Stewart et al recently concluded that “opiate detoxification … can be successfully achieved in compliant parturients.” They cite as evidence the fact that 53 of the 95 women (56%) who completed inpatient detoxification neither reported relapse nor tested positive for illicit substances at the time of delivery. I have an opposite interpretation: “opiate detoxification” as described by the authors cannot be called successful as it is associated with a high rate of relapse (44%).

Data interpretation is dependent on the nature of the comparison group. By only comparing results among those “with complete data” who underwent detoxification, the authors neglect the population of women maintained on opioid-assisted therapy during pregnancy, a population with lower relapse.

Relapse is problematic because it exposes the fetus to episodic withdrawal, and because it exposes both the mother and the fetus to infectious risks. In addition, as the authors note, continued illicit opioid use is associated with “high-risk behaviors … as well as legal ramifications.” It is precisely because medically supervised withdrawal is associated with high relapse rates that ACOG recommends against the practice, a recommendation that is not mentioned in the article.

Detoxification has been repeatedly found to be unsuccessful in nonpregnant patients. It is concerning that such an approach is widely provided to pregnant women.

Clinical care should not be only evidence-based but also individually determined. There are certainly scenarios where medically supervised withdrawal is reasonable. However, the risk of relapse (and overdose) must be discussed with the patient. It is unclear from the article if this is included in counseling. The authors state that “prior to making their decision, women are noncoercively counseled about potential benefits of reducing fetal opioid exposure and about the hazards of uncontrolled maternal opioid use.” I am concerned that this describes a false dichotomy between detoxification and “uncontrolled” use, as opioid-assisted therapy is not mentioned. Although not inherently coercive, the options detailed are at least misleading and map onto a broader cultural debate which, to borrow a phrase, pits “the rights of unborn children [against] the value of pregnant women”.

Neonatal abstinence syndrome (NAS) is treatable and the treatment is without long-term evidence of harm. Avoiding NAS by prioritizing detoxification is unwise, especially when evaluated from the perspective of relapse, as detoxification is harmful to almost half of the women who received it. I am unaware of the metric by which this is measured as success.