methadone is usually
dis-pensed in liquid form in fruit juice or in
tablets. Both of these are readily ingested by children. A small child who ingests a full
adult dose of methadone or even residual amounts of liquid containing the drug, can progress from a drowsy state to coma in as brief a period as one-half hour, and may die
of respiratory failure within a few hours if he is untreated. Recognition of this form of
poisoning can be made by history
primar-ily, when it is known that a parent or other adult is being treated with methadone, and when a methadone container is discovered.
The treatment of choice appears to be
naloxone hydrochloride, (Narcan
)
0.01 mg/kg intravenously, which Endo Labora-tories is about to make commercially avail-able, although its safe and effective use inchildren has not been fully established. It is suggested that the package insert be stud-ied before administration of Narcan. If Narcan is not used, intravenous nalorphine
hydrochloride (Nalline), 0.1 mg/kg, or
levallorphan tartrate (Lorfan), 0.02 mg/kg, are effective for this form of narcotic
poison-ing. Nalline and Lorfan may increase
respi-ratory depression if the diagnosis of narcotic poisoning is incorrect; this is especially true if respiration is impaired as a result of barbi-turate poisoning. Because Narcan is free of
this problem, it is the antidote of choice when the precise diagnosis is in question. The first injection of antidote will usually produce marked, rapid improvement in the
comatose child. If the diagnosis is in
ques-tion, and there is no dramatic response to
174 METHADONE AND CHILDREN the first dose of antidote, it is safe to repeat
the injection of Narcan, whereas continued
administration of Nalline or Lorfan should be held in abeyance. Careful, continuous
observation of the child is essential even though initial response to the narcotic an-tagonist occurs, since the depressant action
of methadone may last for from 24 to 48 hours, or even longer, while the antidotal action of the narcotic antagonist lasts only for 2 to 3 hours. It is, therefore, possible to effect successful resuscitation in a child who later lapses into fatal coma if adminis-tration of the narcotic antagonist is not
re-peated. Immediate emptying of the stomach of the child who ingests methadone may be helpful, but if delayed an hour or more, Ia-vage or emesis may only serve to interfere with respiration. Dialysis is not indicated, because the amount of methadone in the blood is minute. Central nervous system
stimulants are likewise not indicated, since they demonstrate no effect against the de-pressant manifestations of methadone and may only augment its stimulant effects. Hos-pital emergency rooms and pediatric ser-vices should be made aware of the problem of accidental methadone poisoning in chil-dren and should post a protocol for the treat-ment of this form of poisoning.
Infants born to women who are treated with large amounts of methadone daily dur-ing pregnancy are under study by several groups. From the point of view of the
child’s well-being, preliminary results8 indi-cate that there are decided advantages in
bringing pregnant women into methadone treatment programs as opposed to allowing them to remain on heroin. Advantages in-clude the more frequent participation in prenatal care by the pregnant addict, shorter hospital stay for infants in the neona-tal period, and improved attention to child health care by the mother who is participat-ing in a methadone maintenance program. These advantages for the children can be attributed to a more stable social environ-ment of methadone-treated mothers
com-pared with those who are on heroin. The incidence of congenital malformations has
apparently not increased in babies born to women maintained on high dosage of
meth-adone. While withdrawal symptoms in in-fants need to be studied at greater length, preliminary indications are that those born to women who took methadone during pregnancy do not experience more severe symptoms than infants born to women on heroin. Studies of the relationship and
tim-ing
of the last dose of methadone or heroin, as well as the sedatives and analgesicsad-ministered before delivery, are necessary. Follow-up of babies born to mothers main-tained on methadone indicates that up to age 4 years the offspring show normal phys-ical and mental development.8 This study is
being continued. There is no evidence to justify the stigma of “addict” which has at
times been applied to babies born to women maintained on methadone during pregnancy. Such babies are usually asymp-tomatic and normal by age 10 days and thereafter.
