Plenary Session:Screening, Assessing and Treatment Pregnant Women with Substance Use Disorders

Wednesday, July 10, 2019

9:45 am – 11:00 am

Dr. Mishka Terplan, M.D., Professor, Obstetrics and Gynecology And Psychiatry, Associate Director Of Addiction Medicine, Virginia Commonwealth University

Screening, Assessing, and Treating Pregnant Women with Substance Use Disorder

Mishka Terplan MD MPH FACOG DFASAMProfessor Departments OBGYN and Psychiatry

Virginia Commonwealth University

Drug Use is Common

Substance Lifetime UseN

Lifetime Use%

IllicitCannabis

131 mil119 mil

49%44%

Tobacco 169 mil 63%

Alcohol 216 mil 80%

Lifetime Drug Use US

4

20.1 million people in US (7.5%) with SUDNSDUH 2016 (aged 12 and older)

Not everyone who uses drugs becomes addicted

What is the risk of opioid addiction among individuals prescribed opioids for pain?

Rates of misuse 12-29% (95%CI:13-38%)Rates of addiction averaged between 8-12% (95% CI: 3-17%)

Addiction is not only harm of substance use

What happens when women who use drugs become pregnant?

0

10

20

30

40

50

60

Alcohol Cigarettes Illicit

What happens when women who use drugs get pregnant?

Not Pregnant First Trimester Second Trimester Third Trimester

National Survey Drug Use and Health 2017 Past Month Use Data, women ages 12-44

Those who can’t quit or cut back –likely have a substance use disorder

All pregnant women are motivated to maximize their health and that of their baby-to-be

Continued use in pregnancy is pathognomonic for addiction

Addiction: A Brain-Centered Disease Whose Symptoms are Behaviors

Salient Feature: Continued use in spite of adverse consequences

The Pregnancy Box

Outline

• Assessment (screening and testing)

• Treatment

• The 4th Trimester

• Stigma and Discrimination

SAMHSA’s Clinical Guide

https://store.samhsa.gov/product/SMA18-5054

The Clinical Guide consists of 16 factsheets that are organized into 3 sections: Prenatal Care (Factsheets #1–8); Infant Care (Factsheets #9–13); and Maternal Postnatal Care (Factsheets #14–16).

1) Assessment: Universal

• Ask permission– “Is it OK if I ask you some questions about smoking, alcohol and other

drugs?”– Patients are usually not offended by questions about substance use if

asked in caring and nonjudgmental manner

• Consider (Validated) Instrument (ACOG recommended)– Alcohol: T-ACE (Sokol 1989); TWEAK (Chang 1999)– Alcohol and other drugs: DAST and MAST (Kemper 1993); 4P’s Plus

(Chasnoff 1999); CRAFFT (Chang 2011) for pregnant adolescents

• Selective screening based on “risk factors” perpetuates discrimination and misses women with addiction

Urine Drug Testing

Screening:Elisa (Point of Care)

Definitive:Gas Chromatography / Mas Spec

Point of Care Urine Drug Testing

Definitive Testing

https://www.asam.org/resources/guidelines-and-consensus-documents/drug-testing

Limits of Urine Testing

http://www.ezkeycup.com/iCup-Drug-Screen-8-p/i-dud-187-013.htm

• It is not a parenting test

• Toxicology tests for

drugs are not sufficient

for a diagnosis of a

substance use disorder

• Having a substance

use disorder is only

one of many other

factors in determining

child safety

• Urine toxicology

screening and

confirmatory testing

• Patient consent

required before

specimen collection

Toxicology screens are not a substitute for verbal, interactive questioning and screening of

patients about their drug and alcohol use.

Number of tests increased 4537% from 2000-2009

2011 – 2014: spending on urine tests increased from c $2 to $8.5 billion/year31 Pain Medicine Practices in US received >80% of total income from urine testing

Comprehensive Pain Specialists (54 clinics: largest pain treatment practice in Southeast)2014: Medicare paid CPS at least $11 million for urine tests2015: Medical Director billed $1.8 million

2) Treatment

Individuals with the Condition of Addiction Need Treatment

Prenatal Care

Medication

Behavioral Counseling

“Gold Standard” is Integration: Comprehensive co-located service delivery

1976

1974

No Addiction Treated Addiction Untreated Addiction

Preterm Birth 8.7% 10.1% 19.0%

Low Birthweight 5.5% 7.8% 18.0

Fetal Death 0.4% 0.5% 0.8%

Neonatal Mortality 0.4% 0.4% 1.2%

Post Neonatal Mortality

0.05% 0.03% 0.1%

Treated vs Untreated Addiction

How effective is treatment?

