Medication Assisted Therapy and Pregnancy: An Introduction

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1 Medication Assisted Therapy and Pregnancy: An Introduction Deborah A. Orr, Ph.D. The Center For Drug Free Living Adapted from the NIDA Blending Initiative Curriculum

2 Presentation Objectives Define opioids Describe withdrawal, cravings Describe opioids effect on the brain Explain opioid replacement therapy Explain pregnancy and newborn effects of Medication Assisted Treatment

3 Is there really a problem? Hospital ER admissions related to opioids are increasing Substance abuse treatment admissions related to opioids are increasing

4 Is there really a problem? Teenager use of opioids is increasing Death rate from opioids is increasing

5 What is an opioid? Opiate A term that refers to drugs or medications that are derived from the opium poppy, such as heroin, morphine, and codeine. Opioid A more general term that includes opiates as well as the synthetic drugs or medications, such as buprenorphine, methadone, meperidine (Demerol ), fentanyl that produce analgesia and other effects similar to morphine.

6 Basic Opioid Facts Description: Opium-derived, or synthetics which relieve pain, produce morphine-like addiction, and relieve withdrawal from opioids Medical Uses: Pain relief, cough suppression, diarrhea, treatment of opioid dependence Methods of Use: Intravenously injected, smoked, snorted, or orally administered

7 What s What? Agonists, Partial Agonists, and Antagonists 1. Agonist 2. Partial Agonist 3. Antagonist Morphine-like effect (e.g., heroin) Maximum effect is less than a full agonist (e.g., buprenorphine) No effect in absence of an opiate or opiate dependence (e.g., naloxone)

8 Opioid Agonists Natural derivatives of opium poppy - Opium - Morphine - Codeine

9 SOURCE: Opium

10 SOURCE: Morphine

11 Opioid Agonists Semisynthetics: Derived from chemicals in opium - diacetylmorphine Heroin - hydromorphone Dilaudid - oxycodone, Roxicodone, Percodan, Percocet, - hydrocodone Vicodin

12 Heroin SOURCE:

13 Opioid Agonists SOURCE:

14 Opioid Agonists Synthetics - propoxyphene Darvon, Darvocet - meperidine Demerol - fentanyl citrate Fentanyl - methadone Dolophine - levo-alpha-acetylmethadol ORLAAM

15 Methadone Darvocet SOURCE:

16 Opioid Partial Agonists buprenorphine Buprenex, Suboxone, Subutex pentazocine Talwin butorphanol - Stadol

17 Buprenorphine/Naloxone combination and Buprenorphine Alone

18 Opioid Antagonists Naloxone Narcan Naltrexone ReVia, Trexan

19 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone)

20 Opioids and the Brain: Pharmacology and Half-Life

21 SOURCE: National Institute on Drug Abuse,

22 Opioid Addiction and the Brain 1. Opioids attach to receptors in brain -> PLEASURE 2. Repeated opioid use -> TOLERANCE 3. Absence of opioids after prolonged use: -> WITHDRAWAL

23 What Happens When You Use Opioids? Acute Effects: Sedation, euphoria, pupil constriction, constipation, itching, and lowered pulse, respiration and blood pressure Results of Chronic Use: Tolerance, addiction, medical complications Withdrawal Symptoms: Sweating, gooseflesh, yawning, chills, runny nose, tearing, nausea, vomiting, diarrhea, and muscle and joint aches

24 Cravings How do cravings and withdrawal relate to relapse?

25 Withdrawal and Pregnancy Goals: prevent fetal withdrawal, which can cause miscarriage in early pregnancy, and premature labor

26 Withdrawal What is the relationship between discomfort from physical withdrawal symptoms and the ability to successfully tolerate detoxification?

27 Partial vs. Full Opioid Agonist death Opiate Effect Full Agonist (e.g., methadone) Partial Agonist (e.g. buprenorphine) Dose of Opiate Antagonist (e.g. Naloxone)

28 Treatment of Opioid Addiction

29 Treatment Options for Opioid-Addicted Individuals Behavioral treatments Medications Combining behavioral and medication treatments

30 How Can You Treat Opioid Addiction? Medically-Assisted Detoxification (short versus longer taper) Not clinically recommended during pregnancy Medication Maintenance SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

31 Benefits of Opioid Replacement Medications for Opioid Addiction Better social functioning Less HIV, viral hepatitis, and STD risk behavior Better able to participate in substance abuse treatment (the brain works better!) SOURCE: Principles of Drug Addiction Treatment: A Research-Based Guide, NIDA, 2000.

32 Agonist: Methadone Must be dispensed from a licensed opioid treatment center (methadone program). Pros + Cons Only approved treatment for pregnant opioid dependent women (prevent fetal withdrawal)

33 Opioids and Pregnancy Opioids cross the placenta Depending on dose, frequency, and duration of maternal opioid use, fetus may become dependent.

34 Methadone and Pregnancy Effective medical maintenance treatment with methadone has the same benefits for pregnant patients as for patients in general. In addition, methadone substantially reduces fluctuations in maternal serum opioid levels, so it protects a fetus from repeated withdrawal episodes. SAMHSA TIP 43, Medication Assisted Treatment for Opiod Addiction in Opioid Treatment Programs, p. 211

35 Methadone and Pregnancy Clinical Standard: Methadone is the only opioid medication approved by FDA for MAT in pregnant patients Methadone dose may vary throughout pregnancy (physiological changes) SAMHSA TIP 43, Medication Assisted Treatment for Opiod Addiction in Opioid Treatment Programs, p. 217

36 Methadone and Pregnancy The fetal liver metabolizes the methadone, preventing fetal withdrawal. The newborn will be dependent on methadone. This is expected pharmacologically. Breast milk contains minimal amounts of methadone; breast feeding is not contra-indicated

37 Partial Agonist: Suboxone (buprenorphine/naloxone) Must be prescribed by MD May be inpatient or office based May be for detoxification or maintenance Not yet FDA approved for use in pregnancy, although initial studies report no harmful effects. Despite this, some pregnant women do receive suboxone or subutex for MAT

38 Neonatal Abstinence Syndrome (NAS) High incidence in pregnant women dependent on opioids, whether medically prescribed or illilcit use Hyperactivity of the CNS and ANS (diarrhea, irregular breathing, agitation, uncoordinated sucking reflex, irregular sleep cycles, etc.) Onset usually within 72 hours of birth, but is variable influenced by maternal methadone dose and timing re: delivery delivery medications infant maturity metabolic rate of infant s liver, etc

39 Neonatal Abstinence Syndrome (NAS) Newborn is assessed at regular intervals for NAS If indicated, newborn is treated with a morphine-equivalent solution based on infant s weight and response Newborn is assessed and dose is modified frequently until stable Stable x 72 hours before slow taper (continue observing newborn)

40 Treatment Regimen Concomitant behavioral counseling (relapse prevention, managing triggers, increased coping skills, etc.) Detox versus prolonged detox versus maintenance for mother after delivery

41 Free publications TIP #40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction TIP# 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs TIP # 51: Substance Abuse Treatment: Addressing the Specific Needs of Women The Safety of Methadone Maintenance During Pregnancy

42 Thank you

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