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Managing Opiate Addiction in

the Modern AmericanPregnancy

Lauren A. Miller MD MPH

February 22, 2018

Disclosures

• No financial disclosures to report

Audience Participation

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What do these celebrities all have in common? ..

Academy Award

Winners A

Heroin

addiction 8

Lived in Idaho C

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Objectives

1. Review current scope of the opiate problem

2. Brief review of current treatment options and their risks in pregnancy

3. Barriers to pre-conception / antenatal treatment

4. Challenges on L&D and Post-Partum units

5. Post-partum and long-term care

Cases

Patient “Melissa”32yo G7P2133 at 32w5d

“I’m withdrawing and I had a high fever at home yesterday (103F)”

-Complete prenatal care

-‘Kicked out’ of buprenorphine program for illicit use - 2nd Tri

- Incarcerated 1 month, “detoxed”

-Out of jail 1 month ago, relapsed on heroin 1 week ago, last use 1 day prior, took 1mg street suboxone that morning

Patient “Carla”26yo G4P3003 at 37w0d

“Active labor”

-Dating US in our ER at 7 weeks

- No other prenatal care

- Last used heroin that morning

- 5cm dilation on admission

-Started on subutex for withdrawal prevention on arrival

1.

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CDC.gov

Prescription Opiate Prescribing

2. Idaho Board of Pharmacy, Prescription Drug Monitoring Program, 4/1/2015-3/31/2016; Idaho Office of Drug Policy, Opioid Needs Assessment

3. CDC, 2017. Source for all prescribing data: QuintilesI MS Transactional

Data Warehouse (TDW) 2006–2016.

Which gender is more likely to die from an opiate-related

overdose?

Males A

Females B

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Overdose Deaths by Gender

4. Kaiser Family Foundation

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Drug overdose deaths by race

..2.0. deat1s pe· 100.000... .. ... ... .. ... ... .. ... ... . . . . . .. ... ... ... .. ... .. ... ... . ... .... . . . .. . .

'05 ·10

Whie

Ame . Indian

Black

Hispanic

5

Asian

6.

7.

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8.

What isBuprenorphine? ..

Bup-re-nor-phene -Am I saying

that right? Never heard of it...A

Different formulation of

Methadone B

A partial agonist at the

mu-opioid receptor C

A fullagonist at the mu-opioid

receptor D

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Medication-Assisted Treatment

Medication-Assisted Treatment = MAT Methadone, Buprenorphine, Naltrexone

Proven Benefits:▪ Methadone and Buprenorphine availability decreases the

number of fatal overdoses▪ Some MATs increase patients' retention in treatment▪ All MAT improve social functioning▪ All reduce the risks of infectious-disease transmission▪ All reduce engagement in criminal activities

9. Medication-Assisted Therapies — Tackling the Opioid-Overdose EpidemicNora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D. 10. N Engl J Med 2014; 370:2063-2066May 29, 2014DOI: 10.1056/NEJMp1402780

TreatmentOptions

Buprenorphine

(Suboxone or Subutex)

• Sublingual: Tablet or Film

• Buccal: Film

• Subdermal Implant

Maternal Risks/SE:

Insufficient coverage of cravings (therapeutic ceiling)

Overdose rare

Neonatal Risk: NAS

Methadone

• Oral: Liquid or Tablet

Maternal Risks/SE:

Overdose

Feeling high

Neonatal Risk: NAS

Detoxification

“Abstinence”

+/-Counseling

+/- Narcotics Anonymous

Maternal Risks/SE:

Relapse

Neonatal Risk: dependent on maternal relapse

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BuprenorphineBackgroundBuprenorphineBackground

Shorter hospital stay 10 vs 17.5 days

Shorter total tx duration4.1 vs 9.9 days

Less morphine1.1mg v 10.4mg

MOTHER Trial 2010Double blind placebo controlled RCT

131 neonates

58 buprenorphine

73 methadone

11. NIDA. (2017, May 25). Medications to Treat Opioid Addiction. Retrieved from https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-addiction on 2018, January 14

Name one potential barrier pregnant women face in trying to..

receive opiate addiction treatment?

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Barriers toTreatment

ACCESS to Prescribers!!

