The Opioid Epidemic’s Impact on the Most VulnerableGINA CONNELLY MDTMC OBSTETRICSMEDICAL DIRECTOR; OBSTETRICS SERVICES; TUCSON MEDICAL CENTER

Illicit Drug Use in Pregnancy Opioid use during pregnancy has escalated, in parallel with the opioid

epidemic in the general population. Pregnant women who use opioids are at increased risk for pregnancy-

associated complications and death. Their infants are at risk for Neonatal Abstinence Syndrome

5.4% of pregnant women admit to using one or more illicit drug By age group

15-17: 14.6% 18-25: 8.6% 26-44: 3.2%

More women drink alcohol (9.4%) and smoke (15.4%) than all other drugs combined. 90% of women addicted to opioids smoke cigarettes

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PatientsVisits

Illicit Drug Use and Pregnancy A drug’s effects on the fetus depend on

many things: How much? How often? Fetal response? When during pregnancy was it

used? First trimester

The early stage of pregnancy is the time when main body parts of the fetus form.

Second, Third trimester Interfere with the growth of

the fetus Increase preterm birth Increase in fetal death

Other confounding factors Other Medical Conditions Social Psychological

Lack of Prenatal Care 86% of pregnant opioid –using women report pregnancy was

unintended Establish late care

Missed opportunities for screening, diagnosis, and treatment of pregnancy and medical problems that can improve outcomes for mother and baby

Ashamed to seek care Legal ramifications

Users may not even realize that they are pregnant Misinterpret early signs of pregnancy as opioid withdrawal

Nausea, vomiting, abdominal cramping

Pregnant women are typically highly motivated to modify their behavior in order to help their unborn child. In a national survey from the United States, the mean rate of pregnancy-

related abstinence among users of illicit drugs was 57 percent.

Opioid Associated Maternal Complications Infections

Needle sharing Hepatitis B, C and HIV

Bacteremia/Sepsis

Cellulitis

Endocarditis

Sexually transmitted infections HIV, Syphilis, Gonorrhea, Chlamydia

Opioid Related Pregnancy Complications

6-fold increase in obstetrical complications Intra-amniotic infection Abruption Fetal passage of meconium

21-46% versus12-13%

Premature labor 28% versus 12%

Preeclampsia Postpartum hemorrhage Victims of violence

Opioid Associated Pregnancy Complications: Fetal

Recent study that opioids users had increased risk of congenital heart defects Observational and poor study, no

direct evidence

Decreased birthweight 2490g versus 3176g

Fetal growth restriction Placental Insufficiency

Flucuations in drug level causes placental changes that decrease nutrients to fetus

20% versus 4%

Fetal death Stillbirth

Miscarriage

Neonatal abstinence syndrome (NAS) Drug withdrawal syndrome that

opioid-exposed neonates may experience shortly after birth

Meconium passage

AZ: NAS and Other Drug Exposure

Neonatal Abstinence Syndrome (NAS): Symptoms

Yawning, stuffy nose, sneezing Vomiting Diarrhea Dehydration Sweating Fever or Unstable Temperature

Tremors Irritability(excessive crying) Sleep problems High-Pitched cry Tight muscle tone Hyperactive reflexes Seizures

Poor feeding and suck

Other Drugs with Associated with Neonatal Withdrawal Syndromes

SSRI-Poor Neonatal Adaption Syndrome10-30% chance of symptoms if taken in the last trimester of pregnancy

Non-narcotic withdrawal Alcohol, Barbiturates, Benzodiazepines, Hydroxyzine

Marijuana

No withdrawal but may have long term developmental effects

Cocaine

Symptoms at birth are of the drug toxicity, withdrawal may come later, usually shorter

Hesitant breathing at birthJitterinessSeizuresExaggerated startle reflexWeak cryIncreased motor activity

Poor self regulationHigher arousal Poor muscle toneHypoglycemia Jaundice

Withdrawal ScoringFinnegan Neonatal Abstinence Scoring

An objective numerical scoring system that permits standardized care if inter-rater reliability is verifiedDivided into three assessment groupingsWhen an infant scores a certain amount then medication is often initiatedAs scores stabilize, then the treatment doses are decreased

Which infants develop NAS that requires treatment?

VARIABLE!

