Compassionate Care In Treating Opioid Dependence During Pregnancy
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1 Compassionate Care In Treating Opioid Dependence During Pregnancy Michelle Lofwall, M.D. University of Kentucky College of Medicine Depts. of Behavioral Science and Psychiatry April 26,
2 None Faculty Disclosure
3 Educational Need/Practice Gap Gap = Lack of understanding of challenges, needs, and treatment of opioid dependence during pregnancy Need = Improved understanding of the challenges pregnant opioid dependent women face and improved communication and treatment opportunities for pregnant women with opioid addiction
4 Objectives Upon completion of this educational activity, you will be able to: -Describe challenges & barriers patients face -Communicate hope to patients -Describe treatment to patients, including why methadone works
5 Expected Outcome Improved patient care
6 Challenging to Treat Health providers have inadequate training Medical & legal system prejudices State reporting requirements Provider-patient alliance problems 6
7 What You Need to Know Punishment effective deterrent Comprehensive treatment works! 3x in mom s opiate use Prenatal care 3x low birth weight (LBW: <2500 grams) Perinatal HIV transmission to <2% 2x maternal custody in 1 st yr 7
8 This Talks Reviews Definitions Causes, course, prevalence & comorbidity Medical complications Treatment 8
9 9
10 Abuse & Dependence Abuse 1 of: Obligations Hazardous use Legal Interpersonal problems Dependence 3 of: Tolerance Withdrawal Amounts or more time Desire or unable cut down Time get, use, or recover Non-drug activities Physical/psychological problems 10
11 Opioid Withdrawal Occurs with /no opioid use OR opioid antagonist 3 of: Dysphoria (unhappy) Nausea or vomit Muscle aches Lacrimation (watery eyes) or rhinorrhea (runny nose) Diarrhea Yawning Fever Insomnia Mydriasis (big pupils), piloerection (goose bumps), or sweating 11
12 This Talk Reviews Definitions Causes, course, prevalence & comorbidity Medical complications Treatment 12
13 Etiology 50% Genes 50% Environment Availability Peer use Drug-using partners Hx victimization 13
14 Chronic Relapsing Course >50% relapse >90% use opioids before pregnancy 20x mortality vs. Ø substance disorder dx 14
15 Prevalence of Opiate Use % Opiate Maternal selfreport Meconium 15
16 Other Drugs & Psych Dxs > 90% Cigs LBW Premature SIDS Stillbirths >10% Cocaine Placental abruption Premature >10% Axis I LBW with mood disorder 16
17 Complex Social Problems >50% single moms & unemployed >25% hx of physical/sexual abuse Low socioeconomic status Adversely affects pregnancy Prenatal care Direct harm 17
18 Risky Behaviors Sharing needles, unprotected sex, dealing Mom s infections risk of: Premature contractions & labor Breakdown fetal membranes & abortion Difficult to separate out opioid effects 18
19 This Talk Reviews Definitions Causes, course, prevalence & comorbidities Medical complications Treatment 19
20 Maternal & Fetal Problems Multifactorial etiology HIV: 25% transmit Hep C: ~5% transmit Endocarditis heart failure hypoxia Nutritional deficiency e.g., 25% Fe-defic 20
21 Fetal Hypoxia Intoxication Withdrawal Unstable fetal environment 21
22 Newborn Birth Outcomes ~50% LBW (~20% with rx) Death ~25% HIV (<2% with rx) Meconium aspiration (stool inhaled into lungs) ~10% Microcephaly (small head) 22
23 Neonatal Abstinence Syndrome (NAS) 23
24 NAS Definition Central nervous system excitability Autonomic nervous system GI system malfunction Respiratory distress 24
25 NAS Time course depends on: Opioid half-life (T ½) Fetal opioid storage & metabolism Risk factors: Opioid dependent mom ~70% NAS Smoking cigarettes severity Prematurity severity Opioid dose not a clear relationship More recently genetic / SNP influences 25
26 NAS Treatment = Life-saving Supportive Swaddle Quiet/Dim Light Frequent feeds/suct ion Medication ~60% require meds Morphine Drops
27 This Talk Reviews Definitions Causes, course, prevalence & comorbidities Medical complications Treatment 27
28 4 Treatments Reviewed Psychosocial rx without medication Methadone maintenance (MM) Methadone-assisted withdrawal Buprenorphine maintenance 28
29 Psychosocial Interventions Cornerstone Therapeutic alliance Expect demanding & resistant behavior Complete assessment (father, too!) Assist with all problems Educate: many misbeliefs, guilt & shame Discuss family planning 29
30 Methadone Maintenance Long T ½ (27 hrs), synthetic opioid agonist Strict federal regulations Opioid dependent > 1 yr (unless preg) > 18 yrs unless parental consent/failed rx Daily visits x 90 days 30
31 Many Treatment Goals Mother: /stop withdrawal /stop drug use Prenatal/med/psych rx Psychosocial probs Supportive network Parenting skills 31
32 Many Treatment Goals Fetus/neonate Stable intrauterine environment Stop intox/withdrawal cycles Deliver term/healthy newborn + maternal/fetal bond 32
33 Components of MM Treatment Multidisciplinary team Individual & group counseling Parenting classes Daily oral methadone dosing 1 st dose = max 30 mg > 50 mg maintenance dose Blocks + illicit opioid effects Prevents withdrawal 33
34 MM Benefits 3x in mom s opiate use Prenatal care 3x LBW Perinatal HIV transmission to <2% 2x maternal custody of newborn 34
35 MM Limitations Availability Limited patient acceptance Does not incidence of NAS Report of fine motor skill problems 35
36 Methadone-assisted Withdrawal 1970 s = standard rx until fetal deaths Utilized if MM not available or accepted Goals: Mother/fetus opioid withdrawal Achieve opioid free state in mom/fetus Deliver term, healthy fetus with no NAS 36
37 Components of Withdrawal Treatment Inpatient OB monitors fetus daily for distress Stabilize on methadone then taper dose If fetal distress slow taper, dose 3 & 7 day tapers at specialty units Discharge Con t outpatient rx to maintain abstinence 37
38 Withdrawal Outcomes >50% relapse Problem > opioid withdrawal Problem = medical & psychosocial Compared to MM, detox alone results in: 2x + urine drug test at delivery 5x days in trt 6 fewer OB appts No diff in NAS or birth outcomes 38
39 Buprenorphine Maintenance 2002 approved rx for non-preg opioid depend Partial opioid agonist Enhanced safety profile T ½ = 37 hrs Office-based 39
40 Buprenorphine Maintenance Must become qualified to prescribe Potential advantages Similar outcomes as MM severity NAS shorter NICU stays and less morphine drops required to tx 40
41 Summary Definitions Causes, course, prevalence & comorbidities Medical complications Treatment 41
42 References Dr. Lori Devlin from Univ. of Louisville (Neonatologist) and Dr. Jonathon Weeks from Univ. of Louisville (OB/GYN - MFM expert) webinars coming soon please check Univ. of KY CE central website in late September ( Treating Women with Substance Use Disorders During Pregnancy: A Comprehensive Approach to Caring for Mother and Child by Drs. Hendree Jones and Karol Kaltenbach List of references available as handout 42
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