ob addiction lecture addiction medicine (1)

ADDICTION AND PREGNANCY

KRISTI DIVELY, D.O., FACOOG

OBJECTIVES

• Understand treatment of opiate addiction in pregnancy

• Understand treatment of benzodiazepine addiction in pregnancy

• Understand treatment of alcohol addiction in pregnancy

• Understand treatment of nicotine addiction in pregnancy

• Review consequences of substance abuse in pregnancy

TRENDS IN SUBSTANCE ABUSE

2013 5.4% of pregnant women were illicit drug users (not including nicotine)

15.9% of pregnant women smoke

8.5% of pregnant women report current alcohol use

0.3% report ‘heavy’ use

•Prevalence in public clinic = private practice

•Caucasian > African American > Hispanic

WHY SHOULD WE SCREEN?SCREENING

MATERNAL COMPLICATIONS

• Bacteremia, endocarditis (IV drug use)

• Sexually transmitted infections (HIV, Hepatitis C)

• Increase in spontaneous abortion

• Placental insufficiency/abruption

• Postpartum hemorrhage

• Pre-eclampsia/Eclampsia

• Preterm labor

• Premature rupture of membranes

FETAL COMPLICATIONS

• Intrauterine growth restriction

• Congenital defects (teratogenic effects)

• Intellectual disability

• Low birth weight

• Neonatal Abstinence Syndrome

WHY SHOULD WE SCREEN?SCREENING

Substance use disorders are treatable

ETHICAL DUTY TO SCREEN PREGNANT WOMEN FOR SUBSTANCE USE

• American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 422 addresses the ethical rationale for universal screening for at-risk drinking and illicit drug use

• American Medical Association (AMA) also endorses universal screening

Blum LN, Nielson NH, Riggs, JA. Alcoholism and alcohol abuse among women: report of the Counsel on Scientific Affairs. American Medical Association. J Womens Health 1998;7:861-871

WHY SCREEN?

• TREATMENT WORKS – 70-80% of pregnant women can have ‘favorable UDS’ at delivery

• Early intervention can reduce many of the adverse effects of tobacco and cocaine

• Treatment in pregnancy enhances long term recovery – up to 65% are abstinent at 1 year

• Brief physician advice has been shown to be as effective as conventional treatment for substance abuse

HOW DO WE SCREEN?

• Every pregnant patient should be asked about substance use

At the first prenatal visit

At least once per trimester

ACOG Committee Opinion No. 422, December 2008

START WITH THE TWO – ITEM SCREEN

• In the last year have you ever smoked cigarettes, drank alcohol or used any drugs more than you meant to?

• Have you felt you wanted or needed to cut down on your smoking or drinking or drug use in the last year

Two No Answers

• If patient states she does not use alcohol, tobacco or drugs, she is at low risk for substance use

• Proceed to 4Ps plus

NEXT STEPS

FOUR P’S (PLUS) SCREENING

• Did any of your PARENTS have a problem with alcohol or drugs?

• Do any of your PEERS have a problem with alcohol or drugs?

• Does your PARTNER have a problem with alcohol or drugs?

• Have you had a PROBLEM with alcohol or drugs in the past?

• (Plus) Have you smoked any cigarettes, used any alcohol or any drug in this PREGNANCY?

Morse B, Gehshan S, Hutchins E. Screening for substance abuse during pregnancy: improving care, improving health. Washington, DC: National Center for Education in Maternal and Child Health; 1977.

NEGATIVE ANSWERS TWO ITEM SCREEN AND 4P’S PLUS

• This is typical of 85% of your patients. You have accomplished universal screening in about 90 seconds

• These women are low risk for addiction and should receive routine prenatal care for the remainder of the pregnancy

• BUT, ask about alcohol, tobacco and drug use each trimester

ANY POSITIVE ANSWER

• ANY yes answer on Two-Item Screen or 4P’s Plus

• Patient at risk for substance use

• Urine Drug Test is indicated

• Brief intervention is indicated

• Assess for psychiatric co-morbidity

• Re-evaluate in 2 weeks, if no change in behavior, refer for treatment

TREATMENT BARRIERS• Fear, shame and guilt about use

Will she lose other children if in treatment?

