Opioid Use & Pregnancy the opportunity to learn from. Soraya - - PowerPoint PPT Presentation

Opioid Use & Pregnancy

Soraya Azari, MD Associate Professor of Medicine

• I have no disclosures.
• I am thankful to my patients who I have had

the opportunity to learn from.

Learning Objectives

• To be able to describe best practices for

management of opioid use disorder in pregnant women

• To have some understanding of what happens in

narcotic treatment programs

• To cultivate empathy for women that are

pregnant and struggling with substance use disorders

• To be able to list evidence-based interventions for

treatment of neonatal abstinence syndrome

Case 1

• EB is a 23yo F with a hx of HTN, G1P0 at 19 weeks

gestation that was found living in an encampment in San Francisco. She is injecting opioids and methamphetamine and sharing needles. She uses tobacco (1-1.5ppd). She denies use of alcohol, cocaine,

• r benzodiazepines.
• Partner is HIV positive; she is negative to the best of her

knowledge.

• She describes intermittent periods of opioid
• withdrawal. She had one OB appointment at Kaiser

w/sono providing EDD; otherwise no prenatal care. She desires to keep the pregnancy.

• She is taking no medications and has no allergies.

Case 1 continued

• She used to be living with her mother but is

no longer (was on her kaiser insurance plan). FOB HIV positive, unclear whether he is on meds (she is aware of his status)

• No current employment; receiving general

assistance benefits

Question

Which of the following is the best course of action:

• A. Admit for acute detoxification
• B. Admit to a residential treatment

program for behavioral interventions

• C. Refer to methadone maintenance

program

• D. Offer buprenophine-naloxone

E. Offer IM extended-release naltrexone

A d m i t f

• r

a c u t e d e t

• x

i f i . . . A d m i t t

• a

r e s i d e n t i a l t r . . . R e f e r t

• m

e t h a d

• n

e m a i . . . O f f e r b u p r e n

• p

h i n e

• n

a l . . . O f f e r I M e x t e n d e d

• r

e l e a s . . .

10% 33% 5% 14% 38%

Background: OUD & Pregnancy

Prevalence of OUD in Deliveries: Increase 333% from 1999 – 2014: 1.5 cases/1000 delivery hospitalizations  6.5 cases/1000 delivery hospitalizations WORST: West Virginia and Vermont 2011 2016 2018 CDC Guidelines MMWR: Opioid Overdose Overdose rising

• verprescribing was not the sole cause
• f the problem. While increased opioid

prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic

• pportunity, poor working conditions,

and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and

• ther substances.

Pew Research, SSA; Am J Pub Health 2018

Prescribing Patterns

J Pain Res. 2017; 10: 383–387.

Let’s Back Up: Screening & Diagnosis

• Screening

– ACOG recommendation for universal screening. Options: 4Ps Plus, NIDA Quick Screen, and CRAFFT (<26yo) – 4P’s Plus (yes to anything = positive screen)

• Parents: Did either of your parents ever have a problem with

alcohol or drugs?

• Partner: Does your partner have a problem with alcohol or

drugs?

• Past: Have you ever drunk alcohol?
• Pregnancy: In the month before you knew you were

pregnant, how many cigarettes did you smoke?

– How many beers/wine/liquor did you drink – How many opioids did you use (non-medically)

Screening & Diagnosis

• Urine toxicology testing

– Obtained only with patient’s consent and in compliance with state laws – Pregnant women should be informed of the possible consequences of a positive test (including mandatory reporting) – Pros: increase detection of use – Cons: only shows recent use; imperfect sensitivity; does not test for many synthetic drugs; risk FP; need to understand how to interpret – Universal Screening experiments*:

• Cincinnati community hospital: 5% positive (3.2% opioids)

– 20% of the opioid-positive samples were in moms without screening risk factors » 37% of these (7/19): required admission to special care nursery for NAS