106 Licensed Physicians in Idaho36 ADA County 392,36516 Kootenai 188,92311 Canyon 138,4946 Bannock 82,8398 Bonner 40,8776 Bonnerville 104,2344 TwinFalls 77,2304 Nez Perce 39,2652 Valley 9,8622 Gooding 15,4642 Freemont 13,2421 Clearwater 8,7611 Cassia 22,9521 Caribou 9,6931 Teton 10,1701 Shoshone 12,7651 Payette 22,6231 Bear Lake 5,9861 Bingham 45,607

# Opiate Rx’s

Rate Opiate-RelatedOverdoses 2015 (218 total)

Rate of Opioid-Involved Overdose

Deaths per 100,000 Persons by State

and County for 2012-2016

13. Bureau of Vital Records and Health Statistics; Division of Public Health (July 2017)

CDCCDC

Barriers toTreatment

INSURANCE ACCESS

The Mental Health Parity and Addiction Equity Act Act (MHPAEA)

• 2008 federal law about access to mental health (MH) and substance use disorder (SUD) services

• The law does not require insurance and Medicaid plans to cover MH and SUD services, but when a service is covered, the service is subject to the MHPAEA rules

Barriers toTreatment

ACCESS to Insurance Coverage Opioid Needs Assessment

Idaho

August 2017

14. Prepared by: Idaho Department of Health and Welfare, Division of Behavioral Health

as a Component of Idaho’s Response to the Opioid Crisis Project

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OtherBarriers

Lack of Mental Health Services

• 60-80% of opiate abusers have at least 1 comorbid mental health diagnosis; Depression is most common, Bipolar also common15

• 50% of women with PTSD will have some type of SUD16

• History of prior suicide attempt is also high (10% range)

• Risk of relapse ? higher in people with comorbidities –data conflicting

OtherBarriers

Hiding their addiction

▪ Negative attitudes from health care providers

▪ Fear of Child Protective Service (CPS)

▪ Fear of inadequate treatment for their actual pain /disorder

➢No one realizes their was an opiate problem until the baby starts to withdraw post-partum

Screening and creating a “SAFE” environment is key!

Which of the following is a validated opiate abuse screening ..

tool in pregnancy?

COWS (Clinical Opiate AW ithdrawal Scale)

CAGE-AID 8

4Ps C

T-ACE D

Tweak E

NIDA quick screen F

CRAFT G

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Screening

ACOG Recommendations20-23:

• Early universal screening, brief intervention (such as engaging the patient in a short conversation, providing feedback and advice), and referral for treatment of pregnant women with opioid use and opioid use disorder improve maternal and infant outcomes.

• Screening for substance use should be part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Screening based only on factors, such as poor adherence to prenatal care or prior adverse pregnancy outcome, can lead to missed cases, and may add to stereotyping and stigma. Therefore, it is essential that screening be universal.

• Routine screening should rely on validated screening tools, such asquestionnaires, including 4Ps, NIDA Quick Screen, and CRAFFT (forwomen 26 years or younger).

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CAGE Questions Adapted to Include Drug

Use (CAGE-AID)

CAGE Questions Adapted to Include Drug Use (CAGE-AID)

1. Have you ever felt you ought to cut down on your drinking or drug use?

2. Have people annoyed you by criticizing your drinking or drug use?

3. Have you felt bad or guilty about your drinking or drug use?

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

Scoring: Item responses on the CAGE questions are scored 0 for "no" and 1 for "yes" answers, with a higher score being an indication of alcohol problems.

A total score of two or greater is considered clinically significant.

4Ps

1. Have you ever used drugs or alcohol during this Pregnancy?

2. Have you had a problem with drugs or alcohol in the Past?

3. Does your Partner have a problem with drugs or alcohol?

4. Do you consider one of your Parents to be an addict of alcoholic?

Further evaluation is recommended if the answer is YES to any of these questions

Substance Use RiskProfile-Pregnancy

1a. Ever smoked nicotinecigarettes?1b. Number of cigarettes smoked in month before knowing about pregnancy

2a. Ever drunk alcohol?2b. Number of alcoholic drinks consumed in month before knowing about pregnancy

3.Ever smoked marijuana?4. Ever used cocaine?5. Ever used sedatives, tranquilizers, sleeping pills, or other?6. Ever used heroin?7. Do you currently live with anyone who uses: Alcohol Nicotine cigarettes Marijuana Cocaine Heroin8. Have parents ever had problem with drugs or alcohol?9. Does partner have problem with drugs or alcohol?10. Number of drinks or hits or lines needed to feel effect?11. In the past year, did friends or family worry or complain about drinking or drug use?12. Do you drink or use drugs in the morning?