If methadone alone:

Genetic basis

Longer the treatment and the higher the dose may correlate with severity but not predictable

If methadone + SSRI or benzodiazepines,

Prolong the withdrawal period

Early data suggest buprenorphine withdrawal is shorter

Heroin withdrawal is shorter than methadone, but the health consequences during pregnancy are worse

Long-Term Outcomes

Specific long term effects of isolated drugs are difficult to determine due to comorbid substance exposure and also environmental and medical risk factors

A variety of results of NAS studies:

minimal to no effect greater than the underlying drug use

effect during toddlerhood that then resolves

persistent effect

Motor effects (more tense, less active, and poor coordination) may recover or are more closely correlated to sociodemographic factors (SES status, nutrition-birthweight, head circumference at birth)

Behavioral effects include less social responsivity, short attention span, and poor social engagement

Beyond the NurseryInfant Discharge Planning

All newborns should have a medical home (PCP) determined prior to discharge to allow flow of information on risk status, referrals, and follow upCare-givers with a substance abuse disorder are more likely to perceive care of a child as stressful and miss well child visitsEarly intervention services can positively impact drug exposed newborns at risk for developmental delayHome nurse visitation programs may reduce encounters for ingestions, injuries, and maltreatment; also can pick up behavioral problems in the children or parental stress

Detoxification in Pregnancy Associated with poor neonatal outcomes.

Early preterm birth or fetal demise The major reason not to attempt detoxification is that it is generally unsuccessful,

Relapse rates of 50% or more. If attempted, it is best to wait until the end of the first trimester

Limited data suggest that miscarriage rates may be higher in the first trimester. Robust evidence has demonstrated that maintenance therapy during pregnancy can

improve outcomes Opioid use during pregnancy can put infants at risk of Neonatal Abstinence

Syndrome Including MAT, prescription opioid use for pain, or non-medical opioid use However, NAS is both expected and treatable, and evidence has shown that it does not

lead to long-term complications ACOG continues to recommend use of Medication Assisted Therapy (MAT) as the

standard of care during pregnancy for women with opioid use disorders.

Opioid Substitution Therapy in Pregnancy Agent

1 g heroin 80 mg methadone

8 mg buprenorphine

Advantages Oral administration

Known dose and purity

Safe and steady availability

Improved maternal/fetal/neonatal outcomes

Opportunity to enter obstetrical care

Barriers to treatment Lack of health insurance

Incarceration

Mental Illness

Transportation

Childcare needs

Guilt about the effect of drugs on the fetus

Fear of legal consequences

Loss of custody of children

Benefits of Methadone Maintenance Have been demonstrated in the pregnant

population. Earlier and more-compliant prenatal care

Improved nutrition and weight gain

Fewer children in the foster system

Improved enrollment in substance abuse treatment and recovery programs

Remain opiate dependent, but generally become more functional

The goal of treatment is to provide sufficient dosing to prevent drug cravings, eliminate illicit use, and keep additional opiates from creating euphoria.

Goal of harm reduction, rather than elimination through abstinence.

The average dose needed to achieve clinical stability is between 80 and 120 mg daily. A dose lower than 60 mg is believed to be

insufficient to prevent drug-seeking behavior.

Due to the physiology of pregnancy, split daily dosing is sometimes recommended

Buprenorphine (Subutex)

Gaining recognition as a treatment for opioid addiction during pregnancy. Favored over buprenorphine/naloxone (Suboxone)

Lack of safety data regarding the combination product

May produce maternal and subsequently fetal hormonal changes.

Less autonomic withdrawal associated with buprenorphine Buprenorphine demonstrates favorable qualities similar to methadone

Decreasing drug cravings with daily dosing Additional benefit of being prescribed by specifically certified physicians as opposed

to federally funded clinics. This benefits patient autonomy and opiate maintenance. Controversial as there are many social and mental health benefits that are less available in

this model.

Comparison of Methadone/Buprenorphine

Jones et al , NEJM 2010;363(24):2320 Continued treatment to end of

pregnancy Methadone 82% Buprenorphine 67%

NAS Buprenorphine needed

less morphine: Shorter hospital stay: 10d

versus 17.5d Shorter treatment for NAS:

4.1 versus 9.9d

The 2010 MOTHER (Maternal Opioid Treatment: Human Experimental Research) Addiction 2012 Nov;107 Suppl 1:1-4 Buprenorphine was associated

with Significantly lower doses

of morphine for treatment of NAS

Shorter duration of treatment

Shorter hospital stay than methadone.

CASE PRESENTATION

A.A. is a 23yo G3P2 at 28 weeks of pregnancy Presents to the Emergency Room Friday evening at 11pm requesting

to “detox” from her heroin addiction Unplanned pregnancy No prenatal care Past medical history includes anxiety and depression for which she

stopped her medications when she found out she was pregnant Other children in foster care with a family member

PAPN: Polysubstance Abuse in Pregnancy and Newborn

Coordinate community resources in Tucson, Arizona Community wide effort to improve

patient care in women with polysubstance abuse in pregnancy with focus on opioid addiction Social Services

Community Treatment Programs

Physicians

Pharmacists

Successes Community wide drug

screening tool

Develop protocols for safe transition to methadone/subutex in ”off” hours.