* Not standard of care

Diagnosis

Am J Psychiatry 2013;170:834-851

Opioid Use Disorder Diagnosis

– Opioid use disorder

• 4 Rs

– Risk of bodily harm – Relationship trouble – Role failure – Repeated attempts to cut back

• 4 Cs

– Loss of Control – Continued use despite harm – Compulsion (time & activities) – Craving

• Withdrawal and tolerance

Homeless, not working Use of needles, sharing needles Estranged from mother Injection of heroin despite pregnancy Having periods of withdrawal

Case Continued

• EB first used substances at age 13 (cigarettes,

alcohol) and tried prescription opioids at 14, which were prescribed to her mother. Using

• pioids made her feel less anxious and like she

could “act like herself.”

• She quickly escalated to daily use. When it

became difficult to take her mother’s pills, she started dating an older man that introduced her to heroin, which was less expensive and more easily obtained.

• She left home repeatedly to spend time with her

male partner. She hid her use from her family.

Question

In cohort studies of women who are pregnant and have a substance use disorder, what percentage have a history of adverse childhood events (ACE)?

• A. 30%
• B. 50%
• C. 70%
• D. 90%

3 % 5 % 7 % 9 %

7% 27% 47% 20%

Language & Stigma

• Stigma: attribute, behavior, or

condition that is socially discrediting

– Cause – Controllability

• WHO study, 18 most stigmatized

social problems (including criminal behavior): drug UD (#1)

• Stigma – large factor in the

“treatment gap”

Kelly, Wakeman, and Saitz. Am J Med. 2015;128(1): 8-9..

Causes and Controllability

• Causes

– Iatrogenic (overprescribing of

• pioids)

– Genetics – Adverse childhood events – Person-related: Early age

• f first use, “Risk taking”

behavior, use of other substances

• Controllability

– Addiction is a chronic, relapsing brain disorder characterized by compulsive drug seeking and use despite harmful consequences as well as neurochemical and molecular changes in the brain

Criminal Prosecution of Women with a Substance Use Disorder

• 22 states, District of Columbia – use of any illegal

substance during pregnancy constitutes child abuse

– Minnesota, South Dakota, Wisconsin – grounds for court-ordered institutionalization regardless of woman’s wishes

• WI: woman can be detained against her will for duration
• f pregnancy, fetus has court-appointed lawyer, she can

lose custody after birth, and proceedings are mostly secret

• 24 states, DC – require health care professionals

to report

• https://www.guttmacher.org/state-

policy/explore/substance-use-during-pregnancy

Guttmacher Institute website

Who Is this Person?

• Likely, a victim of severe trauma

– Expectant mothers from FQHCs in Philadelphia area, examining 7 ACEs: 72% had at least 1 ACE (52% physical, 18% shooting); dose-response w/SU – S Africa study of women with alcohol use disorder – 64% with exposure to some form

• f trauma (childhood abuse or IPV); 48%

both

• Has also probably inherited severe

poverty: “intergenerational disadvantage”

• Also, likely depressed: 30% with mod-sev

depression

Chung et al. Acad Pediatr. 2010;10(4): 245-51.Choi KW et al. BMC Pregnancy Childbirth. 2014;14:97. Holbrook et al. Am J Drug Alc Abuse 2012;38:575-9.

Nytimes.com

Language & Stigma

• Study: Comparison of written vignettes about

a patient in legal trouble given to doctoral- level mental health and addiction clinicians.

• “substance abuser”
• “having a substance use disorder”

– Clinicians exposed to “substance abuser” term were more likely to judge the person as deserving blame and punishment

• Anti-Stigma

Drug “abuser” or “PSA” “Dirty” utox “Addict” in and out of program Relapse Person with a substance use disorder Abnormal urine toxicology test Severe SUD with repeated treatment attempts Recurrence of chronic illness

Case Continued

• EB had been trialed in one detoxification

program at Kaiser in the past while on her mother’s insurance, but relapsed. She tried several times to stop opioids herself once she knew she was pregnant, but those attempts were unsuccessful also.

