Transcript Opioid use in the perinatal period: Prevalence and treatment strategies

Anne Merewood PhD MPH IBCLC
Associate Professor of Pediatrics, Boston University
School of Medicine
Consultant to the Rocky Mountain Tribal Leaders Council
Illicit drug use in adolescents and pregnant
women
 A growing problem across the US; health care
workers struggling to meet the challenges
 On some reservations, the problem is
overwhelming in both hospital and community
 No easy answers but raising awareness is
critical
Illicit substance use around the time of
birth: Broader implications
 Not just a “maternal” problem
 Domestic violence
 Suicide
Illicit substance use around the time of
birth: Broader implications
 Child neglect/abuse
 Multiple drug use; alcohol use
 Law enforcement and custody issues
 Financial issues; poverty; hunger
 Medical issues – Hepatitis C; HIV; mental
health, etc
Illicit substance use around the time of
birth
 Ongoing ‘tension’ of personal ‘stance’…
 A moral issue?
 A medical issue?
 Emotional and complex when infants/young
children are involved
 Even more complex among health care
professionals who may have been exposed to
the same issues
Illicit substance use around the time of
birth
 Beliefs of health care workers may impact how
they react; lead to conflict
 Policies are critical to ensure consistent
treatment
 Health care workers often from the same
community – pressures, confidentiality?
 Burnout/compassion fatigue among health
care professionals
Illicit substance use around the time of
birth
 Small communities with complex relationships
 Some clinicians experience pressure from
patients (“we need opiates”) which conflicts
with current work to reduce iatrogenicinduced opiate dependency
Prevalence of illicit drug use
in the US
Illicit drug use SAMHSA: Results from the 2013
National Survey on Drug Use and Health:
Summary of National Findings, NSDUH Series
H-48, HHS Publication No. (SMA) 14-4863.
Rockville, MD
SAHMSA report (2013)
 9.4% of the US population over 12 had used
illicit drugs in the month prior to the survey
 Marijuana was the most commonly used illicit
drug (7% of population, or 80% of users used
marijuana)
 2 million Americans addicted to prescription
opioids
Drug use by race/ethnicity
 Asians – 3.1%
 Hispanics – 8.8%
 Whites – 9.5%
 Blacks – 10.5%
 AI/AN – 12.3%
 Native Hawaiians/Pacific Islanders – 14%
 2 or more races – 17.4%
Trauma increases chance of use
 Among women in treatment, 84% reported history
of childhood sexual abuse or neglectFrederick S. Cohen and Judianne DensenGerber J.D., M.D
 Adolescents who had experienced physical or sexual
abuse/assault 3 x more likely to report past or
National Survey of Adolescents 2003
current substance abuse
 >70% adolescents receiving treatment for substance
abuse reported a history of trauma exposure
Funk RR, McDermeit M, Godley SH, Adams L. Child
Maltreat 2003
SAHMSA data: 2013
Drug Availability: Prescription
Opioid Statistics in US
Opioid Prescriptions (in millions)
1991, 2010
0
50
100
150
200
250
1991
76
206
2010
Drug use in pregnancy
 5% illicit drug use overall
 11% rate in same group, not pregnant
 15% among pregnant 15-17 year olds
 9% among pregnant 18-25 year olds
 3% among pregnant 26-44 year olds
Opioid use in pregnancy
 5.6 infants/1,000 births,
nationally
 9/1000 in Montana
 30%+ on some MT
reservations
Treatment for pregnant women
who use opioids
 Maintenance therapy: ACOG’s standard of care
 Methadone or buprenorphine commonly
prescribed, backed by testing and counseling
 Goal: Dose just high enough to stop use and
block cravings
 Dose may need adjustment during pregnancy
 Dose unrelated to severity of infant withdrawal
Positives of opioid maintenance
 For pregnant woman:
 Prevents detox/relapse cycle
 Reduces illicit drug use and related
complications
 For the fetus/baby:
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
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Prevents in utero opioid peaks/depressions
Decreases preterm delivery and IUGR
Decreases morbidity/ mortality
Still likely to suffer NAS (Neonatal Abstinence
Syndrome)
Neonatal Abstinence Syndrome
