PROJECT DOVEImproving Maternal and Neonatal Health

Through Safer Opioid Prescribing

MODULE 3

Partners

SupportBureau of Justice Assistance,

Department of JusticeGrant # PM-BX-Koo4

3Treatment Plan Adjustment and Perinatal Care

MODULE

Monitor pregnant patients in treatment for opioid use disorder

Manage pain and medications during delivery

Identify maternal and neonatal needs following delivery and coordinate with neonatal/pediatric team to assess for NAS

Module 3 provides youwith information and tools to:Learning Objectives

This symbol indicates that the documents referenced are available for download in the Resources section of the online course.

www.brown-cme.com/opioids-pregnancy

Downloadable Resources

Continuous Monitoring and Treatment Plan Adjustment

Monitoring

Use monitoring tools on a schedule that reflects patient needs

Prescription Drug Monitoring Program (PDMP)

Urine drug testing

Structured screening tools for pain, substance use, mental health

Communication with patient

Review treatment plan at each visit

Affirm and promote positive outcomes:

▪ Focus on the goals the patient has achieved

▪ Offer verbal praise

What if the patient is not meeting her treatment goals?

Reassess and affirm whether the goals are still meaningful to her

Identify barriers

Offer resources to help overcome barriers

Break goals into smaller steps

Work with patient to set more attainable goals

Brief history

At her first visit, Carol presented with:

▪ Pregnancy at 12 weeks gestation

▪ Use of oxycodone 15 mg bid following spinal fusion; no signs of nonmedical use

▪ Moderate depression and anxiety treated with SSRI

At the conclusion of her first visit, Carol:

▪ Decided to taper off opioids

▪ Received referrals to acupuncture, physical therapy, and a pain specialist

Purpose of visit

▪ Follow-up visit

PATIENT 1

Carol

Age 27

Carol is no longer taking oxycodone. She is at 28 weeks

gestation. Carol has completed the pre-appointment

paperwork, which included the GAD and PHQ. Both

indicate increased symptoms of anxiety and depression.

Carol’s PEG score (Pain, Enjoyment of life, General

activity Scale) is steady.

Carol’s status at visit

Carol Video

Dr. Hayes will continue to monitor the screening

scores. He offers Carol suggestions for

medication-free strategies for coping with pain

such as complementary and alternative medicine

and mindfulness options.

Carol’s visit conclusion

Brief history

PATIENT 2

Sarah

Age 28

At her first visit, Sarah presented with:

▪ Pregnancy at 8 weeks gestation

▪ Methadone treatment for 2 years, with relapse 8 months prior to visit

▪ A desire to discontinue methadone out of concern for the fetus

At the conclusion of the first visit, Sarah:

▪ Decided to maintain methadone

▪ Received informational brochures

▪ Scheduled a follow-up visit to discuss methadone recommendations and NAS with the clinician and her boyfriend

▪ Regular prenatal visit

Purpose of visit

Sarah has regularly attended prenatal care. She is at 31 weeks gestation. Sarah has been getting urine toxicology testing, and her screening results have been appropriate for her methadone treatment with no nonprescribed substances.

Sarah’s status at visit

Dosage Adjustments in Pregnancy

Patients on opioid agonist treatment may be concerned about the effect of dosage increases on the fetus.

Clinicians should reassure patients that multiple studies have found no relationship between methadone dosage and NAS severity or other neonatal outcomes.

Cleary et al., 2010; Jones et al., 2013 & 2014

Of great concern are withdrawal symptoms due to inadequate dosage because withdrawal increases risk of relapse and the fetus feels the withdrawal that the mother feels.

Sarah Video

After the ultrasound, Dr. Brown asks Sarah about the referrals her team provided at earlier visits. Sarah tried the prenatal yoga, but has not continued due to transportation issues. She has been attending the mothers in recovery support group.

After the visit, Dr. Brown contacts the methadone treatment provider to alert the treatment provider to the potential need for dosage increase.

Sarah’s visit conclusion

At her first visit, Angela presented with:

▪ Pregnancy at 10 weeks gestation

▪ Signs of nonmedical Rx opioid use in PDMP

▪ History of anxiety

▪ Request for opioid fill

At the conclusion of her first visit, Angela:

▪ Agreed to buprenorphine treatment with another clinician

▪ Accepted information about recovery coach and home visiting services but did not schedule appointments

Age 34

PATIENT 3

Angela

Brief history

▪ Prenatal visit after buprenorphine induction

Purpose of visit

Angela attends a scheduled follow-up visit with Dr. Jones 3 weeks after her initial visit. She has begun buprenorphine treatment with Dr. Burrell. At her initial visit with Dr. Jones, Angela signed a release of information so that Dr. Jones could coordinate with Dr. Burrell.

Angela’s status at visit

Angela Video

Before Angela leaves the appointment, Dr. Jones’ scheduler:

▪ Arranges an appointment for Angela to tour the neonatal nursery and NICU and meet the hospital social worker.

▪ Contacts the home visiting program to schedule an appointment for Angela.

