maternal addiction treatment
TRANSCRIPT
Maternal Addiction
Treatment:Preventing Neonatal Abstinence Syndrome
LAURIE SCOTT, MD
ALBERTO AUGSTEN, PHARMD, BCPP, CPH
CLAUDIA P. VICENCIO, LCSW, LMFT
MEMORIAL HEALTHCARE SYSTEM
American Hospital Association, October 26, 2016
Objectives:
Review the history of treatment of opioid use disorder in pregnant women.
Understand the importance of addressing substance use disorders in pregnancy to prevent Neonatal Abstinence Syndrome (NAS).
Compare efficacy of available drug therapies for the treatment of opioid use disorders in pregnancy.
Present a multidisciplinary, hospital-based, and community involved program for the treatment of substance use disorders in pregnancy.
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Every 25 Minutes…
• Shrill, high pitched cry• Irritability• Hypertonicity• Tremors• Short sleep cycles• Apnea• Stuffy nose• Diarrhea• Vomiting• Sweating• Fever• Sneezing
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Opioid epidemic = NAS
epidemic
$1.5 billion in healthcare expenditures
80% paid by Medicaid
5 fold increase from 2000 - 2012
Up to 50% of total NICU annual hospital days
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A Brief History of
Treatment of Opioid Use
Disorder in Pregnancy
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Laurie Scott, MD
Medical Director of Maternal Fetal Medicine at Memorial
Healthcare System
For over 40 years…
This has been the standard of care for the
treatment of opioid use disorders in
pregnancy.
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The Heroin Epidemic of
the 1970’s: Neonatal Risks
Heroin addiction increasingly recognized as a
fetal / neonatal risk
Possible small increase in congenital
abnormalities
Fetal growth restriction
Abruption
Fetal demise
Preterm delivery and sequelae
NAS
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The Heroin Epidemic of
the 1970’s: Maternal Risks
Infectious disease (Hepatitis, HIV)
Other illnesses (endocarditis, sepsis, osteomyelitis)
Overdose
Domino effect of drug lifestyle (prostitution, criminal records, poverty, family estrangement, malnourishment)
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Methadone Maintenance
Becomes the Standard of
Care Prevent complications of illicit opioid use and withdrawal
Encourage prenatal care and drug treatment
Reduce criminal activity
Avoid association with drug culture
Recommendations against complete withdrawal
High recidivism rate
Fetal distress / demise
“NAS is an expected and treatable condition.”
“Lifestyle of continued use of [illicit Opioids] represents the greatest risk.”
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Prescription Opioid &
Heroin Use Continue to
Increase… Pregnant women: 4.4% illicit drug use in “last 30 days”
0.1% heroin, 1% non-heroin Opioids
2.6% infants screen positive for Opioids
Admissions for substance abuse
4% pregnant
Opioids 2% 1992, 28% 2012
Drug of choice: Opioids 1% 1992, 19% 2012
Overdose deaths increased 500% since 1999
Causes more deaths than MVA
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Today’s Opioid Epidemic:
Demographics
Ages 21-29
Unmarried
Non-Hispanic white
High school educated but unemployed
1/3 have a psychiatric co morbidity
75% are using multiple substances
High cocaine use
100% smoke cigarettes
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Methadone Maintenance
is Not Without Fetal Risk
Increased intrauterine growth restriction (IUGR) – 25%
Increased preterm delivery
Severe NAS and long length of stay post delivery
Emerging information re: long term ocular abnormalities
Long term safety of maintenance therapy not well studied and
uncertain
Neurobehavioral abnormalities related to polysubtance abuse
Adverse maternal impact
Increased risk for C-section
Limited and restrictive access
Social stigma and lifestyle / work challenges
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Buprenorphine Introduced
as Alternative to
Methadone (2002)
Pros and Cons compared to methadone
May be a better choice (decreased overdose risk,
decreased NAS symptoms, less intrauterine growth
retardation, preterm delivery)
Improved access
Less stigma
Increasing acceptance
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New Studies Support Full
Detoxification in Pregnancy
Pregnancy increases motivation of patient, partner and family
Decreased risk for NAS
Safe when controlled
Relapse reduced with appropriate Behavioral Health support
1998 Dashe
34 patients, 59% drug free, 12% maintenance, 29% relapse
No fetal distress, demise, intrauterine growth restriction (IUGR) or preterm delivery (PTD)
2013 Stewart
95 patients, 56% drug free at delivery
No fetal distress, demise, IUGR or PTD
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Detoxification in
Pregnancy, cont’d
2012 Lund
Detoxification and complete withdrawal decreased NAS
Safe for fetus
2014 Haabrekke
Birthweight, head circumference, gestational age at delivery,
NAS all improved with detox and withdrawal
Safe for fetus
2016 Bell
301 patients no adverse fetal outcomes from complete
withdrawal
Total 600 published cases with no report of fetal harm
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Maintenance exchanges
one form of dependency
for another.