The continuing abuse of drugs by school age children, particularly by adolescents, and the failure of therapeutic approaches to
adolescent heroin users draws attention of the pediatrician to this problem. In addi-tion, heroin-related deaths in large numbers
of adolescents call for an evaluation of methadone treatment of teen-age heroin users. Recent studies9”#{176} indicate that further work is needed before specific
recommen-dations can be made. Perhaps it would be advisable to treat adolescent heroin users in
slow detoxification programs; it may be
pos-sible to withdraw both heroin and metha-done in this way and not commit the ado-lescent to indefinite methadone treatment. Because of the special rehabilitation needs
of adolescent addicts, it may be advisable
to assemble special treatment units for them. Properly evaluated programs estab-lished for this purpose could supply an-swers, and such programs are now under
way.9
SAUL BLATMAN, M.D. Department of Pediatrics
Beth Israel Medical Center
REFERENCES
1.Dole, V. P., Nyswander, M. E., and Kreek,
M. J.: Narcotic blockade. Arch. Intern. Med.,
118:304, 1936.
2. Dole, V. P., Nyswander, M. E., and Warner, A.: Successful treatment of 750 criminal ad-dicts. J.A.M.A., 206:2708, 1968.
3. Dole, V. P., and Warner, A.: Evaluation of
narcotics treatment programs. Amer J. Pub-lic Health, 57:2000, 1967.
4. Dole, V. P.: Methadone maintenance treatment
for 25,000 heroin addicts. J.A.MA., 215:
1131, 1971.
5. McCurley, W. S., and Tunnessen, W. W., Jr.:
Methadone toxicity in a child. Pnwriucs,
43:90, 1969.
6. Sey, M. J., Rubenstein, D., and Smith, D. S.: Accidental methadone intoxication in a child.
PEDIAmIc5, 48:294, 1971.
7. Dole, V. P., Foldes, F. F., Trigg, H., Robinson,
J.
W., Blatman, S.: Methadone poisoning. N.Y. State J. Med., 71:541, 1971.8. Blatxnan, S., and Lipsitz, P.: Infants born to heroin addicts maintained on methadone: Neonatal observations and follow-up. Pro-ceedings of the third National Con-ference on Methadone Treatment, 1970 (N.I.M.H.).
9. Milln’ian, R. B., and Nyswander, M. E.: Slow detoxification of adolescent heroin addicts in
New York City. Proceedings of the third Na-tional Conference on Methadone Treatment,
1970 (N.I.M.H.).
10. Nightingale, S. L., Wurmser, L., Platt, P. C.,
and Michaux, W. W.: Adolescents on meth-adone: Preliminary observations. Proceed-ings of the third National Conference on Methadone Treatment, 1970 (N.I.M.H.).
POSITIVE
TRANSPULMONARY
AIRWAY
PRESSURE
T
HERE is now good evidence unpub-lished and published1’2 that neonatal intensive care is associated with increased survival. The major cause of neonatal mor-tality is the idiopathic respiratory distress syndrome (IRDS); hence the decrease in neonatal mortality can be ascribed, in part at least, to improvement in the management of infants with this syndrome. The arterialoxygen
tension
while breathing 100%oxy-gen has been shown to be the most valuable
prognosticator for outcome in this disease;’
an oxygen tension less than 100 mm Hg (in 100% oxygen) during the first 24 hours
is associated with a markedly increased mortality. Thus central in the management scheme is adequate oxygenation. In the past this has been accomplished by
increas-ing
the inspired oxygen concentration and when this fails, the use of ventilatorysup-port.5-8 Groups using respirator care have uniformly reported improvement in
oxy-genation. Survival has probably been im-proved as well although no controlled studies have been reported.
Respirator therapy requires intensive care of the highest order and for this reason is not widely applicable. Furthermore its use combined with
high
concentrations ofoxygen (or perhaps the latter alone) has led to evidence of pulmonary toxicity,#{176}’1 and hence to what Clements and Fisher12
have labeled the oxygen dilemma.
For many years it has been appreciated
that infants with IRDS have an