Does she have family support?

Attitudes of medical providers

• Lack of comprehensive clinical care services for all the problems of pregnancy AND addiction

Can she get to treatment? Transportation problems?

Lack of childcare while in treatment

Basic needs must be met for her to engage in treatment

• Co-morbid diagnosis impacting ability to access services

Difficulty addressing many issues simultaneously

Depression, anxiety, personality disorder

Immaturity/lack of coping skills

TREATMENT BARRIERS

• Pregnant women may avoid prenatal care due to drug use

Shame, guilt, fear of involvement of child protective services

• Lack of prenatal care leads to a myriad of other complications

• Lifestyle associated with addiction also impacts pregnancy

Poor nutrition, intimate partner violence, prostitution, theft/criminal activities

MEDICATIONS IN PREGNANCY

• Bentyl

• Catapres

• Claritin

• Colace

• Flexeril

• Guaifenesin

• Imodium

• Maalox

• Melatonin

• Milk of Magnesia

• Mucinex

• Prental Vitamins

• Pepto-Bismol

• Phenergan

• Senna

• Trazdone

• Tums

• Tylenol

COMMONLY USED MEDICATIONS (SAFE)

• Seroquel

• Elavil

• Amoxicillin

• Macrodantin

• Zofran

• Reglan

• Zithromax

• Some SSRIs – Lexapro, Celexa, Prozac, Zoloft

• SNRIs – Cymbalta, Effexor

• Wellbutrin

• Buspar

• Vistaril is OK after 12 weeks

MEDICATIONS TO AVOID

• Most antibiotics ending in –mycin (except azithromycin)

• Neurontin

• Ibuprofen

• Abilify

• Sinequan

• Elavil (3rd trimester)

• Diflucan

OPIATE SUBSTANCE USE DISORDER

• Risks to Mother

Postpartum hemorrhage

Pre-eclampsia/Eclampisa

Septic thrombophlebitis

• Risks to Fetus

Spontaneous abortion

Amnionitis

Intrauterine Growth Restriction

Placental insufficiency

Preterm labor/delivery

Premature rupture of membranes

OPIATE SUBSTANCE USE DISORDER

• Narcan should ONLY be used as a last resort in pregnant patients

Spontaneous abortion

Preterm labor

Intrauterine fetal demise

TREATMENT OF OPIOID USE DISORDER

• ACOG Committee Opinion 524 – standard of care is methadone maintenance

• Buprenorphine is an effective option

• Withdrawal from opiates while pregnant is NOT recommended

Risk of preterm labor, fetal distress, intrauterine fetal demise

Significant risk of relapse (41%-96%)

• Medication alone is not enough – also needs therapy and psychiatric care

Medication Assisted Treatment

PREGNANCY OUTCOMES

• Methadone Maintenance Therapy (MMT) is regarded as an established treatment with birth outcomes comparable to a general obstetrical population (Kreek MJ, 2000)

Fewer Preterm Births

Less Intrauterine Growth Restriction

Fewer Low Birth Weight Babies

• Less Maternal Drug Use

Greater reduction in drug use with higher dose of methadone

• Improved Prenatal Care Compliance (Burns L, 2004; Goler NC, 2008)

• There appears “to be no differential effect of either treatment (methadone or buprenorphine) – it was exposure to stable treatment that was important” (Gibson, 2008)

• MMT in pregnancy is supported by over 50 years of research

INTERDISCIPLINARY CARE

• Crucial in treatment of addiction in pregnancy

• Comprehensive MMT with adequate prenatal care can reduce the incidence of obstetrical and fetal complications, intrauterine growth restriction, and neonatal morbidity and mortality (Finnegan, 1991)

MEDICATION OPTIONSMedication Primary Use Formulation Treatment Setting Administration

Methadone • Agonist:Suppresses cravings and withdrawals

• Detoxification• Maintenance

• Liquid• Tablet/Diskette• Powder

SAMHSA Certified Opioid Treatment Program (OTP)

• Daily at OTP• Some individuals may qualify for take-home

prescriptions lasting up to 30 days

Buprenorphine (Subutex) • Partial Agonist: Suppressescravings and withdrawals partial stimulation of brain receptors

• Detoxification• Maintenance

• Tablet• Film (Suboxone)

• Physician or psychiatrist granted a DEA waiver

• Some SAMSHACertified OTP’s

• Daily• Individuals can be prescribed a supply to be

taken outside of the treatment setting

METHADONE OR BUPRENORPHINE?

