SubstanceAbuseinwomen

LeenaMittal,MDDirector,ReproductivePsychiatryConsultation

BrighamandWomen’sHospitalHarvardMedicalSchool

ASAMDisclosureofRelevantFinancialRelationships

ContentofActivity:ASAM Medical–ScientificConference2014

• Ihavenorelevantdisclosuresregardingfinancialconflictsofinterest

Objectives

• Overviewofsubstanceusedisorders(SUD)inwomen

• HowpregnancyaffectspresentationandmanagementofSUD

• Opioids• Alcohol• Cannabis• Cocaine/Stimulants

“Iwasgoodfor51yrs”

MsCisa52yo woman,divorced1.5yrsago,whowasadmittedtothemedicalhospitalfortreatmentofpancreatitis

• Treatedforalcoholwithdrawalatthebeginningofadmission

• Alcoholuseescalatedafterdivorce• Lostherjobasadentalhygienistandnearlylosingherhome

• Declinedreferralfortreatment

NSDUH2012

Sexbaseddifferences• SUDaremorecommoninmenthanwomen– Thegapisclosing–Maybeagerelated

• Differentcourse/naturalhistory– Telescoping– lateronset,morerapidprogressionfrominitiationtoonsetofdependence/tx entry– seenwithETOH,opioids,cannabis

– Interpersonalfactorsmodulateprogression(partnersandchildren)

Sexbaseddifferences• Biological–Menstrualcycle,pregnancy,agingandmenopause– Ovariansexsteroidsimpacteffectsofcocaine,amphetamines,cannabis

– Sex-basedETOHthresholds• Psychiatriccomorbidity–Mooddisorders– EatingDisorders– PTSD

“Ijustcan’tgetittogether”

• Christyisa32yo FwhopresentedtoLaborandDeliveryreportingshehadabdominalpainandwas“around7monthspregnant”– Oneprenatalvisit- “smelledofalcohol”– Outreachcallsfrommidwifefoundpatienttohaveslurredspeech

– DV,unstablehousing,lossofcustody,pooraccesstofoodandhealthcare

– Drinkingdaily– Acceptedreferralforsubstancetx thoughdidnotshowforappt

Substanceuseduringpregnancyincreasesriskforwomanandfetus– ExposuretoTeratogens– Limitedparticipationinprenatalcare– Poornutrition– Placentalinsufficiency– Difficultieswithlabormanagement–Withdrawal– Infectiousrisk(eg HIV,HCV)– Overdose– Psychiatriccomorbidity

KeeganJetal.JAddictiveDiseases.2010.29(2)175-91

DrugUseinthepastmonth,Females15-44

NSDUH2012

SubstanceAbuseduringpregnancy

• Pregnancyisamotivatorforcessation

• Persistenceofsubstanceabuseduringpregnancymayrepresentaparticularlyrefractoryandhighrisksubpopulation

• Higherlevelsofusepriortopregnancycorrelatewithcontinueduseduringpregnancy

• Mostwomenreturntopre-pregnancyratesofsmokingandalcoholabusewithin6-12monthspostpartum

HavensJRetal.DrugandAlcoholDependence99(2009)89–95;NSDUH2010;HarrisonetalMaternChildHealthJ(2009)13:386–394

CommonPresentations

• Latepresentationtoprenatalcare• Acuteintoxication• Positivetoxicologic screeninmotherorbaby• Placentalabruption,uterinerupture,PTL• Fetaleffects– eg IUGRdetectedduringantepartum testing

• Neonataleffects– suspectedwithdrawal/NAS;suspectedFASD

GOAL:EarlyidentificationofSUD

MaternalSubstanceUsecancomplicatelabor:– Acutecocaineusemayinfluencechoiceofanestheticgas

– Tobaccoandcannabisusecancomplicateintubation

–Withdrawalfromalcoholorbenzos ->hyperautonomic state

– Opiatedependenceinfluencespainmanagement

Challengestotreatment

• Stigmaandshame• Refractoryillness• Providers’ownemotionalreactions• Legalissues• Accesstotreatment• Delayinseekingcare

Screening

• OBprovidersshouldbeencouragedtoscreen– Guidelines– Inconsistentscreeningpractices