13.Ever been told about things you said or did while drinking or using drugs that you could not remember?14. Ever felt the need to cut down on alcohol or drug use?15. Hurt by someone in the home?16. Feel safe at home?

*Answers are yes or no unless otherwise specified.Data in items 1a, 2a, and 3–7 are from the Addiction Severity Index.13 Data in items 1b, 2a–b, 8, and 9 are from the 4Ps Plus.11 Data in items 10–14 are from TWEAK (Tolerance, Worried, Eye-openers, Amnesia, K[C] Cut Down).

0=low risk, 1=moderate risk, 2–3=high risk

25. Yonkers KA, Gotman N, Kershaw T, Forray A, Howell HB, Rounsaville BJ. Screening for Prenatal Substance Use: Development of the Substance Use Risk Profile-Pregnancy Scale. Obstetrics and gynecology. 2010;116(4):827-833. doi:10.1097/AOG.0b013e3181ed8290.

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Nobody made a greater mistake than he

who did nothing because he could only

do a little- Edmund Burke

It Takes aVillage!

Social Work / Community Resources

• Transportation

• Car seat

• Pack n’ play

• Diapers and other newborn basics

• Legal Resources

• Post-incarceration follow-up

• Women’s Shelters

• In-patient treatment allowing children

• Nurse-Family Partnership and other community-based outreach for new mothers

Antepartum

• Possible increase risk of fetal demise

• NSTs weekly 32+

• Option for IOL at term if desired

• Q4 week growth ultrasounds (especially if comorbid substance use like tobacco, on methadone, or frequent relapse)

INTRAPARTUM CONSIDERATIONS

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True or False: Women taking buprenorphine cannot receive ..

full-agonist opiates for post-partum pain?

True A

False B

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Labor & Delivery

Common misconceptions:

1. Women must stop buprenorphine while in labor – FALSE!

2. After a cesarean women must stop buprenorphine and

switch to a full agonist (dilaudid, oxycodone etc) – FALSE!

3. Full agonists are not as effective for pain control if women

remain on buprenorphine – FALSE!

4. 100% of Newborn will have neonatal abstinence syndrome –

FASLE!

5. Women cannot breastfeed while taking buprenorphine or

methadone – FALSE!

Pre-Admission

Discuss patients concerns about the delivery process

Pain Control

• Regional anesthesia, doula, massage, jacuzzi's

• Multimodal pain plan: Tylenol, Toradol/Motrin, Gabapentin?, Liposomal Bupivicane?

• Plan to continue current dose of buprenorphine!“Important to explain that there is no evidence that the use of opioids to treat acute pain increases the rate of relapse and that a more likely trigger may be unrelieved pain”26

• Subjects who stop their buprenorphine require significantly more opiate to control their pain27,28

• If stopped, restarting buprenorphine may require some degree of withdrawal from the opiates prescribed for their acute pain event

Drug Interactions toRemember

Nalbuphine “Nubain” or butorphanol “Stadol”(opioid agonist-antagonist) should be avoided = risk of precipitated withdrawal when taking opioid agonists29-31

St. John’s Wort = Increases metabolism of buprenorphine

Certain HIV medications may decrease clearance of buprenorphine

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Pre-Admission

Concerns about NAS

NAS is an expected and manageable condition

• Pre-Delivery consultation with Neonatologist / NNP / Pediatrician about expectations

• Review the Finnegan scoring system used

• Review how long babies are monitored in the hospital

• Ensure hospital staff are trained to be non-judgmental

• Secretaries, L&D Nurses, Hospitalists, Pediatricians, NNPs, Neonatologists, Lactation Consultants, Social Workers

Pre-Admission

Fear or Relapse, Depression, Manic Episode

• Have a plan to resume medications post-partum if she stopped them

• Plan a consultation with a lactation specialists if needed to review the safety of her planned medications

• Schedule psychiatry / psychology weekly after delivery

• Develop a safety plan, especially if SI / SA history

• Teach friends/family who come with the patient about post-partum depression and psychosis warning signs

• Discuss alternative to medications: exercise, meditation, group therapy, individual therapy

Will I be able to breastfeed my baby?