Increase communication and entry into community treatment programs and prenatal care

Establish neonatal abstinence program

PAPN Universal Screening Tool Multiple societies and agencies

consider screening for substance abuse a part of complete obstetric care and recommend asking all pregnant women about their use of alcohol and illicit drugs Universal screening

Substance users come from all economic strata, ages and races

Ideally, screening is performed at the initial prenatal visit

All Hospitals involved in development

In past 12 months, have you used the following? Please include onetime use. Yes No Last Used Frequency

Alcohol (beer, wine, liquor) Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Tobacco (Patch, Vape) Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Cannabis (marijuana, pot, grass, hash, spice, etc) *Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Cocaine (coke, crack, etc.) *Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Prescription stimulants (Ritalin, Concerta, Dexedrine, Adderall, Diet Pills, etc) Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Methamphetamine (Speed, Crystal Meth, Ice, etc) *Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Inhalants (Nitrous oxide, glue, gas, paint thinner, etc) Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Sedatives or Sleeping pills (Valium, Serepax, Ativan, Xanax, Librium, Rohypnol, GHB, etc)

Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Hallucinogens (LSD, Acid, Mushrooms, PCP, Special K, Ecstasy, Molly, Bath Salts, etc) *

Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Street Opioids (Heroin, Opium, etc * Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Prescription Opioids (Fentanyl, Oxycodone, [OxyContin, Percocet], Hydrocodone [Vicodin], Methadone, Buprenorphine, etc) *

Never Once or Twice Daily Weekly Monthly

Amount used:____________________________Script?

Other – Specify Never Once or Twice Daily Weekly Monthly

Amount used:____________________________

Risk Factors for Drug Testing Substance Abuse Indications for testing

Positive screening tool Previous positive drug test History of illicit drug use Monitoring compliance with methadone/subutex Pregnancy complications associated with drug use Frequent requests for prescription drugs of abuse Noncompliance with prenatal care

Universal Drug Laboratory Testing Generally still not recommended

because of the limitations of these tests

There is no consensus regarding when drug tests should be used in pregnant women or the best method for analyzing biological samples (urine, blood, hair, saliva) Urine drug testing is the most

common

Positive tests for illicit drugs can havelegal and economic implications.

Women should be informed of thepotential ramifications of a positivetest result and should give informedconsent prior to testing

Must have a plan to treat Random testing is unethical unless

patient: Unconscious Obvious signs of intoxication and

testingto provide approprtiatemedical interventions

Know State requirements for testingand reporting drug test results.

ACOG Toolkit on STATE LEGISLATION Pregnant women & drug abuse, dependence and addiction

If considering mandatory urine testing, Legislation should specify: Testing is permitted only with the patient’s consent and to

confirm suspected or reported drug use. Patient consent also applies to testing by hospitals when

pregnant women are admitted for labor and delivery. In the Medicaid program, a pregnant woman’s eligibility for

Medicaid should not be contingent on submitting to a mandatory urine drug test.

Similarly, reimbursement for prenatal, labor and delivery care should not be contingent on performance of urine drug testing.

Methadone Induction Team Sport

Patient agrees to long term treatment program and MAT therapy Physician and Pharmacy team initiate therapy under standardized

guidelines Social worker to identify outpatient program Outpatient program facilitates timely admission to care Obstetrical care is instituted All within a limited timeline

NASA

Neonatal Abstinence Syndrome AnnexSeparate area of the NICU so sights and sounds can be better regulated according to infant state

Parents know they are all in the same situation so less shame is felt

A group of nurses who self identified with personal interest in this population

Aromatherapy-lavender and peppermint oil

Neonatal massage, integration with pediatric therapies

Standardized protocol for medical and nutritional management

Preventing Pregnancy Risk Associated with Opioids

Types of Long Acting Reversible Contraception

Postpartum LARC The immediate postpartum period is a particularly favorable time for IUD

or implant insertion. 45% of women who planned on an IUD postpartum failed to return for

insertion Women who have recently given birth are often highly motivated to use

contraception, they are known not to be pregnant, and the hospital setting offers convenience for both the patient and the health care provider.

Postpartum LARC is now reimbursed by AHCCCS Not reimbursed by all commercial plans

In addition, women are at risk of an unintended pregnancy in the period immediately after delivery. In a study in which women were instructed to abstain from sexual

intercourse until 6 weeks postpartum, 45% of participants reported unprotected sex before that time.

Parting thoughts….. Opioid abuse in pregnancy is a significant problem affecting 2

patients – mother and newborn Developing standardized screening, more cases in pregnancy will

be identified and possible intervention started Establishing coordinated referral to treatment and prenatal care can

improve outcomes Coordinating community resources will empower us to more

efficiently treat the problem Mental health support Emphasis on contraception and planned pregnancy

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