Transcript Substance Abuse During Pregnancy

Moms on Meds
Substance Abuse During Pregnancy:
Jennifer Anderson Maddron, M.D.
Prescription Painkiller
Overdoses. July 2013
• Approximately 18 women die every day of a
prescription painkiller overdose in the US.
More than 6,600 deaths in 2010
• Deaths from prescription painkiller overdoses
among women have increased more than
400% since 1999, compared to 265% increase
among men
• Prescription painkillers are involved in 1 in 10
suicides among women.
• For every woman who dies of a prescription
painkiller overdose, 30 go to the ER for
painkiller misuse or abuse
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“Prescription Painkiller Overdoses”. (2013). Retrieved on August 4, 2013, from
http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/
Prescription painkiller overdose deaths are a growing
problem among women
2010 National Survey on Drug
Use and Health
4.4% of pregnant women reported
use of an illicit substance within the
past 30 days
Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on
Drug Use and Health: summary of national findings. NSDUH Series H-41. HHS Publication No. (SMA) 114658. Rockville (MD) SAHMSA: 2011
Deliveries at LeConte Medical Center
Maternal Complications of
Substance Abuse
• Many barriers exist for pregnant
substance abusers
• Lifestyle issues may result in pregnant
women engaging in high risk behavior
– Prostitution
– Sharing of IV needles
– Intimate Partner Violence
– Theft and other criminal activities
Maternal Complications of
Substance Abuse
Confounding variables of
substance abuse
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Socioeconomic status
Ethnicity
Access to prenatal care
Poly-substance abuse
Substances Most Commonly
Abused During Pregnancy
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Tobacco
Alcohol
Marijuana
Opiates
Cocaine
Benzodiazepines
Amphetamines
Hallucinogens
Opioid Addiction
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Oxycodone
Hydrocodone
Methadone
Roxicodone
Heroin
Fentanyl
Meperidine
Hydromorphone
Propoxyphene
Opioid use in Pregnancy:
Maternal Complications
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Altered Mental Status
Somnolence
Respiratory Depression
Death
IV Use may result in
– Hepatitis B & C
– HIV
– Skin infections
– Endocarditis
– Sepsis
Opioid Effects on Pregnancy
Antenatal Complications
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Preterm Delivery
Growth Restriction
Low Birth Weight
Placental Abruption
Fetal Death
Neonatal Effects
• Neonatal Abstinence
Syndrome (NAS)
Neonatal Abstinence Syndrome (NAS)
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Constellation of withdrawal symptoms
Central Nervous System
 Inconsolability, high-pitched crying, skin excoriation, hyperactive
reflexes, tremors, seizures
 Gastrointestinal System
 Poor feeding, excessive sucking, feeding intolerance, loose or
watery stools
 Autonomic/metabolic
 Sweating, nasal stuffiness, sneezing, fever, tachypnea, mottling
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Treatment options
• Holistic Multidisciplinary Approach to
treatment of Neonatal Abstinence
Syndrome
– Non-pharmacological
• Cuddler
• Environmental
• Diet
– Pharmacological
• Narcotics
• Non-narcotics
Pharmacological
Treatment
• Approximately 67% of babies
– Are weaned from opioid in about 20 days
– Do not require adjuvant treatment
– Stay in the NICU approximately 24 days
• Approximately 33% of babies
– Require weaning time of 60 days (range up
to 155 days)
– Require adjuvant treatment with up to two
additional medications
– Stay in the NICU for about 68 days (some
up to 155 days)
Mother’s TennCare status at
time of delivery for NAS children
TennCare cost associated with
treatment of NAS infants
Treatment of Substance Abuse
During Pregnancy
Screening
• Universal Screening of all women
before and during pregnancy
• Identify women currently using
illicit substances & women at risk
• Toxicology testing: Urine Drug
Screens
Intervention
• Multidisciplinary approach needed
to address Physical, Psychological
and social issues
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Obstetrical and Neonatal Care
Addiction Medicine Specialist
Mental Health Services
Social Services
Treatment of Opioid Addiction in
Pregnancy
• For Opioid addicted Pregnant
patients:
– Detoxification
• Relapse rates are high and dangerous
– Opioid Replacement Therapy
• Methadone versus Buprenorphine
– Alcohol and Drug Counseling
– Treatment of Co-existing Mental
Health Disorders
Treatment of Opioid Addiction in
Pregnancy
• “Comprehensive care provided at
one location is cost effective and
produces better outcomes for both
mother and child.”
Early Start Program at Kaiser
Permanente, California
Patients who were screened, assessed and treated had
lower rates of preterm delivery, low birth weight, and
neonatal-assisted ventilation
American College of Obstetrics &
Gynecology Committee Opinion in 2004
wrote that “using a protocol for universal
screening, brief intervention, and referral
to treatment…results in a mean net savings
of $4644 in medical expenses per mother/
infant pair.”
Treatment Cost Considerations
Annual treatment cost for a person with drug addiction
One year in prison
$51-$73/day
$25,900
Outpatient
$15/day x 120 days
$1,800
Intensive Outpatient
9 hrs/week x 6
$2,500
months maintenance
Methadone
Maintenance
$13/day x 300 days
$3,900
Short term
residential treatment
$130/day x 30 days
+ $400 x 25 weeks
$4,400
Long term
residential treatment
$49/day x 140 days
$6,800
Reference: Position Paper on Drug Policy published by the Physician Leadership on
National Drug Policy January, 2000. Data source: Center for Substance Abuse
Treatment, Federal Bureau of Prisons. 1997 National Treatment Improvement Evaluation
Study
Pregnancy is an ideal time to provide
intervention to women with substance
abuse problems, as motivation to modify
harmful behavior is increased.