• She was ashamed to tell her family about her

pregnancy.

Treatment: Terms

Detox

Hospital MAD Ambulatory MAD Residential MAD Social Model

Relapse Prevention

Residential Intensive Outpatient Outpatient with MAT (i.e. methadone) 12 Step/ Peer Office- Based, including Medication Mgmt

MAD = Medically Assisted Detoxification MAT = Medication Assisted Treatment

Outpatient w/o MAT

Maintenance Treatment for OUD: Standard of Care Question

Which of the following summarizes the evidence of buprenorphine versus methadone for pregnant women with OUD?

• A. Duration of neonatal abstinence syndrome is

shorter in bupe-maintained women, compared to methadone

• B. Fetal indicators (i.e., HR, HR variability, fetal

activity) appear superior in methadone- maintained women

• C. Buprenorphine is better if the woman desires

to breast feed

• D. Methadone is associated with a higher risk of

congenital abnormalities

Duration of neonatal ab... Fetal indicators (i.e., HR, .. Buprenorphine is better i... Methadone is associated...

61% 5% 11% 23%

Treatment of OUD During Pregnancy

• Benefits of Treatment for OUD

– Prevents opioid withdrawal symptoms – Improves adherence to prenatal care – Reduces the risk of obstetric complications (i.e., pre-term birth) – Decreases illicit drug use, criminal behavior, disease transmisison

• With no treatment for OUD:

– Decreased engagement in prenatal care – IUGR – Abruptio placentae – Fetal death – Preterm labor – Meconium passage – High-risk activities: prostitution, criminal behavior – Overall; 6-fold increased risk OB complications. Thought to be from repeated cycles of withdrawal experienced by pregnant woman and fetus

• Standard of Care

– ACOG recommendation (ACOG Committee Opinion)

Treatment: Medication Assisted Treatment (MAT) for Relapse Prevention

• Methadone

– Pharm: full mu-opioid receptor agonist – Provision: narcotic treatment program (NTP) – Dosing: daily, though often split into 2 doses during pregnancy – Outcomes: dec illicit drug use, dec disease transmission, more prenatal care, longer retention tx, better fetal

• utcomes
• Buprenorphine

– Pharm: partial opioid agonist

• Co-formulated with

naloxone for treatment of OUD (Suboxone

– Provision: by prescription

• r NTP
• Special x license to

prescribe

– Dosing: also frequently split during pregnancy – Outcomes: similar

NOTE: Naltrexone (opioid receptor blocker) is NOT approved or recommended in pregnancy

Get Your X-License!

• Burpenorphine Waiver Training

– DATA 2000 act specifies that training is necesarry for physicians to obtain a waiver to engage in office-based treatment of OUD with schedule III, IV, and V narcotic medications (like bupe) – Requires 8 hours of training that can be done online,

• r in-person (“half and half” courses)

– NP/Pas require 24 hours of training – Options: local trainings, ASAM 8hr online training, PCSS trainings, APA – Help:

• Get a mentor! (PCSS)
• Substance use warm line: 855-300-3595

Treatment: Medication Assisted Treatment

• Methadone
• Buprenorphine

Treatment: Medication Assisted Treatment

• Methadone

– What happens to a patient in treatment:

• Weekly urine toxicology

testing

• Monthly visits with a

provider (weekly until dose stabilized)

• Special treatment counselor

w/experience in pregnant clients (50min/mon)

• Discussion of: need for

prenatal care, use of other substances, level of care, and issues r/t pregnancy (i.e., pain control, post partum period, breastfeeding)

• Buprenorphine

– What happens to a patient in treatment:

• Monthly (to more

frequent) visits with a provider

• Urine toxicology

monitoring per prov.

• Engagement with

behavioral health per prov.

• Discussion/education per

prov.

