Transcript Opioid Use and Maternal Health

Substance Abuse In the
Obstetric Patient
Dr. Erika Brandenstein M.D. F.A.C.O.G.
Objectives
• Identifying the Patient
• Maternal and fetal complications
• Managing the Patient and Infant
• Prevention
The Disease: It’s a Medical
Condition!
• Clearly defined diagnostic criteria in the
DSM –IV
- Chronic and relapsing condition
- Behavior disorder
- Affects brain and body functions
The Disease: The Role of the
Provider
• Recognize addiction as a medical issue
– Avoid viewing addiction as a moral issue
– Not a personal failure of sign of weakness
Addiction In the Pregnant Patient
• Opioid use in pregnant women double between 1998
and 2011
• Poly-substance use is common
• Non-medical use of prescription drugs increasing
2012-2013 National Survey on
Drug Use and Health
Ages
% Current Illicit Drug Users
15-17
14.6 %
18-25
8.6 %
26-44
3.2 %
Positive Drug Screens at Reid 2016
70
66
58
60
54
53
50
53
52
46
40
30
20
14
10
0
13
65
2
26%1
12
10
8
6
66
28%0 0
22%0 0
17
16
14
10
56
17%0
2
66
5
26%0 0
30%0 0
78
0
2
Jan
Feb
Mar
Apr
May
June
July
# of births
53
46
54
58
52
53
66
total # of pos drug screens
17
14
13
12
10
14
16
% of pos drugs screens
26%
28%
22%
17%
26%
30%
# of pos opiate screens
6
6
6
5
6
5
7
# of pos cannibus screens
5
8
6
6
6
10
8
# of pos MDMA (ecstasy)
1
0
0
0
0
0
0
# of pos cocaine screens
0
2
2
1
0
2
0
# of pos amphetamine screens
2
0
0
2
0
0
2
# of pos benzodiazipines
0
2
2
1
0
1
2
# of pos barbituates
0
0
0
1
2
1
3
Aug
Sept
Oct
Nov
Dec
Identification
• All patients should be
screened
• Consider face to face
interview
• The 4 P’s, CRAFFT
• Urine drug screens
Identification
The four Ps
• Parents: Did any of your parents have a problem with alcohol
or other drug use?
• Partner: Does your partner have a problem with alcohol or
drug use?
• Past: In the past, have you had difficulties in your life because
of alcohol or other drugs, including prescription medications?
• Present: In the past month, have you consumed any alcohol
or used other drugs?
• Scoring: Any “yes” answer should trigger further questions
Identification
• CRAFFT: Substance Abuse Screen for Adolescents and Young Adults
• C: Have you ever ridden in a CAR driven by someone (including yourself)
who was high or had been using alcohol or drugs?
• R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or
fit in?
• A: Do you ever use alcohol or drugs while you are by yourself or ALONE?
• F: Do you ever FORGET things you did while using alcohol or drugs?
• F: Do your FAMILY or friends ever tell you that you should cut down on
your drinking or drug use?
• T: Have you ever gotten into TROUBLE while using alcohol or drugs?
• Scoring: Two or more positive answers indicate the need for further
assessment
Urine Drug Screens: Patient
Selection
• Late or no prenatal care
• Diagnosis of stillbirth, placental abruption
• Always perform with patient’s knowledge and
consent
• Universal vs. selective screening controversy
– No uniform policy
– Reporting requirements
– Consider consequences of criminalization
Consent
• General consent for Maternity and Newborn
Care
– “ I understand that for my safety and that of my
infant a blood and/or urine sample will be
obtained and can be used to test for…”
– Review by hospital legal team
Testing the Infant
• Urine
• Meconium
• Cord segment
Marijuana Use in Pregnancy
• Most commonly used illicit drug in pregnancy (selfreported prevalence of 2-5%)
• 48-60% of marijuana users continue in pregnancy
(worsening with legalization)
• Crosses placenta/ fetal plasma levels 10% of
maternal levels
• Limited data shows transmission to breast milk
Marijuana use in pregnancy:
Adverse outcomes
• Disruption in brain
development in animal
models
• Mental and behavioral
issues
• No structural anatomic
defects
• Addictive in some
individuals
• Studies limited by
confounders
–
–
–
–
–
Polysubstance use
Lifestyle issues
Self-reporting
Recall bias
Inconsistent data
Marijuana and Lactation
• Insufficient data
• Encourage discontinuance
Medical Marijuana
•
•
•
•
Not regulated or evaluated by the FDA
No approved indications
Smoking cannot be condoned
Alternative therapy with pregnancy-specific
data
Opioid Use and Maternal Health:
• Heroin is most widely abused opioid and has highest
addiction potential
• Injecting increases risk for cellulitis/abscess,
endocarditis, osteomyelitis, Hep B, Hep C, HIV