YES!!!

“Concentrations of both buprenorphine and methadone in human

breast milk are quite low, and pose little risk for neonates” (Klaman, ASAM32-35)

• WHO recommends breastfeeding

• Academy of Breastfeeding Medicine recommends breastfeeding

Breastfed neonates may have lower withdrawal scores➢ uncertain if this is due to the low amounts of drug they’re

receiving or if its from the actual act of breastfeeding

Pre-Admission

Will my baby be in the NICU or Nursery immediately?

It depends… on hospital policies and other factors that may necessitate neonatal evaluation

• Research suggests that the first-line approach to managing neonates may be a rooming-in model36

• Minimizes stimulation from outside sources

• Maximizes maternal-infant contact

• Encourages breastfeeding

Pre-Admission

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Post-Partum

Unknown if lower methadone or buprenorphine doses are needed after delivery

Øif on a stable dose from pre-pregnancyà don’t change

Øif increased throughout gestation, need close office follow-up to monitor for over-sedation, may need to reduce37-40

Post-partum visit at 2 and 6 weeks – mood and craving check

Should have plan in place for who will be managing their buprenorphine post-partum if the OB was the prescriber during the pregnancy

à major limiting factor for obstetricians to prescribe!

Cases

Melissa• MSSA Bacteremia, Sepsis

• Sepsis protocol, Cat 1 FHR

• Multifocal Pneumonia, Endocarditis, Homogenous frontal lobe infection

• Day 4 Chorioamnionitis, NSVD

• PICC DVT HD#9

• 6 weeks Naficillin

Carla• Quickly progressed and had NSVD

• Baby to newborn nursery for observation à NAS treatment

• Bottle feeding only

• Discharged to in-patient rehab on Suboxone PPD#3

• 4 weeks later Carla died from a heroin overdose

Questions?

References

1.CDC/NCHS, National Vital statistics Systems, Mortality. CDC WONDER, Atlanta, GA. US department of health and human services, CDC 2016.

http://wonder.cdc.gov/

2. Idaho Board of Pharmacy, Prescription Drug Monitoring Program, 4/1/2015-3/31/2016; Idaho Office of Drug Policy, Opioid Needs Assessment

3. CDC, 2017. Source for all prescribing data: QuintilesI MS Transactional Data Warehouse (TDW) 2006–2016.

4. Kaiser Family Foundation. http://wonder.cdc.gov/mcd-icd10.html

5. Josh Katz, Abby Goodnough. The Opioid Crisis Is Getting Worse, Particularly for Black Americans. New York Time. December, 22, 2017

6. Maeda A. Bateman BT, Clancy CR, et al. Anesthesiology. 2014 Dec;121(6):1158-65

7. NIH. Patrick et. al, JAMA 2012, Patrick et. al. Journal of Perinatology

8. Ko JY, Patrick SW, Tong VT, et al. MMWR Morb Mortal Wkly Rep. 2016; 65:799-802

9.Nora D. Volkow, M.D., Thomas R. Frieden, M.D., M.P.H., Pamela S. Hyde, J.D., and Stephen S. Cha, M.D. Medication-Assisted Therapies —

Tackling the Opioid-Overdose Epidemic

10. N Engl J Med 2014; 370:2063-2066. May 29, 2014 DOI:10.1056/NEJMp1402780

11.NIDA. (2017, May 25). Medications to Treat Opioid Addiction. Retrieved from https://www.drugabuse.gov/publications/research-

reports/medications-to-treat-opioid-addiction on 2018, January 14

12. Opioid Use disorder in Pregnancy. Actionable Strategies to improve management and outcomes. November 2017.

13. Bureau of Vital Records and Health Statistics; Division of Public Health (July 2017)

14. Opioid Needs assessment. Idaho 2017. Idaho department of Health and Welfare. Division of behavioral health.

15.Darke, S. and J. Ross (1997). "Polydrug dependence and psychiatric comorbidity among heroin injectors." Drug and Alcohol Dependence

48(2): 135-141.

16.Feske U, Tarter RE, Kirisci K, et al. Borderline Personality and Substance Use in Women. The American Journal on

Addictions.2006;15(2):131–137.