• Validatedscreeningtools– 4P’sandCRAFFT– T-ACEandTWEAKforalcoholidentifydependencenotat-riskuse

– Toxicologic screen• Maternal– urineandserum• Neonatal– urine,meconium,hairACOGObstetricandGynecologyVol119No

5May2012

• 4P’s– Validatedforscreeninginpregnancyandpostpartum

• CRAFFT– validatedforuseinadolescents

ObstetricandGynecologyVol 119No5May2012

ReportingtoSocialServices

• Lawsvaryregionally• Reportonbehalfofthechildafterdelivery• PsychiatricevaluationisonlyaPARToftheassessmentforparentingcapacity

• Encouragestafftodocumentparentingknowledge,feedingawareness,carebehaviors

• Allowthemothertodemonstratehercapacity

Opioid UseDisordersinPregnancy

• Opioids arenotlikelydirectlyteratogenic1,2

• Opioid dependenceduringpregnancyisassociatedwith:– intrauterinegrowthrestriction– intrauterinefetaldemiseandstillbirth– pretermlabor– placentalabruption– postpartumhemorrage

• Risksrelatedtopeaks/troughsandintermittentw/d

• Lifestylefactorsassociatedwithuse/relapse1.Kaltenbach etal.ObstetricsandGynecologyClinics.1998;25:139-51 2.Jick etalJAMA.1981;246:343-6

Opioid Dependenceinpregnancy

• 90%offemaleopioid usersintheUSareofchildbearingage

• 5.63in1000births– deliveringmothersdefinedasdependentonorusingopioids antenatally

• Highcostsassociatedwithmaternalandneonatalcare• NeonatalAbstinenceSyndrome

Finnegan1986,Patrick2012

OpioidUseDisorderinPregnancy

• NoFDAapprovedtreatment• Mainstayoftreatmentismaintenance–Methadone– Buprenorphine

• Withdrawalmaypresentarisktothefetus1-4– Riskofstillbirth,IUFD,pretermlabor,meconium

• Highriskofrelapseafterdiscontinuationofopioids51. Rementeria etal.AJOG.1973;116(8):1152-6.2.Zuspan AJOG.1975;122(1):43-46.3.Fricker ArchofPedi&Adol Med. 1978;132(4):360. 4Luty J ofSubAbuseTreat. 2003;24:363-67 .5.Jonesetal.TheAmericanJournalonAddictions. 2008;17:372-386

Methadoneimprovespregnancyoutcomes

- ImprovedOBcare- Increasedfetalgrowth- DecreasedriskofHIV- Decreasedriskofpreeclampsia- Longertreatmentretention- Fewerrelapses

TrendsinBuprenorphinePrescriptions

Greene P. Outpatient Drug Utilization Trends for Buprenorphine Years 2002-2009.

Buprenorphine inPregnancy

• Noapparentdifferencebetweenbuprenorphineandmethadonefor:–Maternalweightgain– Cesareansection– Abnormalpresentation– Useofanalgesia– Positivedrugscreen–Medicalcomplicationsatdelivery

Jones2012

BuprenorphineresultsinshorterlesssevereNAS

• Incidence/severitynotdosedependent• Comparedtomethadone:– Similarincidence(41%vs27%NS)– Shorterdurationofsxs(4.1daysvs9.9days)– Lowermeanmorphinerequirement(1.1mgvs10.4mg)

– Shorterhospitalstay(10.0dayvs17.5day)

Jones2010,Jones2012

TreatmentwithBuprenorphineDuringPregnancy

• Afterestablishingadiagnosisofopioiddependenceandengagingpatient…

• Inductionphase• Initiationoftreatmentrequiresmildwithdrawalsxs• Roleforfetalmonitoring• Inpatientvs Outpatient

• Maintenancephase• Doseadjustmentsifnecessary• Planningfordeliveryandpostpartum(pain

managementandrelapseprevention)

HowdoIchoose?• Inapatientstableontreatment,noneedto

switch

• Inapatientnewtotreatmentorwhowishestoswitchconsider:• Patientpreference• Access• Needforstructuredtreatment

AlcoholAbuseduringPregnancy

• Epidemiology– 12.2%ofpregnantwomenreportedalcoholuseduringthepriormonth

– NOsafeamountdefined• Fetaleffects– SpontaneousAB,PTL,stillbirth,IUGR– Ethnicvariation,polymorphismschangeriskforfetaleffects