• Patients on maintenance therapy who become pregnant should be maintained on current agent

• Buprenorphine should be initiated when:

Patient cannot tolerate methadone

Methadone program is not accessible

Patient is adamant about avoiding methadone

Patient is capable of informed consent

DOSING IN PREGNANCY

• Dosages of methadone or buprenorphine may need to increase over the course of pregnancy

Metabolic changes

Increased fluid volume

WHAT IS THE RIGHT DOSE IN PREGNANCY?THE DOSE THAT STOPS WITHDRAWAL!

• Increased blood volume

• Larger tissue reservoir

• Methadone loss to amniotic fluid

• Altered maternal metabolism

• Metabolic activity of placenta

• Metabolic activity of fetus

• Patient may require progressive increases throughout pregnancy

• Split dosing is an option to maintain adequate blood levels with fewer increases

• Counseling is essential to address cravings, stress, anxiety

METHADONE INDUCTION

• Opioid intolerant patient – Day 1 10-15 mg maximum

• Opioid tolerance unknown – Day 1 15 mg maximum

• Opioid tolerant – Day 1 25-40 mg maximum

METHADONE INDUCTION

• Start low, go slow

• 5 days until steady state obtained

• Peak 2-3 hours after dosing

• See patients frequently to monitor for oversedation

• Consider dosing in the office and observing the patient for 3 hours

METHADONE INDUCTION

• Some patients over report their opioid use due to fear of not getting enough methadone to prevent withdrawal

• Pregnant women often have decreased tolerance because they have been trying to stop using on their own

METHADONE DOSING/INDUCTION IN THE HOSPITAL

• If methadone maintenance patient is admitted to the hospital, best to continue dosing the way they were dosed at clinic (daily vs. split)

• If you divide the dose, they may have mild withdrawal symptoms for a few days until they reach steady state

• When transitioning from daily dosing to split dosing, you need to give 25-50% more the first day of split dosing

SPLIT DOSE INDUCTION

• Consider split dose in patients who are feeling OK throughout the day but experiencing withdrawal symptoms by bedtime and worse by morning

• Day 1 – 100% of current dose, observed

50 % of dose to take in 12 hours

• Day 2 and beyond – 50% of dose Q12 hours

• Poor results seen from starting with half the usual dose on day 1

BUPRENORPHINE TREATMENT

• Not FDA approved for use in pregnancy

Widely used in Europe

• Recommend buprenorphine monotherapy only (Subutex)

• Improved pregnancy outcomes seen with methadone appear to be duplicated with buprenorphine

• MOTHER Study – less severe NAS, shorter hospital stays for newborns of mothers on buprenorphine

BUPRENORPHINE DOSING• Goal is to find the lowest dose at which patient is not using other opiates, not

experiencing any withdrawal symptoms, minimal or no side effects, and no uncontrollable cravings for drugs of abuse

• Patients must have discontinued the use of opiates and be in the early stages of withdrawal before initiating buprenorphine

• Start with 4 mg buprenorphine, repeat dose in 2-4 hours if indicated. Repeat as needed until patient is comfortable and not exhibiting symptoms of withdrawal (maximum dose 32 mg daily)

• Dosing may be split twice daily or three times daily as needed to minimize withdrawal symptoms

Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.

BREASTFEEDING AND MEDICATION ASSISTED TREATMENT

• ACOG Committee Opinion 524 and 658

• Breastfeeding may reduce Neonatal Abstinence Syndrome symptoms

• Breastfeeding promotes mother-child bonding

• Minimal levels of methadone and buprenorphine are passed into breastmilk

• Contraindicated in women with HIV and current users of illicit substances

WHAT HAPPENS WHEN PATIENT HAS ACUTE PAIN?LABOR AND DELIVERY, SURGERY

ACUTE PAIN MANAGEMENT FOR PATIENTS ON METHADONE

• Ensure maintenance therapy is continued

• Maintenance WILL NOT treat acute pain

• Stadol will cause acute and severe immediate withdrawal of the methadone maintained mother and fetus – Stat Cesarean section!