• Heroin Withdrawal symptoms can develop in 4-6
hours
• Obsessive thinking and drug cravings may persist for
years
• Withdrawal sx: abdominal cramping, nausea,
insomnia, anxiety, and irritability
Opioid Use and the Fetus
Fetal death with acute withdrawal
Possible risk of birth defects
Fetal growth restriction
Abruptio placentae
Preterm labor
Intrauterine passage of meconium
Opioid Use and the Infant
• NAS: hyperactivity of central and autonomic
nervous system
• Finnegan scoring
• Long term affects
– Limited data
– No proven long term cognitive deficiency up to
age 5
Management of Opioid Abuse in
Pregnancy
Social Services
Mental health
professionals
Physicians and
Nurses
Management: Maintenance
Therapy
Prevents acute narcotic withdrawal in
mom and fetus
Prevents illicit opioid use
Reduces criminal activity
Encourages prenatal care and
comprehensive tx
Management: Methadone
• Long acting opioid receptor agonist
• Daily dosing
• Dose change may be required at onset of and
after pregnancy
• Dose titrated to until patient is asymptomatic
Management: Buprenorphine
(Subutex)
• Partial opioid agonist
• Prevents withdrawal symptoms and cravings
• Block euphoric effects of other opioids (higher
affinity for opioid receptors)
• Not a full agonist (less of a high)
Management: Buprenorphine
• Advantages over methadone
– No daily visits
– Less severe NAS (89% less morphine/ 58% shorter
duration)
– Fewer drug interactions
Management: Buprenorphine
• Disadvantages
– No long term data on neurodevelopmental effects
– Less structured tx (abuse/selling on the street)
– Not effective for all patients
Management: Buprenorphine w/
Naloxone (Suboxone)
• Naloxone is an opioid antagonist
– Binds to opioid receptor but does not activate
– Blocks opioids
• Causes severe withdrawal if injected
• Discourage in pregnancy
Buprenorphine
General Management
• Good communication between obstetrician and
addiction treatment program
• Know withdrawal symptoms
• Can initiate tx as an outpatient or in the inpatient
setting
• Illegal for physician to write a prescription for any
other opioid (including methadone) outside of a
licensed tx program. Buprenorphine excluded.
• Pt must be informed of fetal effects
Medically Supervised Withdrawal
• Not recommended due to high relapse rates
• It may be considered if needed (unavailability
or patient refusal)
• Preferably done in the second trimester
Intrapartum and Postpartum
Management
• Treat as if they were not
on opioid-assisted
therapy
• Epidural preferred for
Labor and delivery
• Notify pediatric staff
• Anticipate that
requirement for higher
doses
Management for Infants: NAS
• Tremors, seizures/convulsions, overactive reflexes
• Stuffy nose or sneezing
• Fussiness, excessive crying, high-pitched cry
• Poor feeding, poor sucking, poor weight gain
• High respiratory rate
• Fever, sweating, blotchy skin
• Trouble sleeping , yawning
• Diarrhea, vomiting
NAS
• Opiates, benzodiazepines, barbiturates,
alcohol, methamphetamines
• Assessment through Finnegan scoring
– 21 symptoms
– Initiating medications
Alcohol Use and Maternal Health
• 49.8% of women of childbearing age
• Directly associated w/ leading causes of
preventable death (heart disease, overdoses,
accidents, cirrhosis)
• Cancer and multiple deficiencies (thiamine, vit
C, niacin, pyridoxine)
• Increased risk of breast cancer
• Alcoholic cardiomyopathy
Alcohol Use and the Fetus
• Most common teratogen
• Leading cause of MR, developmental delay,
birth defects
• Greatest risk in first trimester
• FAS
• No established safe level in pregnancy
Fetal Alcohol Syndrome
Growth restriction (prenatal, postnatal, both)
Facial abnormalities ( epicanthal folds, ear
abnormalities, smooth philtrum, thin upper
lip, upturned nose, flat midface)
Central nervous system dysfunction
(behavioral disorders, ADD, microcephaly, MR)
Fetal Alcohol Syndrome
Intrapartum and Postpartum
Management
• Risk of aspiration w/ acute intoxication
• Risk of acute withdrawal w/ associated
symptoms (hypertension, delirium, seizures,
heart failure)
• Malnutrition, coagulopathy, neuropathy
should be considered when choosing
anesthesia
Infant Management
• Infant may have withdrawal symptoms
(jitteriness, poor feeding, irritability)
• Likely to occur within the first 12 hrs of life
• FAS from etoh treated w/ barbiturates
• No breastfeeding if actively abusing etoh.
