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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: [email protected]