• Neonataleffects• FASDandotherdevelopmental/behavioralproblems

– Intoxication– Withdrawal– SIDS

Bailey2011AlcResearch34(1)2011.86-91;HanniganSeminNeonatol2000;5:

243–254

FetalAlcoholSyndrome

WongSetal.JOGC2011;33(4)367-84

AlcoholDependenceduringPregnancy

• Medicallysupervisedwithdrawal– Appropriatesetting– Riskofwithdrawalduringpregnancynotwelldefined

– Riskduringlaborandneonatalwithdrawal– NoRCTstoguidechoiceofmedication• Benzosorbarbiturates

BriefInterventionsforAlcoholAbuse

• Pregnantwomenaregenerallymotivatedtochange

• Physicianrelayinginformation• Motivationalinterviewing• Goalsettingandevaluationoftriggers• Educationrepotentialharms

Floyd2007

Cannabis

• Mostcommonlyused(il)licit substanceinpregnancy

• 48-60%ofuserscontinueduringpregnancy• RatesofuseincreasewithlowSES• Cannabinoids arelipophilic– ReadilycrossBBB,placentaandintobreastmilk– Animalstudiessuggesthigherconcentrationinfetaltissuewithchronicuse

ACOG2015

RisksofCannabisinpregnancy

• Noconsistentdataregardingstructuralteratogenesis

• Nodescribedneonatalintoxicationorwithdrawalsyndrome

• Neonataleffectsincludesubtleneurobehavioraleffects(unclearclin signif)– Increasestartle– SleepandEEGdisturbance– Highpitchedcry

• Neurodevelopmetal effectsinchildren/adol– Visuospatial andworkingmemory,languageMarrounetal(2009)JAACAP;JacquesJournalofPerinatology(2014

RisksofCannabisinpregnancy

• Cannabisuseduringpregnancyleadstogrowthrestriction– Doseresponse– greatereffectwithcontinueduse– Birthweight andheadcircumference– Unclearclinicalsignificance

• Allfindingsconfoundedbyrisksofsmokingandrisksassociatedwithothersubstances

Marroun etal(2009)JAACAP;JacquesJournalofPerinatology (20140;Mclafferty 2015

Cannabis

• Lactation– Readilypassesintobreastmilk• Regularconsumption- 8xhigherconc inBM!

–Mayinhibitmilksupply(inhib GRH,prolactin,TSH)• ACOGOpinionJuly2015–Womenshouldabstain– OB/Gyn discouragedfromRxmedicinal– Reductionifabstinencenotpossible

Marroun etal(2009)JAACAP;JacquesJournalofPerinatology (2014)ACOG2015opinion637

Cannabis

• Cannabinoids arelipophilic– ReadilycrossBBB,placentaandintobreastmilk– Animalstudiessuggesthigherconcentrationinfetaltissuewithchronicuse

• Cannabisuseduringpregnancyleadstogrowthrestriction– Doseresponse– greatereffectwithcontinueduse– Birthweight andheadcircumference– Unclearclinicalsignificance

Marroun etal(2009)JAACAP;JacquesJournalofPerinatology (2014

Cannabis

• Noconsistentdataregardingstructuralteratogenesis

• Nodescribedneonatalintoxicationorwithdrawalsyndrome

• Neonataleffectsincludesubtleneurobehavioraleffects(unclearclin signif)– Increasestartle– SleepandEEGdisturbance– Highpitchedcry

• Neurodevelopmetal effectsinchildren/adol– Visuospatial andworkingmemory,languageMarrounetal(2009)JAACAP;JacquesJournalofPerinatology(2014

Cannabis

• Lactation– Readilypassesintobreastmilk• Regularconsumption- 8xhigherconc inBM!

