We are in receipt of the comments from Dr McCarthy and Dr Terplan regarding our manuscript on opiate detoxification during pregnancy. To begin, we take issue with the statement that we approved of the acute detoxification in our jail system. As stated in the manuscript, the jail system in our region is not allowed to provide opiates. This is a legal/legislative issue that our medical community does not support. However, this jail treatment process was one of the reasons that prompted us to look for potential fetal harm.

Second, the law in Tennessee that criminalized opiate use in pregnancy was clear; a woman could be charged with a misdemeanor if she delivered a child that suffered adverse effects from opiate use in pregnancy if the opiates used were not obtained from a medical provider. All of our patients (other than those incarcerated) are offered placement into maintenance programs, and only those who request detoxification undergo the process, either as an inpatient or outpatient per the patient desire. No “coercion” ever took place. This law was not renewed this year from continued lobbying by the medical community. Furthermore, no pregnant woman was ever charged for this offense in our county where this study was completed.

It is important for readers to understand (and the manuscript states this) that there were no losses from detoxification in the study, and none were reported in the other 5 studies discussed in the publication. The 2 losses (that occurred in the jail population) involved a placental abruption that occurred 8 weeks after the patient was fully detoxifid. Placental abruption occurs at a rate of about 1 in 170 pregnancies, and we had 1 in 301. The second was an anomalous fetus with hydrops at 34 weeks’ gestation 5 months after complete detoxification. Full drug testing in both of these cases were negative, and our corrected perinatal mortality rate was only 3.3 per 1000, which is lower than the low-risk population.

Regarding fetal monitoring, every patient in this study had intense fetal monitoring with biophysical profiles, nonstress tests, and serial growth scans throughout the late second trimester and the third trimester. The 93 slow outpatient buprenorphine detoxification group had this testing performed while they were slowly detoxified. Those incarcerated and those detoxified as an inpatient did not have continuous monitoring during the acute detoxification process but did have testing before and afterward, and no abnormalities were identified. There was no increase in the incidence of meconium in our study population.

Concern about possible fetal stress and long-term outcome from in utero detoxification is an interesting question. The authors of the letter discuss theoretical concerns of fetal stress that can be assessed only by long-term follow-up studies that currently do not exist. However, they seem to choose to ignore the enormous well-documented stress and suffering that neonates experience when they are born with neonatal abstinence syndrome.

It appears that the authors of the letter believe that this stress, as well as the long-term exposure to narcotics, is unimportant to long-term outcome. However, there are studies that report a higher rate of hyperactivity and aggression and delays in cognitive functioning at preschool age in infants born of drug-addicted mothers including those on methadone. One study involving pregnancies maintained on methadone reported more developmental delays, lower IQ scores, and lower heights and weights for children treated for neonatal abstinence syndrome compared with those not treated for neonatal abstinence syndrome. Furthermore, a literature review on long-term neurodevelopmental outcomes of infants exposed to opiates concluded that there was an increased risk of neurodevelopmental problems throughout early childhood. The included studies in this report contained many treated with methadone maintenance.

However, to be fair regarding long-term childhood follow-up and illicit maternal drug exposure, it is always difficult to know how much effect is related to the in utero drug exposure vs neonatal abstinence syndrome vs the lifestyle in which these children grow up. Nevertheless, neonates with neonatal abstinence syndrome do not have normal maternal bonding, which has been shown to improve overall newborn health as well as an ultimate maternal-child relationship.

In conclusion, maintaining pregnant women on methadone or buprenorphine during pregnancy results in a large number of neonates born with neonatal abstinence syndrome, and neonatal abstinence syndrome produces enormous emotional, physical, and social distress. In addition, long-term opiate exposure probably has long-term neurodevelopmental effects on the affected children.