CSAM Guidelines for Physicians Working in California Opioid Treatment Programs. 2008

Comparison of Methadone & Buprenorphine

• Methadone may be easier transition (no risk of

precipitating withdrawal) and has better treatment retention

• Evidence for improved fetal indicators in

buprenorphine-maintained women, compared to methadone (MOTHER study)

– Higher HR variability, more fetal HR accelerations, greater coupling between HR and movement

• Decreased duration of NAS in bupe-maintained women
• No superiority of either for:

– pp pain control – safety in breastfeeding (both present in small amounts & safe in pregnancy) – Risk of congenital malformations

Klaman S et al. Journal of Addiction Medicine 2017;11(3):178-90.

Comparison of Methadone & Bupe

• Buprenorphine

– Less dose titration – Ceiling effect – Office-based – No QTc prolongation – Less drug-drug interactions

• Methadone

– May help with pain management – Structured clinical setting – Frequent touches w/health care providers – “higher” level of care

Case Continued

• EB was admitted to L&D at 19 weeks for buprenorphine
• induction. She was induced onto buprenorphine and then

left AMA. She was HIV negative.

• The street medicine outreach team engaged her in care and

brought her to the methadone clinic.

• Her dose was titrated up to 220mg daily. She was engaged

with the homeless prenatal program to receive services. She was receiving directly observed therapy (DOT) of her PREP, anti-hypertensives, and prenatal vitamins.

• She had perfect attendance at the methadone program,

her dose was split (110mg bid), but her urine drug screens were still positive for codeine (heroin)

• At 34 weeks 5 days she underwent C-section for terminal

bradycardia.

Case Continued

• She received pain control post-partum with short

acting opioids (increased doses required). She was discharged with a 3 day supply of meds.

• Shortly after delivery, the patient was admitted

(with the FOB) to a residential treatment facility. She was very eager to participate with Child Protective Services for the opportunity to have custody of her little boy.

• Jeremy, her son, was in the hospital for 2 weeks

for management of his NAS and support of his growth.

Neonatal Abstinence Syndrome

• Definition: constellation of symptoms that occurs in the

newborn due to absence of the substance. Described for multiple substances, but most commonly associated with

• pioid or BZD use.
• Incidence: occurs in ~50% of bupe- and methadone-

maintained women (no agent clearly superior to prevent)

– Dose does not predict development of NAS

• Outcomes: Bupe-exposed neonates: longer time to onset of

symptoms, require less morphine to treat NAS, spend less time in the hospital, and have a shorter stay.

• Detection: AAP recommends minimum stay of 5-7 days for
• bservation

Overall NAS Incidence Increased 400% (1.2 per 1,000 hospital births in 2000 to 5.8 in 2012

MMWR 2016

Neonatal Abstinence Syndrome Best Practices

• Use of standardized protocols (screening, assessment,

and medication administration)

• Rooming in with baby (minimize environmental

stimuli), skin-to-skin contact

• Promoting adequate rest and sleep
• Providing sufficient calories
• Breastfeeding recommended
• Use a published abstinence assessment tool; do not

medicate unless clearly indicated

• Morphine, methadone, and clonidine are preferred;

paregoric is contra-indicated

Pediatrics 2012;129:e540-e560

• The baby was placed in foster care. EB continued

to meet all the requirements named in her CPS

• case. She was granted reunification (3mos

postpartum) and her son joined her in program.

• She is now 16 months abstinent of drug use,

maintained on methadone (same dose). She is in a vocational rehab program (dental assistant), FOB got job, and she is working on housing

• ptions. She still has a case manager, therapist,

and counselor.

Non-Pharmacologic Interventions for Pregnant Women with OUD

• Multi-disciplinary treatment programs

– Range of services – Education on drug use disorders, use of medications, effect

• n baby, and triggers for relapse

– Relapse prevention services – Early motherhood classes – Vocational rehab – On-site childcare

• Outcomes

– Cost-effective (estimated savings for $4644 per mother/infant pair)

• Remember the need for patient motivation!