(NAS)
 An infant with NAS suffers from ‘withdrawal’
symptoms resulting from maternal opioid use
in pregnancy
 NAS affects 60-80% of exposed infants
 20% of NAS babies in MT are low birthweight
(compared to 9% in non NAS)
 $53,000 per infant; 80% Medicaid patients
Increase in NAS
 2000 to 2012 saw a 5-fold increase in the
proportion of US babies born with NAS
 In 2012, 21,732 US infants born with NAS – 1
every 25 minutes
 http://www.drugabuse.gov/related-topics/trends-
statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatalabstinence-syndrome
NAS
 Typically 48-72 hours after birth but can
surface as late as 7 days after birth
 60-70% require medication treatment –
standard of care is morphine
 Inability to predict/not dose related
 Inpatient monitoring period of at least 5 days
NAS
System
Symptoms
Central Nervous
System
Tremors
Irritability
Sleep disturbance
High pitched crying
Hypertonia
Hyperactive reflexes
Myoclonic Jerks
Generalized convulsions
Slide credit: Elisha Wachman, MD, Boston Medical Center
System
Gastrointestinal
System
Respiratory System
Symptoms
Poor feeding
Vomiting
Diarrhea
Excessive sucking
Tachypnea
Apnea
Respiratory distress
Slide credit: Elisha Wachman, MD, Boston Medical Center
System
Symptoms
Autonomic Nervous System
Sneezing
Nasal stuffiness
Yawning
Mottling
Fever
Sweating
Slide credit: Elisha Wachman, MD, Boston Medical Center
Finnegan’s scoring tool
Central Nervous System
Disturbances
Metabolic, Vasomotor, and Respiratory
Disturbance
Gastrointestinal
Disturbance
Excessive High Pitched Crying – 2
Continuous High Pitched Crying - 3
Sweating – 1
Excessive Sucking – 1
Sleep < 1 Hr After Feeding – 3
Sleep < 2 Hr After Feeding – 2
Sleep < 3 Hr After Feeding – 1
Fever < 101 (37.2 – 38.3 C) – 1
Fever > 101 (38.4 C) – 2
Poor feeding – 2
Hyperactive Moro Reflex – 2
Markedly Hyperactive Moro Reflex – 3
Frequent Yawning (>3) – 1
Regurgitation – 2
Projective Vomiting – 3
Mild Tremors Disturbed – 1
Mod – Severe Tremors Disturbed – 2
Mottling – 1
Loose Stools – 2
Watery Stools – 3
Mild Tremors Undisturbed – 3
Mod – Severe Tremors Undisturbed - 4
Nasal Stuffiness – 1
Increased Muscle Tone - 2
Sneezing (>3) – 1
Excoriation – 1
Nasal Flaring – 2
Myoclonic Jerk – 3
Respiratory Rate (>60) – 1
Respiratory Rate (>60 with Retractions) – 2
Seizures – 5
Protective/ameliorating factors
 Breastfeeding
 Skin to skin care
 Maternal stability and presence at the
bedside
 Low light/stimulation
 Prematurity
Breastfeeding and illicit substance use
 All IHS OB facilities gained Baby-Friendly™
designation by 12/2014
 “Baby-Friendly” is a WHO initiative which
promotes breastfeeding and optimal MCH
practices in the hospital
 Many IHS OB hospitals have high breastfeeding
rates
 During the IHS Baby-Friendly initiative, the
question arose – how to handle breastfeeding and
illicit substance use
A complex context
 Many AI/AN women live in settings where
breastfeeding is the norm and rates are high
 ‘Policing’ breastfeeding is unrealistic
 Not breastfeeding adds to health risks
 Stories emerge about women breastfeeding on
drugs and infants dying
 So what do we advise?
 “Despite the myriad factors that may make
breastfeeding a difficult choice for women
with substance use disorders, drug-exposed
infants, who are at a high risk for an array of
medical, psychological, and developmental
issues, as well as their mothers, stand to
benefit significantly from breastfeeding.”
 Academy of Breastfeeding Medicine Clinical Protocol #21: Guidelines for
Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015
Where can I get a “definitive” answer?
 There are no definitive answers, but LactMed
is an excellent source of information
 http://toxnet.nlm.nih.gov/newtoxnet/lactmed.
htm
 LactMed is a service of the NIH and it updates
with new evidence as it comes in
In conclusion….
 Illicit drug use/opioid use in the perinatal period is a
complex and growing problem
 There are effective treatments but these are not
always made available in Indian Country
 Education is key to assessing options
 This webinar skimmed the surface – questions and
suggestions for additional information?