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Welcome to the March 8, 2016 Webinette!
Information on how to obtain your no-cost .5 NAADAC contact hour provided at conclusion of this live webinette.
www.attcppwtools.org
ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Familieswww.attcppwtools.org
ATTC Regional Center Partners:Great Lakes ATTCMid-America ATTCNew England ATTCSoutheast ATTC
Purpose: The Center was established to develop a family-centered national curricula, web-based toolkit, and provide support for national training and resource dissemination.
Addressing the Peril of Illicit Drug Use for Pregnancy: Medication Assisted Treatment & Integrated Care
Trudee Ettlinger, PhD, APRN, LADC, CCSMaple Leaf Treatment Center
10 Maple Leaf Road
Underhill, VT 05489
802-858-7209 │[email protected]
CoE PPW Webinette 2March 8, 2016
Webinette Overview
• Affects an estimated 5 million Americans
• Health problem does not spare childbearing age women
• An estimated 225,000 babies are born each year with prenatal drug exposure
• Opioid addiction is a chronic, relapsing disease
• Considerations in opiate replacement therapy in correctional settings
Opiate Use and Pregnant Women
Opiate Use and Pregnant Women
• Prevalence ranges 1-2% with some estimates as
high as 21%
Maternal Morbidity
• 6 times more risk for obstetric complications
• Low birth weight (LBW)
• 3rd trimester bleeding
• Fetal distress
• Malpresentation of fetus
Opiate Use and Pregnant Women
Neonatal Conditions
• Neonatal abstinence syndrome (NAS)
• Postnatal growth lags
• Increased risk for Sudden Infant Death Syndrome
(SIDS)
Medication Assisted Treatment
Medication Assisted Treatment
• Opioid Use Disorder causes both neurochemical and
structural brain changes affecting opioid receptors
• Methadone (a full agonist drug) and buprenorphine
(partial opioid agonist drug) are effective in
decreasing opiate drug craving
• Both allow for improved recovery success & prevent
opioid withdrawal
Medication Assisted Maintenance Treatment Options
• Drug Addiction Treatment Act 2000
• Opiate Treatment Programs (OTP)
– Restrictive, daily dosing, earned take-home medication privileges for those free of illicit drugs; serves high risk population
• Office-based Opiate Treatment (OBOT)
– Patient meets stability criteria, prescribed buprenorphine; patient contracts with medical practice
Reduce illicit drug use exposure for fetus
Engage mother in SUD Treatment
Prevent opioid withdrawal and its physiologic cascade
In correctional setting, MAT is an opportunity for improved public health and safety
Goals for Pregnancy & MAT
Methadone Treatment
• Medication of choice for pregnancy (more data
reporting neo-natal outcomes)
• Access barriers (i.e., clinic locations, clinic times)
• Capacity of mother to comply with OBOT clinic
requirements & needing OTP care level structure
Buprenorphine Treatment Considerations
• Formulation Subutex (No Naloxone-buprenorphine monotherapy)
• Stable on buprenorphine prior to pregnancy
• Clinical presentation supports stability for OBOT level of care
• In correctional OTP programs, diversion is sometimes a concern
MAT: Labor and Delivery
• Continue with scheduled methadone or Subutex for labor and delivery and postpartum
• Spinal and epidural analgesia is provided for pain control
• Pain managed with nonsteroidal anti-inflammatory drugs (NSAID’s) and short acting opioids (e.g., codeine, morphine, Percocet, Vicodin)
• Women requiring a Cesarean Section (C-Section) may need decreasing doses of short acting opioids for several days
Neo-Natal Abstinence Syndrome
Buprenorphine Vs. Methadone
Buprenorphine exposed infants require less withdrawal
management treatment (morphine/methadone) and have
a shorter stay in the hospital than methadone-maintained
mothers
Postpartum Care
Breast Feeding
• Low bioavailability with methadone
and buprenorphine
• Breast feeding encouraged
• In correctional settings, diversion has been a concern
Medication Assisted Treatment & Early Postpartum Months
• Maintain on medications
• Watch for relapse 3-6 months after birth
• Discuss contraception: Long Acting Reversible Contraception
– LARC (IUD or hormonal implant); risk potential for rapid
repeat pregnancy
• No evidence of medication interactions between
contraceptives, methadone, or buprenorphine
Justice system involved
Unsuccessful work history
Unsafe housing
Multiple hardships
Risky Life Profile
Generational familial drug use
High exposure to violence
Limited education
Psychiatric co-occurring disorders
Wrap AroundCare
Interrelated Elements include . . .