0

20

40

60

80

100

Pati

en

ts W

ho

Rela

pse,

%

Similar Relapse (or Noncompliance) Rates

for Drug Dependence Versus Other Chronic Diseases

Drug Addiction1,2Type 1 Diabetes3 Hypertension4 Asthma5

Graph adapted from Caron Foundation. http://www.caron.org/pdfs/RelapseRecovery-2003.pdf., 2. Hoffman NG, Miller NS. Psychiatr Ann.1992;22(8):402-408. 3. Graber AL et al. Diabetes Care. 1992;15(11):1477-1483., 4. Clark LT. Am Heart J. 1991;121(2 pt 2):644-669., 5Dekker FW et al. Eur Respir J. 1993;6(6):886-890.

Medications for SUD

Substance Use Disorder Medication

FDA Approved Research Supported

Opioid Use Disorder MethadoneBuprenorphine (+/-naloxone)Naltrexone

Alcohol Use Disorder AcamprosateNaltrexoneDisulfuram

Gabapentin

Nicotine Use Disorder Nicotine Replacement TherapyWellbutrinChantix

Addiction: From Reward Seeking to Relief Seeking

OUD Treatment: Pharmacotherapy

Maternal

• 70% reduction in overdose related deaths

• Decrease in risk of HIV, HBV, HCV acquisition/transmission

• Increased engagement in prenatal care and recovery treatment

• Treatment is platform for delivery of other services

Fetal

• Reduces fluctuations in maternal opioid levels; reducing fetal stress

• Decrease in intrauterine fetal demise

• Decrease in intrauterine growth restriction

• Decrease in preterm delivery

Goal of Pharmacotherapy

• Mu Opioid Receptor Action:

– Decrease or eliminate cravings

– Control physiological withdrawal

– Prevent euphoria from use of other mu agonists

Goal of Pharmacotherapy

• Mu Opioid Receptor Action:

– Decrease or eliminate cravings

– Control physiological withdrawal

– Prevent euphoria from use of other mu agonists

• Stability – platform for recovery

• Improved engagement in behavioral care

• Decrease HIV/HCV

• Psychosocial improvement (employment etc)

• Decrease in overdose

SAMHSA Clinical Guide Recommendations

• Medically supervised withdrawal is not recommended during pregnancy

• Buprenorphine and methadone are the safest medications for managing OUD during pregnancy

• Transitioning from methadone to buprenorphine or from buprenorphine to methadone during pregnancy is not recommended

Methadone and Buprenorphine: Advantages

Methadone Buprenorphine

Advantages

Reduces/eliminates cravings for opioid drugs

Prevents onset of withdrawal for 24 hours

Blocks the effects of other opioids

Promotes increased physical and emotional health

Higher treatment retention than other treatments

Lower risk of overdose

Fewer drug interactions

Office-based treatment delivery

Shorter NAS course

Pharmacotherapy

• Pharmacotherapy supported by:– CDC– WHO– SAMHSA– BOP– NCCHC– ACOG– ASAM– AAP– AAFP– Federal Guidelines for Opioid

Treatment 2015(partial list)

• Pharmacotherapy not supported by:

SAMHSA’s Guidance: Medically Supervised Withdrawal is Not Recommended

• Pharmacotherapy is the recommended standard of care • Pharmacotherapy helps pregnant women with OUD avoid a return

to substance use, which has the potential for overdose or death

• A decision to withdraw from pharmacotherapy should be made with great care on a case-by-case basis.