Svikis DS et al. 1997 Drug Alcohol Depend. 45(1-2): 105-13

Recap: 25yo F with hx of OUD, methamphetamine UD, experiencing homelessness.

• Which of the following is the best course of

action:

– A) Admit for acute detoxification – B) Admit to a residential treatment program for behavioral interventions – C) Refer to methadone maintenance program – D) Offer buprenophine-naloxone – E) Offer IM extended-release naltrexone

Recap: 25yo F with hx of OUD, methamphetamine UD, experiencing homelessness.

• In cohort studies of women who are pregnant

and have a substance use disorder, what percentage have a history of adverse childhood events (ACE)?

– A) 30% – B) 50% – C) 70% – E) 90%

Recap: 25yo F with hx of OUD, methamphetamine UD, experiencing homelessness.

• Which of the following summarizes the evidence of

buprenorphine versus methadone for pregnant women with OUD?

– A) Duration of neonatal abstinence syndrome is shorter in bupe-maintained women, compared to methadone – B) Fetal indicators (i.e., HR, HR variability, fetal activity) appear superior in methadone-maintained women – C) Buprenorphine is better if the woman desires to breast feed – D) Methadone is associated with a higher risk of congenital abnormalities

Response to an Epidemic

• Public Health Agencies

– CDD Guidelines for Treatment of Chronic Pain

• Payor Changes

– Medicare to limit payment for opioids to <7 days – Medical has already implemented

• State Government/Medical Board

– Checking prescription activity records (PAR) will be mandatory before all new controlled substance prescriptions starting Oct 2, 2018 (CA)

• Exception: surgical procedure and supply <5d, ED provider and

supply <7d, hospice, on-site adminstration, not reasonably possible to check (or delegate) and <5d

• Accreditation Bodies

– JCAHO: revised pain assessment & management standards

Response to an Epidemic

• Minimize Harm to Your Patients

– Provision of naloxone for reversal of possible

• verdose

– Information on accessing clean needles and supplies – Use of test strips for fentanyl – Education on safety risks associated with different types of administration – Continual message of forgiveness and acceptance

Summary

• Universal screening for subtance use disorders

should be part of comprehensive obstetric care.

• Pregnant women with OUD are increasing in

prevalence.

• Standard of care for pregnant women with OUD

is medication assisted treatment with methadone

• r buprenorphine.
• The choice of methadone versus buprenorphine

will depend on patient preference and degree of medical and psychosocial complexity.

Summary

• More buprenorphine waivered providers are needed to

address the needs of the opioid epidemic.

• Neonatal abstinence syndrome occurs in approximately

half of women on MAT for OUD. It is considered expected and treatable.

• Best non-pharmacologic practices for NAS

management include rooming-in, breast feeding, and skin-skin contact with baby.

• Psychosocial supports, as opposed to punitive

interventions, are recommended for women struggling with SUD during pregnancy.

Additional Resources

• OUD in Pregnancy, NY White Paper: https://www.acog.org/-

/media/Districts/District- II/Public/PDFs/OpioidUseDisorderinPregnancyWhitePaper.pdf?dmc =1&ts=20181001T0355108875

• ACOG Practice Bulletin: Opioid Use and Opioid Use Disorder in

Pregnancy, Aug 2017: https://www.acog.org/Clinical-Guidance- and-Publications/Committee-Opinions/Committee-on-Obstetric- Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

• ACOG Patient Education Fact Sheet:

https://www.acog.org/Patients/FAQs/Important-Information- About-Opioid-Use-Disorder-and-Pregnancy

• Patient Education Sheets, on MAT (linked from PCSS):

https://www.acog.org/About-ACOG/ACOG-Departments/Tobacco-- Alcohol--and-Substance-Abuse/Substance-Abuse/Pamphlets-for- Pregnant-Women

• https://www.youtube.com/watch?v=6NBNKvYSWPo