At a later visit, the neonatal care nurse provides Angela with training on:

▪ Signs of NAS

▪ Environmental conditions to reduce NAS

▪ Soothing techniques

Angela’s visit conclusion

Managing Pain and Medication Intrapartum and Immediate Postpartum

Management of intrapartum and postpartum pain poses particular challenges in women physically dependent on opioids or agonist therapy for opioid use disorder

Jones et al. 2009; Meyer et al. 2007 & 2010; Savage & Schofferman, 1995

Long-term exposure to opioid agonists can result in:

Reduced pain tolerance

Reduced analgesic effect from opioids

Greater postpartum pain

Clinicians should aim to reduce patient anxiety about labor and postpartum pain

Use clear communication about the plan for pain management

Remember that breathing and mindfulness techniques can help patients manage anxiety and prepare for pain

Planning for Pain Management

Hofmann et al., 2010, Rosenzweig et al., 2010

To manage pain in childbirth use:

▪ Contact the opioid agonist provider to verify the dose and ensure the patient has medication during and after delivery.

▪ Hospital must be prepared to provide methadone or buprenorphine doses if needed to maintain schedule

Uninterrupted agonist therapy for opioid use disorder

▪ Initiating early in labor may be particularly beneficial in attaining adequate pain relief

Epidural or combined spinal/epidural analgesia

▪ Titrate to achieve pain relief

▪ Generally higher doses of opioid analgesics needed than other patients, administered at shorter intervals, but for the same duration

Opioid analgesics as needed

Caution: For patients on methadone, partial agonist/antagonist medications nalbuphine, butorphanol, and pentazocine are contraindicateddue to risk of precipitated withdrawal

Preston et al., 1989

For cesarean delivery, multimodal therapy for postoperative pain management can be beneficial:

NSAIDS (beginning with an intraoperative ketorolac dose, if appropriate)

Spinal or epidural morphine

Acetaminophen with or without patient-controlled analgesia for breakthrough pain

Jones et al., 2014

Managing pain after cesarean delivery:

LABOR

▪ Maintain methadone/buprenorphine; consider subdividing dose into 3 or 4 doses administered every 6 to 8 hours

▪ Use epidural analgesia

▪ Do not use partial agonist-antagonists nalbuphine,butorphanol, or pentazocine due to risk of acute withdrawal

▪ Use IV opioids prn

Managing Intrapartum and Postpartum Pain in Patients Receiving Methadone or Buprenorphine

Cesarean Birth

Vaginal Birth ▪ Maintain methadone/buprenorphine

▪ If pain unmanaged with NSAIDS (including ketorolac) or acetaminophen, use short-acting full mu opioid agonists

▪ Maintain methadone/buprenorphine

▪ Can use IV opioids prn for first 24 hours; consider PCA or give short-acting full mu opioid agonists immediately post-op; change to prn after 48 hours

▪ If pain is poorly controlled, change to hydromorphone

POSTPARTUM

NAS Assessment and Treatment

Signs and Symptoms of NAS

Finnegan et al., 1975; Jones & Fielder, 2015; Finnegan & Kaltenbach, 1992

Central nervous system signs

▪ Irritability▪ High-pitched crying▪ Sleep disturbance▪ Tremors▪ Exaggerated reflexes▪ Myoclonic jerks

Autonomic and respiratory signs

▪ Fever▪ Sweating ▪ Yawning▪ Sneezing▪ Nasal stuffiness▪ Rapid breathing

Gastrointestinal signs

▪ Uncoordinated or continuous sucking

▪ Poor feeding ▪ Vomiting▪ Loose stools

Clinicians should describe NAS signs to the mother and train her in the use of the hospital’s NAS scoring tool so that she can actively monitor her newborn.

Be aware that mothers often experience guilt and shame about the possibility of NAS onset. Clinicians should use nonjudgmental explanations.

For example: The baby adapted to the proteins, sugars, and opioids through the placenta and now needs to adapt to this new environment.

Discussing NAS Signs and Symptoms

Jansson & Velez, 2012, Huybrechts et al., Kaltenbach et al., 2012; 2017; Seligman et al., 2008

NAS severity may be increased by polydrug use, benzodiazepine or SSRI use, smoking, full-term gestation, good birth weight, and genetic factors

The onset of NAS presentation after birth varies by opioid

Gaalema et al., 2012; Zelson et al., 1971

usually

24 to 48 hours

usually

48 to 72hours

unclear

The MOTHER study found that the mean time to pharmacotherapy was 34 hours for methadone-exposed neonates and 71 hours for buprenorphine-exposed neonates

Currently there are no systematic studies of time of onset of NAS due to prescription opioid pain medications

Heroin Methadone Buprenorphine Prescription opioids

slower to

present than methadone

Onset of NAS Presentation

Hudak and Tan, 2012

The American Academy of Pediatrics recommends that opioid-exposed neonates be monitored for NAS for 5–7 days to prevent discharge prior to NAS presentation

NAS scoring tools aid in determining need for pharmacotherapy, and in titrating and terminating therapy

Scoring should be performed after feeds, at 3- to 4-hour intervals, when the infant is awake

Kocherlakota, 2014; Sarkar & Dunn, 2006

Research on optimal NAS screening and assessment tools is needed.