POST-OPERATIVE PAIN IN METHADONE PATIENTS

• Give the confirmed maintenance dose of methadone

• Give appropriate analgesic for the surgery, may need to increase dose 15% or

more due to high tolerance

ACUTE PAIN MANAGEMENT FOR PATIENTS ON BUPRENORPHINE

• Buprenorphine – highly avid binding to receptor

• May block or reverse mu opioid analgesia

• Best practices continue to evolve

• Options

• Non-opioid therapies

• Continue maintenance dose of buprenorphine and add avidly binding opioid such as hydromorphone or fentanyl

• Continue buprenorphine in divided 6-8 hour doses and titrate

Gourlay and Heit, 2008; Kornfeld & Manfredi, 2009

EMERGENCY SURGERY/CESAREAN SECTION

• If patient on buprenorphine, there may be some opiate receptor blockade due to high affinity for mu receptor (not from naloxone)

• Regional anesthesia helpful (if possible)

• Fentanyl and hydromorphone can override buprenorphine

• Will need higher dose

RELAPSE PREVENTION PLANPATIENTS REQUIRING POST OPERATIVE PAIN CONTROL WITH OPIATES

• Patient does not touch paper prescription

• Caregiver handles and fills the prescription and administers medication as ordered to the patient

• The patient does not touch pills or bottle

• Patient does not count the pills

• After 24 hours of not requiring opiate pain medications, caregiver disposes of left over medication

• OB and addiction physician work together

POSTPARTUM DOSING OF METHADONE OR BUPRENORPHINE

• May need to decrease dose due to fluid shifts in postpartum period

• See patient immediately upon discharge from the hospital before giving ‘take home’ doses of medication or prescription

• Buprenorphine dose may need to be decreased if it was increased during the third trimester

SEDATIVE/HYPNOTIC SUBSTANCE USE DISORDER

• Risks to Mother

Seizures from abrupt withdrawal

Respiratory depression in overdose

• Risks to Fetus

Congenital defects

Neonatal Abstinence Syndrome

Fetal death/spontaneous abortion if abrupt withdrawal

TREATMENT OF SEDATIVE/HYPNOTIC USE DISORDER

• Slow taper, ideally in the second trimester

• Taper 5-10% /day

• Use the same benzodiazepine they have been abusing for the taper if possible

• Barbituates should be avoided due to risk of congenital defects

• Always in conjunction with interdisciplinary care!

ALCOHOL USE DISORDER

• Risks to Mother

Injury while intoxicated

Delirium Tremens in withdrawal

Nutritional deficiencies

Deficient milk ejection

Precipitous labor

Ataxia

Respiratory depression

• Risks to Fetus

Fetal Alcohol Spectrum Disorder

FETAL ALCOHOL SPECTRUM DISORDER

• Direct Effect of alcohol on developing fetus

• Alcohol affects the fetal brain throughout entire pregnancy

• Binge drinking (5 or more drinks on one occasion) is especially detrimental to the fetus

• Leading known cause of preventable intellectual disability

Two times more common than Down Syndrome

• Alcohol related birth defect (ARBD) and alcohol related neurodevelopmental disorder (ARND)

EFFECTS OF ALCOHOL ON FETUS

• Spontaneous abortion

• Intellectual disability

• Low birth weight

• Cardiac abnormalities

• Skeletal abnormalities

• Ocular problems

• Hemangiomas

FETAL ALCOHOL SYNDROME

• Pre and post natal growth restriction

• CNS deficits

• Facial feature anomalies

Short palpebral fissures

Elongated midface

Thin upper lip

Flattened maxilla

FETAL ALCOHOL SPECTRUM DISORDER (FASD)

• Children are frequently misdiagnosed as having a psychiatric disorder

• Children with FASD:

May not complete tasks

Cannot recall information

May not take in the information

May hit others

Can misinterpret intentions

May take unnecessary risks

Do not perceive danger

TREATMENT OF ALCOHOL USE DISORDER

• Taper using short acting benzodiazepines

• Barbituates should be avoided due to risk of congenital defects

• Always in conjunction with interdisciplinary care!