–Mayinhibitmilksupply(inhib GRH,prolactin,TSH)• Womenshouldbeadvisedtoabstain– Reductionifabstinencenotpossible

Marrounetal(2009)JAACAP;JacquesJournalofPerinatology(2014

Cocaine

• Primaryeffectsareduetovasoconstriction– Spontaneousabortion– Placentalabruption– Placentalinsufficiency

• IncreasedriskforLBW,SGA,PTB• Intoxicationcanmimicpreeclampsia• Notlikelyastructuralteratogen• Lastingeffectsonchildgrowthandneurodevelopment

Cressman etalJOGC2014;CainetalClin OG2013

Stimulants

• Needtodistinguishtherapeuticusevs abuse• Abuseofamphetaminesassociatedwithrisksassociatedwithplacentalvasoconstriction

• Datasuggestwiththerapeuticusebothampandmph:– Notlikelyteratogenic– Impactonfetalgrowth(?beforeweek28)

• Duringpregnancy- appetitesuppression/lowmatwtgain

• Lactation– Relativelylowexposure– Methylphenidate:RIDof<1%– Dextroamphetamine:RID5.7%

Bolea- Alamanac etalBrJourn Pharmac 2013;FreemanAJP2014

BehnkePediatrics2013;131:e1009–e1024

Breastfeeding

• ABMrecommendsagainstbreastfeedingwithanysubstanceusewithin90days

• AAP– SubstancedependentmothercanBFifintreatmentANDHIVnegativeANDneg tox

• Mustbalancetheknownbenefitsofbreastfeedingagainsttherisksineachcase

ABMBreastfeedingMedicine2009;AAPBreastfeedingandtheuseofHumanMilk2011

AddressingPerinatal DepressionandSubstanceUseinObstetric Settings: MCPAPforMoms

Trainings 855-Mom-MCPAP

EducationalMaterials

Theperinatalperiodisidealforthedetectionandtreatmentof mentalhealthneeds

80%ofdepressionistreatedbyprimarycareproviders

Regularopportunitiestoscreenandengagewomenintreatment

Womens Healthprovidershaveapivotalrole

TelephoneConsultation

Obstetricproviders/Midwives

FamilyMedicine

Psychiatricproviders

Primarycareproviders

Pediatricproviders

1-855-Mom-MCPAP(855-666-6272)

TelephoneConsultation

1-855-Mom-MCPAP(855-666-6272)

TelephoneConsultation

MCPAPforMomshasservedmanyprovidersandparentsinourfirst18 months

OBPracticesEnrolled 100(47%)Trainings 86WomenServed 1123Doc-to-DocTelephoneEncounters 996FacetoFaceEvaluations 81CareCoordinationEncounters 1420

*July2014 – February2016

SubstanceUseDisordersarecommoninMCPAPforMomsconsultations

Sinceinception:8%ofconsultationsincludeddiscussionofsubstanceuseOpioid UseDisorderAlcoholCannabisCocaine

Context

https://www.bostonglobe.com/metro/2015/10/22/town-town-look-opioid-epidemic-deadly-toll-massachusetts/FJksUU8hlYJN4Yl4mCKwkI/story.html

Context

https://www.bostonglobe.com/metro/2015/10/22/town-town-look-opioid-epidemic-deadly-toll-massachusetts/FJksUU8hlYJN4Yl4mCKwkI/story.html

NewEnglandhasthesecondhighestrateofNeonatalAbstinenceSyndrome

PatricketalJournalofPerinatology (2015)35,650–655

CalltoAction

CalltoAction

Opportunitiestohelpaddresssubstanceusedisordersamongpregnantandpostpartumwomen

Consultationandcarecoordinationforwomenshealthproviderstobuildtheircapacitytoaddresssubstanceusedisorders

ConsultationforMATproviderstobuildtheircapacitytoaddresspsychiatriccomorbidities

Educationandtraining

JoseY.DiazandRichardChase.WilderResearch,651-280-2700October2010

MCPAPforMomsmaybeabletoovercomebarrierstoaddressingperinatal

SUDinobstetricsettings

Pleasecontactus

Copyright©MCPAPforMoms2014allrightsreserved.FundingprovidedbytheMassachusettsDepartmentofMentalHealth.

Thankyou!

www.mcpapformoms.org

Call855-Mom-MCPAP(855-666-6272)

NancyByatt,DO,MS,MBA,MedicalDirectorNancy.Byatt@umassmemorial.org

KathleenBiebel,PhD,ProgramDirectorKathleen.Biebel@umassmed.edu

LeenaMittal,MD,Director,BostonHublmittal@partners.org

ThankYou!