17.Peles E, Schreiber S, Naumovsky Y, et al. Depression in methadone maintenance treatment patients: Rate and risk factors. Journal of Affective

Disorders.2007;99(1–3):213–220.

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18.Tuten M, Heil SH, O'Grady KE, et al. The Impact of Mood Disorders on the Delivery and Neonatal Outcomes of Methadone-Maintained Pregnant

Patients. The American Journal of Drug and Alcohol Abuse. 2009;35(5):358–363.

19.Coleman, J. (2016). Examination of the Relationship between Trauma Exposure and Substance Use Severity in Pregnant and Recently Pregnant

Opioid Users. (Electronic Thesis or Dissertation). Retrieved from https://etd.ohiolink.edu/

20.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.

21. Martinez (CA): The Born Free Project, Contra Costa County Department of Health Services; 1990.

22.Chang G, Orav EJ, Jones JA, Buynitsky T, Gonzalez S, Wilkins-Haug L. Self-reported alcohol and drug use in pregnant young women: a pilot

study of associated factors and identification. J Addict Med 2011;5:221–6.

23. National Institute on Drug Abuse. Resource guide: screening for drug use in general medical settings. Available

at: https://www.drugabuse.gov/publications/resource-guide-screening-drug-use-in-general-medical-settings/nida-quick-screen. Retrieved March 8,

2017.⇦

24. Wright TE, et.al. . The role of screening, brief intervention, and referral to treatment in the perinatal period. . Am J Obset Gynecol 2016

25.Yonkers KA, Gotman N, Kershaw T, Forray A, Howell HB, Rounsaville BJ. Screening for Prenatal Substance Use: Development of the Substance

Use Risk Profile-Pregnancy Scale. Obstetrics and gynecology. 2010;116(4):827-833. doi:10.1097/AOG.0b013e3181ed8290.

26.Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern

Med 2006; 144:127-134.

27.Macintyre, P. E., et al. (2013). "Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and

methadone opioid substitution therapy." Anaesthesia and Intensive Care 41: 222+.

28.Huxtable, C. A., et al. (2011). "Acute pain management in opioid-tolerant patients: a growing challenge." Anaesthesia and Intensive Care 39:

804+.

29. Savage SR. Long-term opioid therapy: assessment of consequences and risks.J Pain Symptom Manage 1996;11:274–286.

30. Cassidy B, Cyna AM. Challenges that opioid-dependent women present to the obstetric anaesthetist. Anaesth Intensive Care 2004;32:494–501.

31.Jones HE, Deppen K, Hudak ML, et al. Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers. Am J Obstet

Gynecol 2014;210:302–310.

32.Klaman, S. L., et al. (2017). "Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants

and Children: Literature Review to Support National Guidance." Journal of Addiction Medicine 11(3): 178-190.

33.Ilett KF, Hackett LP, Gower S, et al. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk

during maternal buprenorphine substitution treatment. Breastfeed Med 2012;7:269–27

34.Jansson LM, Choo R, Velez ML, et al. Methadone maintenance and breastfeeding in the neonatal period. Pediatrics 2008;121:106–114.

35. Jansson LM, Choo R, Velez ML, et al. Methadone maintenance and long-term lactation. Breastfeed Med 2008;3:34–37.

36.Abrahams RR, MacKay-Dunn MH, Nevmerjitskaia V, et al. An evaluation of rooming-in among substance-exposed newborns in British

Columbia. J Obstet Gynaecol Can 2010;32:866–871

37.Bogen DL, Perel JM, Helsel JC, et al. Pharmacologic evidence to support clinical decision making for peripartum methadone treatment.

Psychopharmacology (Berl) 2013;225:441–451.

38.Jones HE, Johnson RE, O’Grady KE, et al. Milio L. Dosing adjustments in postpartum patients maintained on buprenorphine or methadone. J

Addict Med 2008;2:103–107.

39. Pace CA, Kaminetzky LB,Winter M, et al. Postpartum changes in methadone maintenance dose. J Subst Abuse Treat 2014;47:229–232.

40.Bastian JR, Chen H, Zhang H, et al. Dose-adjusted plasma concentrations of sublingual buprenorphine are lower during than after pregnancy.

Am J Obstet Gynecol 2016;216:64.e1–64.e7