Incorporating Medication-Assisted Therapies with Pregnant Women

1. Commonwealth Partnership for Women and Children Affected by Substance Use Incorporating Medication-Assisted Therapies withPregnant Women Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center November 12, 2009

2. Objectives • Consequences of substance abuse • Initiating addiction treatment with pregnant women • Methadone in pregnancy • Effects on fetus and newborn • Addiction and parenting

3. Substance abuseand sexual behaviors • Risk-taking behavior while intoxicated • Unprotected sex may lead to pregnancy • Drug use causes irregular menstrual cycles, but can still conceive • May not realize she is pregnant for several months

4. Alcohol • CNS depressant • Depresses inhibitions • Reduce anxiety (fun at parties) • Sedation • Oversedation, respiratory depression

5. Alcohol: Effects on fetus • Fetal Alcohol Syndrome/Fetal Alcohol Effects • Spectrum disorder • Increased risk of preterm delivery • Even moderate drinking • Encourage abstinence as soon as pregnancy suspected

6. Opioids • Morphine, heroin, OxyContin, methadone • Analgesics: disconnect from pain • Euphoria, disconnection, sedation • Oversedation, respiratory depression

7. Opioids: Effects on fetus • No known fetal anomalies • Higher incidence of prematurity • Heroin • Methadone • Pain meds • Neonatal abstinence syndrome • Continuous exposure • Use up to delivery

8. Stimulants • Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine • Enhanced concentration, alertness • Edginess, paranoia, hypervigilance, psychosis • Hypertension, hyperthermia, vasoconstriction • Heart attack, stroke

9. Stimulants: Effects on fetus • Preterm labor • Spontaneous abortion • Placental abruption • Fetal hypertension • ‘Crack baby syndrome’ disproven

10. Nicotine • Cigarettes, cigars, pipes, “snuff,” “chew” • Stimulant & relaxes • Acute effects • Vasoconstriction • Very short-acting, so high-frequency use • Very reinforcing

11. Smoking: Effects on fetus • Most common fetal exposure • Leading preventable cause of prematurity • Higher rates of spontaneous abortion, placenta previa, etc. • Nicotine patch better than smoking cigarettes

12. Marijuana • Marijuana, hashish, hash oil • active ingredient: THC • relaxation, hallucination • panic attacks • short-term memory impairment, anterograde amnesia

13. Marijuana: Effects on fetus • Widespread use among women of childbearing age • Not clearly associated with major physical or developmental effects in humans • Low birthweight • Often seen in combination with other substances • More research is needed

14. Injection drug use • Emboli • Particles go to lungs and cause damage • Talc, pill fragments, etc. • Lack of sterile technique • Local abscesses, cellulitis • Bloodstream infections to heart, other places • Needle sharing • Blood-borne infections (HBV, HCV, HIV) • Legal (paraphernalia laws)

15. Adulteration • White powder • Varies dealer to dealer & batch to batch • “Buyer beware” • Common adulterants • Sugar, condensed milk • OTC or Rx meds • User doesn’t know what is in the drug she bought

16. Overdose • Intake of a toxic or lethal amount of a substance into the body • More likely with heroin than prescription opioid abuse • More variability between dealers/batches • Most deaths occur in users in late 20s-early 30s who have used heroin for 5-10 years • Only 17% of deaths occur among novice users

17. Withdrawal • Reduction in the amount of drug being taken • rapid or slow • often results in a characteristic set of signs & symptoms known as the withdrawal syndrome • mild with flu-like symptoms or severe with seizures and cardiovascular collapse • Immediately reversed with administration of a drug in the same class

18. Barriers to treatment • Women wary of acknowledging problem • Fear of legal consequences (loss of custody) • Reporting requirements • Public health authorities, child protective services • Criminal justice system • When identified or at time of delivery • Inform patient of legal obligation

19. Initiating Addiction Treatment • Addiction is a complex disorder, & like other medical disorders, the patient is not totally responsible for acquiring it • The patient is responsible for her own recovery • Addiction is treatable--be optimistic about the patient’s ability to overcome the disease • Present reasons why it is best to stop using the substance(s) • Effects on unborn child • Maternal health/social effects • Recommend a practical treatment plan

20. Nicotine Patch • Highest success rate of available pharmacotherapies • Nicoderm, Nicotrol, Habitrol, Prostep • Most come in 3 strengths: 21, 14, & 7mg • Start with 21mg patch for 6 wks, taper to 14 mg for 2 wks, finally 7 mg for 2 weeks • Use new patch in different spot on upper trunk every 24 hrs

21. Nicotine Gum • Nicorette - 2 or 4mg per piece doses • Requires correct “chewing technique” -- don’t chew like regular chewing gum • Chew 1 piece for 30 minutes every 1 to 2 hrs to prevent nicotine W/D • Chew regularly for first month, then taper off over 6 months

22. Opioid addiction treatments • Abstinence-based • Narcotics Anonymous • Residential (with or after detox) • Antagonist maintenance • Naltrexone • Not for pregnant women • Opioid maintenance • Methadone • Buprenorphine

23. Maintenance pharmacotherapy • Long-acting medication in controlled setting • Counseling • Social services • Avoid withdrawal & craving • Reduce disease & crime • Maintenance vs. detoxification

24. Methadone • Opioid substitution therapy • Harm reduction • Individual • Society • Highly regulated • Narcotic treatment programs must be licensed • Very effective

25. Mechanism of Action • Methadone is a mu opioid agonist • No withdrawal symptoms • No craving • Long-acting • Multiple metabolites • Metabolized by Cytochrome P450 enzyme system • drug interactions

26. Methadone maintenance • Single daily dose of the long-acting opioid in a controlled setting • Use of methadone for >180 days (6 mo.) • Counseling and social services • Referral for primary medical services