Limit drinking to equivalent of 8 oz glass of
wine or 2 beers and wait 2 hrs until
breastfeeding
Cocaine Use and Maternal Health
Seizures
CVA
Cardiac
Disease
Poor
Nutrition
Psychosis
Cocaine Use and the Fetus
Placental abruption
Preterm birth
Low birth weight
Microcephaly, cognitive and motor disorders
Intrapartum and Postpartum
Management
• Maternal complications
– Thrombocytopenia
– Hypo or hypertension
– Cardia arrhythmias
• Pain control issues
• No acute neonatal
withdrawal syndrome
• No breastfeeding if
actively abusing
Methamphetamines and Maternal
Health
• Most frequently used after alcohol and
marijuana
• Arrhythmias, HTN, Seizures, hyperthermia
• Increased high risk sexual activity
• Insomnia, anxiety, confusion, memory loss,
and psychotic features w/ long term use
• Severe dental issues
Methamphetamine Use and the
Fetus
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•
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CNS Defects
Cardiac defects
Oral cleft and limb defects
GI defects
Long term effects on attention, memory and
visual motor integration
• No case-control or prospective studies
Intrapartum and Postpartum
Management
• Consider maternal complications
• Anticipate problems with infant
– Decreased arousal, increased stress, poor quality
of newborn movement
• Breastmilk 2.8-7.5 x higher than maternal
plasma
• Do not breastfeed!
Pregnancy Management Pearls
• Meds alone will not be
successful
– Prenatal care
– Chemical dependency
counseling
– Family therapy
– Group therapy
– Psychosocial services
Pregnancy Management Pearls
Education
Goal not to
judge
(Affect on
baby and
treatment)
Monitoring
(high risk)
Minimize
maternal
and fetal
separation
Barriers to Identification and
Treatment
• Poverty
– Transportation
– Education
– Inability to afford tx
• Fear
– Losing baby
– Jail
• Illness
Our Plan: Early Detection
Face to face interview
Office urine drug screen
Hospital urine drug screen
Our Plan: Management
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•
•
•
•
Patient education
Treatment referral
Medications
Correspondence
Close follow-up/ surveillance (office visits,
DCS)
• Support (WIC, transportation, classes)
• Encouragement and compassion
Our Plan: Prevention
Contraception
• Free clinic
• LARCs
Postpartum
treatment
• Supervised
withdrawal
Postpartum
support
• Early follow-up
• Inpatient or
transitional facility
Our Plan: Prevention
• Hospital wide and unit based discussions with
multidisciplinary teams.
• Community outreach
Resources
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American Congress of Obstetricians and Gynecologists. Patent safety update: routine urine drug screens on our pregnant patients?.
Available at:://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/January-2015/Patient-Safety.
Retrieved on Sept 19, 2015.
Center for Adolescent Substance Abuse Research, Children’s Hospital Boston. The CRAFFT Screening Interview. (2009). Boston: CeASAR;
2009. Available at: www.ceasar.org/CRAFFT/pdf/ CRAFFT_English.pdf. Retrieved September 19, 2015.
Daniel J et al, Fetal alcohol spectrum disorders, National Human Genome Research Institute, National Institutes of Health, Bethesda
Maryland, Am Fam Physican, 2005 July 15; 72 (2): 279-285.
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 Dept of Health Services, 1990.
How buprenorphine works. Available at https://advancedpainmanagementclinic.com /addiction/suboxone-pharmacolo . Retrieved Oct
3, 2016.
Marijuana use during pregnancy and lactation. Committee Opinion No. 637. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2015;126:234-8.
Methamphetamine abuse in women of reproductive age. Committee Opinion No. 479. Americn collete of Obstetricians and
Gynecologists. Obstet Gynecol 2011:117:751-5.
Resources cont.
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Neonatal Abstinence Syndrome. Available at: http://www.marchofdimes.org/baby/neonatal-abstinence-syndrome-(nas).aspx Retrieved Oct 4,
2016.
Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2012; 119:1070-6.
Reece-Stremtan S, Marnelli A, Academy of Breastfeeding Medicine. AMB clinical protocol #21: Guidelines for breastfeeding and substance use
or substance use disorder. Breastfeeding medicine 2015, 10: 3.
Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist. Committee Opinion No. 473. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2011; 11:200-1.
Substance Abuse and Mental Health Services Administration. 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: Substance Abuse and Mental Health Services
Administration, 2014.
Substance Use Disorders in Pregnancy Consensus Statement Executive Summary 2007.Indiana perinatal Network. www.indianaperinatal.org.
Retrieved October 4, 2016.
Thank You!!!