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Medication Assisted Treatment in Pregnancy

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Kaitlan Elston

on 16 August 2017

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Transcript of Medication Assisted Treatment in Pregnancy

Treatment Types
Medicine/Addiction Medicine

Behavioral Drug and Alcohol Counseling
Medical Concerns with Substance Use
in Pregnancy:
Teratogenicity

Obstetric Problems

Fetal Development

NAS


Kaitlan Baston, MD MSc
Medical Director
Addiction Medicine Program
Cooper University Hospital

NO DISCLOSURES

Kate is a 28 year old who was just arrested for possession of paraphernalia after being pulled over for speeding. She has been injecting heroin for the past year. She tells the officer making the arrest that she is afraid to go to jail because she is pregnant.


Understanding Perinatal Substance Use Disorders
Assessing Risk
Medication Assisted Treatment
"I have wanted to stop using for so long, but I keep trying and failing . I was afraid to tell anyone about the pregnancy. I need help."
Kate stops answering her cell phone.

3 months later, you are able to track her down. She is now 26 weeks pregnant and she has not yet gone to a prenatal care appointment.
What is the mother feeling?
SHAME
" I wanted to quit (on my own) before I go to the clinic."
"My inability to quit means I don’t care about my baby."
"Everyone is going to think I don't deserve this baby."
"I'm a horrible person because I can't quit for this baby."

FEAR
" I have already messed up my baby."
"I can't keep this baby because it has birth defects now."
"If I am on methadone, they will treat me like an addict and take my baby."

DENIAL
"I can't possibly be pregnant, I haven't had a period in 2 years."
"I'll probably miscarry anyway."
"I can't deal with this right now. I can't even take care of myself."

DEDICATION

" This time is going to be different!"

"Now I really want it."

"I can do anything for this baby."

"I am never going to use again."

"I can do it on my own! I have really strong willpower!"

High Risk

Criminal

Unfit to parent

The Damage is Done

"I can't believe she would do that to her baby."
How are YOU Feeling?
Fear of Judgment & Stigma

Lack of Social Supports

Desire for a nuclear family

Physical/Emotional Challenges of Pregnancy

Challenges of Parenting

Environment Environment Environment

How Can We Better Reach
This Population?
Incentivize Getting Help

Push for Evidence Based Treatments

Make Treatment Access EASIER

Standard Urine Screening
for all Pregnant Patients
Identify it Early
How Do You Ask???
What does this mean for her future?
For the fetus's future?
IS THE BABY OK???
JAMA 2001 March 28; 285(12):1613-1625 Growth, Development, and Behavior in Early Childhood Following Prenatal Cocaine Exposure: A systematic review. Frank DA, Augustyn M

Bettancourt, L Hurt, H, et al. Adolescents with and without Gestational Cocaine Exposure: Longitudinal Analysis of Inhibitory Control, Memory and Receptive Language


Bauer CR. Arch Pediat Adolesc Med 2005 Sep; 159; 824-834. Acute Neonatal Effects of Cocaine Exposure During Pregnancy


What About Neurodevelopment?
All studies confirm that growing up in a using household impacts intelligence & emotional well being
JAMA 2001 March 28; 285(12):1613-1625 Growth, Development, and Behavior in Early Childhood Following Prenatal Cocaine Exposure: A systematic review. Frank DA, Augustyn M

Shift The Focus Away From
Criminalizing Gestational Exposure

Preventing obstetrical harms

Promoting a sober environment
for child raising
IUGR, Preterm Delivery, Abruption, Infectious Disease Exposure

opioid withdrawal*
injection drug use
stimulant
& nicotine use
poor nutrition
trauma exposure
poverty





THE REAL RISKS
ARE OBSTETRIC
Preventing Obstetrical Complications
Placental Problems

Kistin N. Paediatr Perinat Epidemiol. 1996 Jul;10(3):269-78. Cocaine and cigarettes: a comparison of risks.
Cocaine:

4 x preterm labor
5 x low birth weight
10 x placental abruption
5 x fetal demise

Nicotine:

Same risks as cocaine
Lower magnitude
GREATER PREVALENCE

64
cocaine users,
3000
smokers,
14,000
controls
Common

Bad Outcomes
46%
~55% of women who smoke quit just before or during pregnancy
~40% of women who quit resume in the first 6 months after delivery

Infant morbidity and mortality attributable to prenatal smoking in the U.S. Dietz PM, et al. Am J Prev Med. 2010 Jul;39(1):45-52.