NAS Assessment Tools

Non-NASS MeasuresNASS Measures

▪ Neonatal Abstinence Scoring System (NASS)aka the Finnegan tool is the most widely known, though challenging to administer

▪ MOTHER NAS Scale (MNS) improved the NASS,

and a short form has been developed

▪ Neonatal Drug Withdrawal Scoring System (NDWSS) aka the Lipsitz scale is commonly used

▪ Neonatal Narcotic Withdrawal Index (NNWI)

▪ Neonatal Withdrawal Inventory (NWI)

Clear evidence does not exist favoring a specific assessment tool, opioid treatment medication, or adjuvant medication. Evidence suggests, however, that adherence to a treatment protocol shortens length of treatment and length of stay.

Patrick et al., 2016

Avoid the NICU setting in favor of “rooming in” mother and baby or a neonatal nursery.

Optimal environmental conditions for neonates exposed to opioids in utero include minimal stimulation, dim light, and low noise. Low music may help some newborns.

Rooming in allows for skin contact and breastfeeding(shown to reduce NAS) and improved maternal bonding.

Rooming In

Abrahams et al., 2007, 2010; Hodgson and Abrahams, 2012; Newman et al., 2015

Active Caregiver Participation

Hudak & Tan, 2012; Kocherlakota, 2014

Active maternal participation in care and handling by caregivers is beneficial:

▪ Skin-to-skin contact (kangaroo care)

▪ Holding, cuddling, gentle handling

▪ Pacifiers, swaddling

▪ Frequent feeding, breastfeeding

Early detection of and response to NAS symptoms is important: at first sign of irritability neonates should be soothed.

Breastfeeding

Evidence suggests that breastfeeding decreases NAS scores,the need for treatment, length of pharmacological therapy, and length of hospital stay in infants prenatally exposed to methadone or buprenorphine.

Abdel-Latif et al., 2006; Pritham et al., 2012; Welle-Strand et al., 2013

Abdel-Latif et al., 2006; Pritham et al., 2012; Wachman et al., 2013; Welle-Strand et al., 2013.

Breastfeeding is contraindicated if the mother is HIV positive or using illicit drugs or select prescribed medications.

If the patient is taking short-acting opioids for pain, advise breastfeeding before taking the medication.

The FDA recommends caution in use of tramadol or codeine when breastfeeding, as some patients are ultrarapid metabolizers.

Special considerations:

Opioids and Adjuvant Medications

Morphine sulfate is the most common medication used to treat NAS.

Methadone is also common. Can be more difficult to titrate than

morphine due to longer half-life.

Buprenorphine is a newer addition. In a recent clinical trial,

buprenorphine showed shorter treatment and hospital stay duration than morphine.

Opioids are the first-line NAS treatment:

Adjuvant medications can reduce NAS treatment duration:

Phenobarbital lowers the cumulative dose of opioids needed.

Clonidine aids in treating the signs and symptoms of NAS.

Brown et al., 2014; Kraft et al., 2017

Maternal Postpartum Care

After Delivery

Monitor the patient for sedative effects of agonist and other postpartum medication

Coordinate hospital release with the opioid agonist provider so the patient does not have an interruption in medication

.

If dosage increased during pregnancy, plan for decreasesbased on symptoms

Remind the patient to return on schedule to her methadone or buprenorphine provider

Immediate Postpartum Period

Continue to monitor for need for dosage decrease

Discuss contraceptives and sexually transmitted infection prevention plans

Rescreen and reassess needs, including screening for postpartum depression and anxiety

Revisit treatment plan especially related to substance use supports, mental health care, and pain management

Ensure that the patient has a postpartum care plan and that linkages to other services have occurred

Ongoing Routine Care

Ask about breastfeeding

Screen for postpartum depression

Screen for substance use, cravings, and withdrawal symptoms

Continue to offer or ask about in-home support such as home visiting and recovery coach services

MODULE 3

KEY POINTS

For monitoring and treatment plan adjustment:

Continue use of monitoring tools

Use affirmations to support patient’s progress

Provide additional resources and referrals as patient’s needs change

Be conscious of dosage adjustment needs, especially in patients on methadone

Key Point

For pain management in delivery and postpartum, expect that patients will need:

Clear communication about plan for pain management in childbirth

Multimodal pain management, including epidurals, and higher opioid dosage (prn) but same duration as other patients

Uninterrupted opioid agonist treatment, if applicable

Key Point

Optimal neonatal care includes:

Promote rooming in to provide a low-stimulation environment and maternal bonding

Skin-to-skin contact, soothing, breastfeeding, frequent feeding

If needed, opioids as the first-line pharmacological treatment

Key Point

For maternal postpartum care:

Monitor for sedative effects of opioid agonist therapy

Screen for postpartum depression, substance use, and pain management

Revisit referral and resource needs

Key Point

Sarah’s Summary (Video)

Dr. Jones’ Summary

congratulations!you have completed Module 3