Transcript Opioid Dependence During Pregnancy

Opioid Dependence
During Pregnancy
Michelle Lofwall, M.D.
University of Kentucky
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Challenging to Treat
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MDs have inadequate training
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Medical & legal system prejudices
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State reporting requirements
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Doctor-patient alliance problems
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What You Need to Know
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Punishment ≠ effective deterrent
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Comprehensive treatment works!
 3x
 in mom’s opiate use

Prenatal care
 3x
 low birth weight (LBW: <2500 grams)

Perinatal HIV transmission to <2%
 2x
 maternal custody in 1st yr
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This Lecture Reviews

Definitions

Causes, course, prevalence & comorbidity

Medical complications

Treatment
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Abuse & Dependence
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Abuse ≥ 1 of:
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Obligations
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Hazardous use

Legal

Interpersonal
problems
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Dependence ≥ 3 of:
 Tolerance
 Withdrawal
  Amounts or more time
 Desire or unable cut down
 Time get, use, or recover
 Non-drug activities 
 Physical/psychological
problems
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Opioid Withdrawal
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Occurs with  /no opioid use OR opioid antagonist
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≥ 3 of:
 Dysphoria (unhappy)
 Nausea or vomit
 Muscle aches
 Lacrimation (watery
eyes) or rhinorrhea
(runny nose)
 Diarrhea
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Yawning
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Fever
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Insomnia
Mydriasis (big pupils),
piloerection (goose
bumps), or sweating
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This Lecture Reviews
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Definitions ✓

Causes, course, prevalence & comorbidity

Medical complications

Treatment
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Etiology
50%
Genes
50%
Environment
Availability
Peer use
Drug-using partners
Hx victimization
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Chronic Relapsing Course
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>50% relapse
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>90% use opioids before pregnancy
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20x  mortality vs. Ø substance disorder dx
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Prevalence of Opiate Use
% Opiate +
10
8.6
8
6
4
2
1
0
Maternal selfreport
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Meconium
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Other Drugs & Psych Dxs
> 90% Cigs
>10% Axis I
• LBW
•LBW with
•Premature
>10% Cocaine mood
•SIDS
disorder
•
Placental
•Stillbirths
abruption
• Premature
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Complex Social Problems
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>50% single moms & unemployed
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>25% hx of physical/sexual abuse
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Low socioeconomic status
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Adversely affects pregnancy

Prenatal care

Direct harm
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Risky Behaviors
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Sharing needles, unprotected sex, dealing

Mom’s infections  risk of:
 Premature
contractions & labor
 Breakdown

fetal membranes & abortion
Difficult to separate out opioid effects
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This Lecture Reviews

Definitions ✓

Causes, course, prevalence & comorbidities ✓

Medical complications

Treatment
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Maternal & Fetal Problems
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Multifactorial etiology
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HIV: 25% transmit
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Hep C: ~5% transmit
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Endocarditis  heart failure  hypoxia
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Nutritional deficiency – e.g., 25% Fe-defic
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Fetal Hypoxia
Intoxication Withdrawal
Unstable fetal environment
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Newborn Birth Outcomes
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~50% LBW (~20% with rx)
Death
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~25% HIV (<2% with rx)
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Meconium aspiration (stool inhaled into lungs)
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~10% Microcephaly (small head)
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Neonatal Abstinence Syndrome
(NAS)
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NAS Definition
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Central nervous system excitability
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Autonomic nervous system 
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GI system malfunction
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Respiratory distress
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NAS
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Time course depends on:
 Opioid
 Fetal

half-life (T ½)
opioid storage & metabolism
Risk factors:
 Opioid
dependent mom  70% chance NAS
 Smoking
 severity
 Prematurity
 severity
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This Lecture Reviews

Definitions ✓

Causes, course, prevalence & comorbidities
✓

Medical complications ✓

Treatment
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4 Treatments Reviewed
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Psychosocial rx without medication
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Methadone maintenance (MM)
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Methadone-assisted withdrawal
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Buprenorphine (Subutex®) maintenance
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Psychosocial Interventions
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Cornerstone
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Therapeutic alliance
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Expect demanding & resistant behavior
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Complete assessment
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Assist with all problems
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Methadone Maintenance
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Long T ½ (27 hrs), synthetic opioid agonist
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Strict federal regulations
 Opioid
>
dependent > 1 yr (unless preg)
18 yrs unless parental consent/failed rx
 Daily
visits x 90 days
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Many Treatment Goals
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Mother:
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/stop withdrawal
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/stop drug use
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Prenatal/med/psych rx
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Psychosocial probs
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Supportive network
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Parenting skills
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Many Treatment Goals
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Fetus/neonate
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Stable intrauterine
environment
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Stop intox/withdrawal
cycles
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Deliver term/healthy
newborn
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+ maternal/fetal bond
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Components of MM Treatment
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Multidisciplinary team
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Individual & group counseling
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Parenting classes
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Daily oral methadone dosing
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Start at 30 mg (40 mg max day 1)
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> 50 mg maintenance dose
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Blocks + illicit opioid effects
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Prevents withdrawal
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MM Benefits
 3x
 in mom’s opiate use

Prenatal care
 3x
 LBW

Perinatal HIV transmission to <2%
 2x
 maternal custody of newborn
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MM Limitations
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Availability
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Limited patient acceptance
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Does not  incidence of NAS
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Report of fine motor skill problems
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Methadone-assisted Withdrawal
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1970’s = standard rx until fetal deaths
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Utilized if MM not available or accepted
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Goals:

Mother/fetus opioid withdrawal
 Achieve
 Deliver
opioid free state in mom/fetus
term, healthy fetus with no NAS
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Components of Withdrawal
Treatment
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Inpatient
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OB monitors fetus daily for distress
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Stabilize on methadone then taper dose
 If
fetal distress – slow taper,  dose
3
& 7 day tapers at specialty units
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Discharge
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Con’t outpatient rx to maintain abstinence
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Withdrawal Outcomes


>50% relapse
 Problem > opioid withdrawal
 Problem = medical & psychosocial
Compared to MM, detox alone results in:
 2x  + urine drug test at delivery
 5x  days in trt
 6 fewer OB appts
 No diff in NAS or birth outcomes
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Buprenorphine Maintenance
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2002 approved rx for non-preg opioid depend
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Partial opioid agonist
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Enhanced safety profile
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T ½ = 37 hrs
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Office-based
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Buprenorphine Maintenance
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Must become qualified to prescribe
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Potential advantages
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Similar outcomes as MM
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Large on-going clinical trial
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This Lecture Reviewed

Definitions ✓

Causes, course, prevalence & comorbidities ✓

Medical complications ✓

Treatment ✓
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