Low risk if any of birth defects 

Use does not cause obstetric risks
  
Opioid WITHDRAWAL has potential risks in pregnancy

Opioid dependence develops in the
mother and fetus

Illicit use has known health risks

PIOIDS
Early 

Agitation
Anxiety
Muscle aches
Lacrimation
Insomnia
Rhinorrhea
Diaphoresis
Yawning

Severe

Abd cramping
Diarrhea
Dilated pupils
Piloerection
Nausea
Vomiting



Fetal

Increased Movements
Passage of Meconium
Bradycardia
Preterm Delivery
Miscarriage
IUFD



Symptoms of Opioid Withdrawal
Individual Counseling
Group Therapy
Intensive Outpatient Treatment
Partial Care/Partial Hospitalization
Inpatient Treatment (28 day +)
Long Term Residential Treatment
Empathy is Evidence Based
MAT for Opioid Use Disorder
Why Not Detox?
Is opiate detoxification unsafe in pregnancy?
J Subst Abuse Treat. 2003 Jun;24(4):363-7.

Bell J, Towers CV, Hennessy MD, Heitzman C, Smith B, Chattin K. Am J Obstet Gynecol. 2016 Mar 17

Stewart RD, Nelson DB, Adhikari EH, McIntire DD, Roberts SW, Dashe JS, Sheffield JS.
Am J Obstet Gynecol. 2013 Sep;209(3):267
"I just want to get off everything"

Maintenance Therapy:
-Bup or MMT: Yes!
-Can decrease NAS



Safety/Monitoring:
-random or regular tox screens
-counseling and support

BREASTFEEDING
Hospital Care
Journal of Perinatology (2008) 28, 597–603. Substance Abuse Treatment Linked with prenatal Care Improves Outcomes. Goler, et al.
Prenatal Exposure to Drugs of Abuse. A Research Update from the National Institute on Drug Abuse. May, 2011.
ACOG Committee Opinion 2012 on Opioid Use and Dependence in Pregnancy.
Am J Obstet Gynecol. 2011 Apr;204(4):314.e1-11. Maternal treatment with opioid analgesics and risk for birth defects. Broussard CS
Pediatrics 2006;118;943. G. David Batty,et al. Effect of Maternal Smoking During Pregnancy on Offspring's Cognitive Ability: Empirical Evidence for Complete Confounding in the US National Longitudinal Survey of Youth.
Infant morbidity and mortality attributable to prenatal smoking in the U.S. Dietz PM, et al. Am J Prev Med. 2010 Jul;39(1):45-52.
Overview and epidemiology of substance abuse in pregnancy. Andria D Wendell. Clinical obstetrics and gynecology ,2013,Vol.56(1),p.91-96
Bauer CR , Langer JC. Arch Pediat Adolesc Med 2005 Sep; 159; 824-834. Acute Neonatal Effects of Cocaine Exposure During Pregnancy
Obstet Gynecol. 1998 Nov;92(5):854-8. Opioid detoxification in pregnancy.
Frank AD. et al.JAMA.2001;285 (12):1613-1625. Growth, Development, and Behavior in Early Childhood Following Cocaine Exposure.
Bauer CR. Arch Pediat Adolesc Med 2005 Sep; 159; 824-834. Acute Neonatal Effects of Cocaine Exposure During Pregnancy
Bettancourt, L Hurt, H, et al. Adolescents with and without Gestational Cocaine Exposure: Longitudinal Analysis of Inhibitory Control, Memory and Receptive Language
National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. 1998; 280:1936–1943
Hendree, J. et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure: NEJM 363:24. 2010
J Subst Abuse Treat. 2003 Jun;24(4):363-7. Is opiate detoxification unsafe in pregnancy?
References
Quick Review
Thank You!
QUESTIONS
&
DISCUSSION
5-8% preterm deliveries