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Pharmacological risks
associated with illicit
opioid use are still present
with maintenance
therapy.
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Medically assisted detox
and withdrawal with
strong follow-up
behavioral health therapy
appears to reduce both
pharmacological risks and
lifestyle risks from Opioid
dependency.
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Maternal Addiction
Treatment (MAT)
Program OverviewALBERTO AUGSTEN, PHARMD, BCPP, CPH &
CLAUDIA P. VICENCIO, LCSW, LMFT
MAT PROGRAM CO-DIRECTORS, MEMORIAL HEALTHCARE SYSTEM
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Case Study: Melodie
32 years old, co-occurring and untreated depression and anxiety
10 years on methadone maintenance (140mg daily) with continuous polysubstance abuse
5 births in those 10 years, all born with NAS, all
removed from her care
Chronic benzodiazepine abuse (high doses), chronic crack cocaine abuse
Partner of 10 years, relationship is abusive
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Assessing Current
Standard of Care
• No prenatal care
• No mental health treatment
• Ongoing domestic violence
Comprehensive care?
• Continued polysubstance abuse
• Partner using drugsAddiction
Treatment?
• 5 babies in 10 years of methadone maintenance, all born with NAS
What about the babies?
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Revising the Standard of
Care Through
Comprehensive Treatment
APPLYING EVIDENCE-BASED APPROACHES THROUGH COLLABORATION
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Primary Goal:
Improving Social Determinants
of Health by Reducing Rates of
NAS ~ $93,000 per infant charges for
NAS hospitalization
2x more likely to be readmitted within 30 days of birth
Children born with NAS are 4.5x more likely to be readmitted to the hospital for maltreatment and 2x more likely to be admitted for mental and behavioral disorders in childhood.
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Creating a New Standard
of Care
1. Universal screening for substance abuse in pregnancy
2. Improved opioid prescribing practices for all women of reproductive age
3. Comprehensive, team-based care
4. Targeted services and outreach for high risk populations
5. Improving access to effective substance abuse treatment
6. Coordinated treatment among all levels of care
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Pharmacology & Birth
OutcomesBuprenorphine Methadone
Mechanism of
Action
Partial μ-agonist Full μ-agonist
Cost Covered by insurance $15 per visit
Availability Certified providers SAMHSA certified
Opioid Treatment
Center
Treatment
Setting
Multiple options Limited
Associated NAS
Rates
~10% ~90%
Fetal Response Reactive nonstress test with
more fetal heart rate
accelerations, ↑ biophysical
profile score
Non-reactive nonstress
test,
↓ biophysical profile
score
Preterm Delivery ~10% ~30%
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Evidence Based Screening:
5 Ps Integrated Screening Tool
Parents: Did any of your parents have a problem with alcohol or other
drug use?
Peers: Do any of your friends have a problem with alcohol or other drug
use?
Partner: Does your partner have a problem with alcohol or other drug use?
Past: In the past, have you had difficulties in your life due to alcohol or
other drugs, including prescription medications?
Present:
In the past month, have you drunk any alcohol or used other drugs?
1. How many days per month do you drink?_______
2. How many drinks on any given day? _______
3. How often did you have 4 or more drinks per day in the last month?
Smoking: Have you smoked any cigarettes in the past three months?