27. Effectiveness • Controlled trials and meta-analyses comparing medication and placebo show the superiority of agonist pharmacotherapy • Improved treatment retention • Reduces and often eliminates use of nonprescribed opioids • Decreases criminal activity • Reduces spread of HIV • Results similar to long-term therapy of most chronic diseases

28. 18 years old or older Physical dependence At least 1 year of use Continuous Intermittent Withdrawal signs Chronic use Needle tracks on skin Exceptions Younger than 18 if Physical dependence Failed 2 other treatments Parental consent Not physically dependent if just released from Incarceration Hospital Pregnant Requirements

29. Methadone and Pregnancy • Standard of care for opioid-dependent pregnant women • Medical withdrawal not recommended • High relapse rates • Risks to fetus • Pregnancy is a high priority, so more rapid entry into programs • Maternal benefits not offset by harm to newborn (withdrawal)

30. Stabilization of mother and fetus Medical and social Improved maternal health and nutrition Better participation Prenatal care Addiction treatment Prepare for arrival of baby Reduces stress on fetus Reduces fluctuations in maternal opioid level Avoids adulterants Improves growth of fetus & newborn Reduces obstetrical complications Methadone and Pregnancy

31. Beneficial effects If heroin had a warning label… • Enhanced recovery • Reduced mortality • 70% reduction • Overdose • Trauma • Homicide • Medical illnesses • Improved health • Medical • Psychiatric • Improved psychosocial functioning • Employment • Criminal activity • Family responsibilities

32. Methadone and Pregnancy • Decreases practice of high-risk behaviors • Injection drug use • HCV, HBV, HIV, etc. • Prostitution • Risk of STDs • Violence • Reduce obstetric complications • Preterm labor (30-40% with opioids)

33. Blocking dose • Majority of opioid receptors are blocked by methadone • No withdrawal symptoms or cravings • Can’t “feel” heroin effects • Different for each patient • Usually 60-100mg daily • May be higher for some patients

34. What is the right dose? • Individually determined • Based on tolerance, withdrawal • Other medications, physical activity level • Induction • Start at 30mg and rapidly titrate up to 60mg or more • Stabilization • Client feedback, slower titration • Blind dosing • Haven’t had adequate trial of MM if hasn’t been on >60mg for several months

35. Methadone and Pregnancy • Daily dose over 60mg is most effective • Higher dose in 3rd trimester • Larger plasma volume • Increased tissue binding • Enhanced methadone metabolism • Increased methadone clearance • Split dosing ideal, but not always possible

36. Side effects • Sedation • Constipation • Sweating • Arrhythmia • Hyperalgesia

37. Does methadone get you high? • No real euphoria • Onset latency • Does cause sedation • Typical opioid effects • Reassuring • Confused with “high” • Mix with other drugs • benzodiazepines

38. Dispensing • Dose set by physician • Feedback from client • Dispensed by nurse or pharmacist • Liquid or tablets • Specific procedure required • Observed dosing • Reduce diversion • Take-out doses

39. Counseling • Required component • Formats • Groups • Individual • 12-Step • Relapse prevention • Coping skills • Case management

40. Methadone forever? • No federal limit for time on methadone • Some states restrict time • Virginia: evaluate every 2 years to see if can come off • Individual variability • Time required to stabilize (use, housing, family, job) • Long-term clients (decades) • Initial: can’t imagine life without something • Stable: able to consider coming off • Taper off comfortably over months/years

41. Dealing with other drug use • In general, all drug use is reduced on MM • May escalate other drug use when heroin not effective • Cocaine • Alcohol • Sedatives (benzos) • Intensify counseling, reaffirm goals for all drug abstinence

42. Buprenorphine • Long-acting opioid agonist-antagonist • Office-based opioid addiction treatment • Schedule III • Buy at local pharmacy (Subutex, Suboxone) • Very low risk of overdose • Combined with naloxone (Suboxone) • Used for acute pain treatment (Buprenex)

43. Buprenorphine and Pregnancy • Pregnancy Category C • Use Subutex instead of Suboxone to avoid naloxone • NAS less intense than with methadone • Studies ongoing, results encouraging

44. Neonatal Abstinence Syndrome • Characterized by • Hyperactivity, irritable • Hypertonia • Difficulty/excessive sucking • High-pitched cries • Begins 3h to 12d after delivery, depending on drugs used by mother

45. Treatment of NAS • Initial treatment is supportive • Swaddling, frequent feeding, IV fluids • Assess regularly for symptoms and failure to thrive • Pharmacotherapy • Usually opioids, occasionally sedative-hypnotic (phenobarbital) • Tincture of opium, paregoric, methadone

46. Breastfeeding • Encouraged • Promote bonding • Optimal nutrition • Passive immunity • Contraindications • Active substance abuse • HIV + • Methadone dose not important consideration

47. Home Environment • Addicted pregnant woman often product of poor parenting • Support network for new mother • Family, 12-Step group, health care workers • Encourage involvement of significant other • Lack of support can lead to relapse • Social services may need to be notified of unsafe living conditions

48. Parenting Skills • Education • Breastfeeding • Umbilical cord care • Approach for ‘fussy’ infant • Age-appropriate discipline for other children • Prevent frustration that leads to relapse

49. Children & Addiction • Young children don’t have to use drugs themselves to be affected • Child neglect & abuse • Loss of family structure • Inappropriate role models • Impair intellectual, social, & ethical behavior

50. Summary • Drug use behaviors may increase risk for unplanned pregnancy • Adulterants also harm mother and fetus • Methadone maintenance is treatment of choice for opioid-addicted pregnant women • Often must increase dose in 3rd trimester • Breastfeeding is encouraged • Support for mother is essential • Anticipate and educate to prevent relapse