Birth plan (correctional settings)
Childcare
Housing
Life management skills
Nutrition
Transportation
Clinical Treatment & Support Services
Parenting groups
Individual counseling
Group counseling
Stress management skills
Psycho-Social Care Package
Motivational Therapeutic Strategies
Optimal Care
Care Continuum
Navigation Skills Building
Cornerstones of Treatment
Counseling Services
Departments relating to Children & Families
Economic Services
Field Correctional Services
Medication Assisted Treatment Clinic
Obstetric Care
Women, Infants, Children (WIC)
Connecting Navigator Helper
Treatment Challenges
Higher Level of Care Indicators(i.e., OTP or residential setting)
• Evidence of benzodiazepines, cocaine, and alcohol
in urine screening
• Not attending substance use disorder counseling
• Diverting prescribed MAT medication (also a
concern in correctional settings)
Summary
Understand:
• OTP and OBOT community resources
• Methadone is the preferred choice for pregnancy
• Opioid addiction is a relapsing chronic brain disease
• Women/mothers need full wrap-around care
Message Board – Keep Both Safe
To access recorded webinette: www.attcppwtools.org
Trudee Ettlinger, PhD, APRN, LADC, CCSMaple Leaf Treatment Center
10 Maple Leaf Road
Underhill, VT 05489
802-858-7209 │[email protected]
CoE PPW Webinette 2March 8, 2016
ABM Clinical Protocol #21. (2009). Guidelines for breastfeeding and drug-dependent women. Academy of Breastfeeding Medicine, 4(4).
Abuse, O. (2012). Dependence, and Addiction in Pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists. Obstetrical Gynecology, 119, 1070-6.
Amaeda, A., Bateman, B.T., Clancy, C.R., Creanga, A.A., & Leffert, L.R. (2014). Opioid abuse and dependence during pregnancy: Temporal trends and obstetrical outcomes. Anesthesiology, 121, 1158-65.
Brown, H.L., Britton, K.A., Mahaffey, D., Brizendine, E., Hiett, A.K., Tumquest, M. A. (1998). Methadone maintenance in pregnancy: A reappraisal. American Journal of Obstetrics and Gynecology, 170, 459-463.
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.)
References (1 of 3)
Goler, N.C., Armstrong, M.A., Taillac, C.J., Osejo, V.M. (2008). Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. Journal of Perinatology, 28, 597-603.
Heil, S. H., Jones, H. E., Arria, A., Kaltenbach, K., Coyle, M., Fischer, G., … Martin, P. R. (2011). Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment, 40(2), 199–202.
Jones, H.E., Fischer, G., Heil, S.H., Kaltenbach, K., Martin, P.R., Coyle, M.G., Selby, P., … Arria, A.M. (2012). Maternal opioid treatment: Human experimental research (MOTHER)--approach, issues, and lessons learned. Addiction, 107, 28-35.
Jones, H.E., Johnson, R.E., Jasinski, D.R., O’Grady, K.E., Chisholm, C. A., Choo, R.E., Crocetti, M., … Milio, L. (2005). Buprenorphine versus methadone in the treatment of opioid-dependent patients: Effects on neonatal abstinence syndrome. Drug & Alcohol Dependence, 79, 1-10.
References (2 of 3)
Kaltenbach, K., Silverman, N., & Wapner, R. (1992). Methadone maintenance during pregnancy. State Methadone Treatment Guidelines. Treatment Improvement Protocol (TIP) Series, 1, 85-94.
Keegan J., Parva, M., Finnegan, M., Gerson, A., Belden, M. (2010). Addiction in Pregnancy. Journal of Addictive Diseases, 29(2), 175-191.
Winklbaur, B., Kopf, N., Ebner, N., Jung, E., Thau, K. & Fischer, G. (2008), 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, 103, 1429–1440.
Young, J. L., & Martin, P. R. (2012). Treatment of opioid dependence in the setting of pregnancy. Psychiatric Clinics of North America, 35(2), 441-460.
References (3 of 3)
Thanks for Participating!
You will be eligible to receive a .5 NAADAC
contact hour if viewed prior to April 1, 2016
Please send your request to receive a certificate
of attendance to: [email protected] no later
than April 1, 2016.
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