We are in receipt of the comments from Mr Gleeson and Drs Eogan and Cleary regarding our article on opiate detoxification during pregnancy. The study initially started because of the unrelenting insistence of our opiate-addicted pregnant population that they did not want to continue taking opiates during their pregnancy and deliver a child who suffered the consequences of their addiction. Until very recently, virtually all of our local drug treatment facilities recommended opiate maintenance therapy during pregnancy and advised that detoxification during pregnancy placed the fetus at significant risk.

We performed a literature review to find published data that documented fetal danger and found only 2 case reports . Five studies on detoxification that were published in 5 different journals over a span of 23 years show otherwise, and our study basically doubled those numbers. Our study was not initiated over concerns about costs as the letter writers suggest (although the cost of treating neonatal abstinence syndrome is substantial) but for concerns about better maternal-fetal care. The information on every patient was collected prospectively, but the data were analyzed for publication retrospectively.

The rates of preterm delivery for each individual subgroup were presented in the Table in the manuscript, and no differences existed; one-half of these were not spontaneous but rather inductions for suspected intrauterine growth restriction. Because of manuscript size limitations, further details on the rate of intrauterine growth restriction were not supplied for each individual group; however, the rate of intrauterine growth restriction (<5% for gestational age) for the study population as a whole was 7%, with no differences between the individual subgroups.

The rate of relapse in our study population overall was 36%, but this primarily occurred in the population that lacked intensive behavioral health follow up (74% rate). The rate of relapse in the groups with behavioral health ranged from 17–23%. No addiction detoxification program (regardless of the addiction) has a no-relapse rate. We therefore continue to recommend that detoxification during pregnancy occur only if good behavioral health programs are available.

Death in opiate abusers, especially when relapse occurs after detoxification, occurs in all populations. This should not mean that all opiate-addicted people should be maintained on opiates for the rest of their life because detoxification may result in a short-term increased risk of overdose. In our county in Tennessee, there have been >300 deaths in women alone from opiate overdose in the past 6 years, but none of these deaths have occurred in a pregnant patient who underwent detoxification (and >500 pregnant patients have been fully detoxed in this period). However, during this same interval, multiple children of opiate-addicted women have died from child abuse and neglect, including a neonate whose mother administered buprenorphine for irritability that resulted in the infant’s death.

Chronic opiate maintenance therapy has not been proved to be benign. In addition to the risk of developing neonatal abstinence syndrome after delivery, there are concerns about the potential adverse effects to the fetus in utero, which includes the risk for altered bone growth and possible microcephaly. A prospective study on this subject will be finished within the next year to see whether it corroborates the findings of the retrospective analysis.

Concern about possible rare adverse outcomes is theoretic and unproven. The authors of the letter seem to discount the suffering that neonates experience when they are born with neonatal abstinence syndrome. In conclusion, the prevalent policy on maintaining pregnant women on opiate maintenance therapy during pregnancy should be reassessed.