NICOTINE USE DISORDER

• Risks to Mother

Lung disease

Multiple types of cancer

Coronary artery disease

Stroke

• Risks to Fetus

Spontaneous abortion

Placental abruption

Placenta previa

Low birth weight

Congenital Defects

Preterm delivery

Uterine bleeding

SIDS

NICOTINE USE DISORDER

• Effects are lifelong in children

ADHD

Asthma and respiratory disorders

Middle ear infections

Increased risk for diabetes

Increased risk for obesity

TREATMENT OF NICOTINE USE DISORDER

• Gradual cessation is best

• If pregnant woman is unable to stop with behavioral interventions, nicotine replacement products can be used

• Limited studies on use of buproprion

STIMULANT USE DISORDER

• Cocaine

• Methamphetamine

STIMULANT USE DISORDER

• Effects on Mother

Seizures

Hypertension/hypertensive crisis

Cardiac events and maternal death

Stroke

• Effects on Fetus

Placental abruption

Premature labor

Spontaneous abortion

Premature rupture of membranes

Congenital defects (meth)

Attention impairments in child

Low birth weight

SIDS

TREATMENT OF STIMULANT USE DISORDER

• No detoxification protocol

• Can use short term benzodiazepines and antidepressants for symptom treatment

• Consider monitoring fetus if patient beyond 24 weeks gestation

• Interdisciplinary care

CANNABINOID USE DISORDER

• Risks to Mother

Panic attacks

Short-term memory impairment, amnesia

• Risks to Fetus

Intrauterine growth restriction

Abnormal startle reflexes in newborns

Reduced memory and verbal skills at age 4 but does not appear to decrease intelligence

CANNABINOID USE DISORDER

• May affect fetal brain development and child behavior

• Treatment the same as non-pregnant patient

• Supportive care and interdisciplinary care

NEONATAL ABSTINENCE SYNDROME

• Neonate suffering withdrawal symptoms

• Primarily seen in opioid use, but also seen with benzodiazepines, alcohol, barbituates, antidepressants (SSRIs) and nicotine

• Onset of symptoms depends on substance

• Myriad of symptoms

NEONATAL ABSTINENCE SYNDROME

• CNS Effects

Irritability

Hypertonia (increased muscle tone)

Hyperreflexia

Seizures (1-3%)

• GI Effects

Diarrhea

Vomiting

Abnormal sucking/poor feeding

Poor weight gain

NEONATAL ABSTINENCE SYNDROME

• Respiratory Effects

Tachypnea

Respiratory Alkalosis

• Autonomic Effects

Sneezing

Lacrimation

Yawning

Sweating

Hyperpyrexia

High pitched cry

NEONATAL ABSTINENCE SYNDROME

• Delayed effects may be seen for 4-6 months

SIDS

TREATMENT OF NEONATAL ABSTINENCE SYNDROME

• Primarily symptomatic

• Decrease environmental stimuli

• Soothing behaviors

• When supportive measures fail, medications can be used

CHILDREN AND YOUTH SERVICES

• Lancaster County PA Children and Youth Services have stated that they cannot open a case on a child that has not been born yet

• Therefore, mandatory reporting of drug use in pregnant patient is not necessary

• If you fear another child in the home is at risk due to maternal drug use, then consideration should be given to reporting use

• Mothers in treatment will be looked upon more favorably than mothers continuing to abuse substances

CHILDREN AND YOUTH SERVICES

• 13 states have legislation to terminate parental rights due to maternal drug use

Florida, Illinois, Indiana, Ohio, Maryland, Minnesota, Nevada, Rhode Island, South Carolina, South Dakota, Texas, Virginia and Wisconsin

• 8 states require reporting of drug testing

Arizona, Illinois, Iowa, Massachusetts, Michigan, Minnesota, Utah and Virginia

REFERENCES

• Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.

• https://www.oasas.ny.gov/AdMed/documents/treatmentpreg.pdf

CONTACT INFORMATION

• Kristi Dively, D.O.

• Retreat at Lancaster County

• 717-859-8000 x1127

• Email: kristid@retreatmail.com