13-19% low birth wt term

23-24% SIDS cases

5-7% preterm related
infant deaths



Medication Assisted Treatment for Perinatal Substance Use Disorders
Ewing H. A practical guide to intervention in health and social services with pregnant and postpartum addicts and alcoholics: theoretical framework, brief screening tool, key interview questions, and strategies for referral to recovery resources. Martinez (CA): The Born Free Project, Contra Costa County Department of Health Services; 1990




A)
Definition of Medication Assisted Treatment and Medication Options for Pregnant Patients

B)
Detox vs Medication Assisted Treatment for Opioid Dependence in Pregnancy: Which is recommended and why?

C) Understanding
the risks of maternal substance use to infants and children.

D) Knowing differences between recommended treatment for pregnant patients and non-pregnant patients with substance use disorders.

E) Other

INCREASES RISK OF OVERDOSE


Major Risk Factor and Typical Outcome: RELAPSE


No known way to ensure safety


Obstetric risk probably least in 2nd trimester


Fetal bad outcomes infrequent, but devastating
(abruption, preterm delivery, IUFD)
NATIONAL PRACTICE GUIDELINES
Pre-Test:
Which of the following is True:

A) Gestational cocaine exposure alone has NOT been shown to cause neurocognitive deficits in longitudinal studies.

B) Fetal Alcohol Syndrome occurs in approximately 70% of cases with documented heavy drinking in pregnancy.

C) Opioid dependent pregnant patients should be counseled to stop opioids immediately to avoid risks associated with opioid use.

D) Gestational exposure to opioids increases the risk of addiction in the child's lifetime.
regulations.gov search : SAMHSA-2016-0002
ACOG Committee Opinion No. 422: at-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2008 Dec;112(6):1449-60
QUICK SURVEY:
Which of the following is most relavent to your work?
On a Public Health Level:


Can a women in your state be prosecuted for using substances in pregnancy?


QUICK SURVEY:
Back to Kate:
young pregnant women with opioid use disorder
Psychosocial Concerns with Substance Use in Pregnancy:
Housing

Ability to Parent

Lack of Social and Family Supports




First Described in 1973

0.5-3 in 1000 live births

Risk inc. significantly > 3-5 drinks

Only 1-3% of “alcoholic” women will have children with FAS.

ALCOHOL: FAS
Marijuana:
small retrospective studies, 1.7 x risk anencephaly
not replicated in larger trials


Sedatives: Benzodiazepines
small retrospective studies-increased risk cleft palate
not replicated in other studies


Opiates:
case-control & small retrospective studies, slight inc risk of heart defects, gastroschisis; inc neural tube defects
not replicated in other studies

Teratogenicity

TAKE HOME:
ALCOHOL IS THE ONLY SUBSTANCE THAT HAS RELIABLY BEEN SHOWN TO CAUSE BIRTH DEFECTS
And the Child's
Future Risk of
Substance Use
Disorder ?

CDC/PRAMS 2011 data
Medication Assisted Treatment:
Opioids
Alcohol
Nicotine
Amphetamines
Cocaine
Marijuana
PCP


Behavioral
Health
Methadone
Buprenorphine
Depo Naltrexone
(Vivitrol)
80%



60%



20%
Evidence Based Counseling
Opioid Pain Medication Expected/Usual Care

C-Section or Other Surgery: Prescription for Opioids Commonly Recommended
Substance Use Disorders are Chronic Diseases
Methadone
Buprenorphine
Depo Naltrexone
(Vivitrol)
80%



60%



20%


<5%
Detox Alone
Risks of Untreated SUD:

1. Obstetric
2. Environmental Exposure
1. Opioids:
MEDICATION assisted treatment
2. Stimulants:
Detox, behavioral health,
environment
3. Sedatives:
Safe monitored detox +
behavioral health
Mitigated by: Appropriate Treatment:
Quick Survey: Which has the highest treatment retention rate?
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