• A pregnant woman receiving treatment for OUD may decide to move forward with medically supervised withdrawal if– It can be conducted in a controlled setting– The benefits to her outweigh the risks

Pregnant patients should be advised that withdrawal during pregnancy increases the risk of relapse without fetal or maternal benefit

Detoxification:

No increased risk of fetal demise

No difference in NAS

Recurrence more common among those who receive detoxification

Detoxification: Acute Intervention for a Chronic Condition:Clinical Mismatch

The Pregnancy Box

3) The 4th Trimester - Postpartum

• Critical Period– Newborn care, breastfeeding, maternal/infant bonding– Mood changes, sleep disturbances, physiologic changes– Cultural norms, “the ideal mother” in conflict with what it is actually like to

have a newborn– Insurance and welfare realignment

• Neglected Period– Care shifts from frequent to infrequent– From Mom-focused (PNC provider) to Baby-focused (Pediatrician)– From “medical” to “social” (WIC)– Continuity of Care: Addiction Provider

The 4th Trimester: Contraception

https://www.colorado.gov/pacific/sites/default/files/PSD_TitleX3_CFPI-Report.pdf

Colorado LARC Experiment

Maternal mortality in the past and its relevance to developing countries today

Am J Clin Nutr. 2000;72(1):241S-246S. doi:10.1093/ajcn/72.1.241S

The 4th Trimester:Maternal Mortality

Opioid Crisis: Hepatitis C

4) It’s more than opioids

Our response to the opioid crisis must not be opioid-exclusive

FETAL ALCOHOL SPECTRUM DISORDERS (FASDS)

AS IDENTIFIED BY

THE NATIONAL ORGANIZATION ON FETAL ALCOHOL SYNDROME (NOFAS)

“……..an umbrella term describing the range of effects that can occur in an individual who is exposed to alcohol during the nine month prenatal period before birth. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis.”

Diagnostic terms under the FASDs umbrella include:

▪ Fetal Alcohol Syndrome (FAS)

▪ Partial Fetal Alcohol Syndrome (pFAS)

▪ Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)

▪ Alcohol Related Neurodevelopmental Disorder (ARND)

▪ Alcohol Related Birth Defects (ARBD)

https://www.nofas.org/about-fasd/

Opioid Use During Pregnancy Alcohol Use During Pregnancy

Prevalence of use 1.6%-8.5% of pregnant women

use opioids; however, it’s on the

rise1

Approximately 8.5% of pregnant women

drink alcohol at some point during

pregnancy1

Likelihood of

developing

NAS is seen in 30-80% of infants

born to women who used

opioids in the third trimester2

2-5% of school age children may have FASDs3

Negative

effects/Disabilities

Neonatal Abstinence Syndrome

(NAS) 4

Fetal Alcohol Spectrum Disorders (FASDs)1

Duration of effects Unknown4 FASDs last a lifetime 5

COMPARING AND CONTRASTING ALCOHOL USE AND OPIOID USE

DURING PREGNANCY

Comparing and Contrasting Alcohol use and Opioid use During

Pregnancy (Continued)

Opioid Use During Pregnancy Alcohol Use During Pregnancy

Cost of Care Average of $90,000 per case of NAS6 Estimate $1.2-2.5 million per case of

FAS7

Screening and Brief

Intervention

Universal screening using the 5 P’s

tool, and brief intervention8

Universal screening using the AUDIT (US)

tool, and brief intervention9

Ethics Avoid separation of mother and

child10

Avoid separation of mother and child 10

Treatment Medication-assisted therapy (MAT)2 Appropriate treatment referral for

alcohol use disorder **See treatment resource directories on ACOG website: https://www.acog.org/About-ACOG/ACOG-Departments/Tobacco--Alcohol--and-Substance-Abuse/Fetal-Alcohol-Spectrum-Disorders-Prevention-Program/Provider-Resources/FASD-Resource-Directory

Conclusion

• Assessment for Substance Use should be universal in PNC

• Urine Drug Testing: poor test characteristics, poorly interpreted, lead to patient discharge from practice (in pain clinics)

• Treatment Works – women with treated SUD have birth outcomes similar to general population

• Need to continue attention past delivery: the 4th Trimester

• Public Health demands a broad response to opioid crisis

Thank You

• Mishka Terplan

• @do_less_harm

• Mishka.Terplan@vcuhealth.org