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Dimensions of Treatment
1. Acute Intoxication and Management of Perinatal Withdrawal (including fetal monitoring during process)
2. Biomedical Conditions and Complications (Hep C, HIV, etc.)
3. Emotional, Behavioral or Cognitive Conditions and Complications (All patients served had co-occurring mood or thought disorder)
4. Readiness to Change (alcohol, drugs, tobacco, explore internal/external motivating factors)
5. Relapse, Continued Use or Continued Problem Potential (prenatal and post partum, psychosocial risk factors)
6. Recovery Environment (social and family support, barriers to engagement: substance-using partner, abusive environment, lack of housing/transportation, legal issues, access to prenatal care/insurance)
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A MAT Program Tracer 28
ER Admission
• Outreach
• Initial OB Work-up
• Initiate social work Involvement
Inpatient Induction
•Average 7 days
•Psychiatric stabilization
•Setting up outpatient resources & support
Outpatient Stabilization
• 14-21 days for detox
• Supportive housing
• Intensive Outpatient Program
• Dialectical Behavior Therapy
• Coordination with outpatient OB/GYN
Goal:
Collaboration &
Coordinated Care
Emergency department, inpatient & outpatient
OB, Psychiatry, Pharmacy, Nursing, Social Work, Peer Support, Administration
Residential treatment programs, OB clinics, child welfare, smoking cessation, Medicaid
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Treatment Consideration:
Intrapartum Concerns
Obstetric pain management/ anesthesia adjunct
Methadone Maintenance – risk of inducing acute Opioid withdrawal
Avoid partial agonist:
Nubain (nalbuphine)
Stadol (butorphanol)
Talwin (pentazocine)
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Postpartum Concerns
Psychological & physiological effects of reintroducing opioid
Consider injectable nonsteroidal anti-inflammatory agents (kertorolac)
Goal is Opioid-free discharge
High risk of relapse
Sober support, structure
Aftercare treatment
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MHS MAT Program Results
to DateOPTIMIZED, INTEGRATED TREATMENT FOR IMPROVED MATERNAL & FETAL OUTCOMES
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MAT Patients Served by
Substance of Choice
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Total Patients Served n=52
Opioid/ Polysubstance
n=48
Methadone n=3
Heroin n=45
Non-Opioid
n=4
Alprazolam n=1
Alpha PVP (Flakka)
n=2
Kratomn=1
MAT Patient Demographics
by Race/Ethnicity (n=52)
90%
4% 6%
White, Non-Hispanic Hispanic/ Latino
Black or African-American
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Birth Outcomes,
May 2015 to Present (n)
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3126
3 2
TOTAL BIRTHS DRUG FREE
BABIES/MOMS
BABIES BORN
EXPOSED
LOST TO
FOLLOW-UP
Drug Free Babies/MomsBabies Born
ExposedLost to Follow-up
84% 10% 6%
Maternal Post-Partum Recovery Rates (%) 36
92
7975
1 1 10
10
20
30
40
50
60
70
80
90
100
3 Months 6 Months 12 Months
MAT Program Mthadone Maintenance
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Chase: born 10/01/2015
Hurricane Matthew
Questions?Alberto Augsten, PharmD, BCPP, CPh
Zeff Ross, FACHE
Laurie Scott, MD
Tammy Tucker, PsyD
Claudia P. Vicencio, LCSW, LMFT
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References1. Association of State and Territorial Health Officials. Neonatal Abstinence Syndrome: How States
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3. Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction. 2008;103(9):1429-1440. doi:10.1111/j.1360-0443.2008.02283.x.
4. Jones HE, Martin PR, Heil SH, et al. Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues. doi:10.1016/j.jsat.2007.10.007.
5. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. doi:10.1056/NEJMoa1005359.
6. Kakko J, Heilig M, Sarman I. Buprenorphine and methadone treatment of Opioid dependence during pregnancy: Comparison of fetal growth and neonatal outcomes in two consecutive case series. Drug Alcohol Depend. 2008;96(1-2):69-78. doi:10.1016/j.drugalcdep.2008.01.025.
7. Salisbury AL, Coyle MG, O’Grady KE, et al. Fetal assessment before and after dosing with buprenorphine or methadone. Addiction. 2012;107(SUPPL.1):36-44. doi:10.1111/j.1360-0443.2012.04037.x.
8. Patrick SW, Burke JF, Biel TJ, Auger KA, Goyal NK, Cooper WO. Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome. Hosp Pediatr. 2015;5(10):513-519. http://hosppeds.aappublications.org/content/5/10/513.abstract.
9. Uebel H, Wright IM, Burns L, et al. Reasons for Rehospitalization in Children Who Had Neonatal Abstinence Syndrome. Pediatrics. 2015;136(4):2014-2767. doi:10.1542/peds.2014-2767
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