Opioid/Opiate Dependent Pregnant Women

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1 Opioid/Opiate Dependent Pregnant Women The epidemic, safety, stigma, and how to help. Presented by Lisa Ramirez MA,LCDC & Kerby Stewart MD

2 The prescription painkiller epidemic is killing more women than ever before.

3 When a women finds out she is pregnant she is highly motivated to stop using drugs.

4 What other influences in her life are advising her to stop?

5 What should she do?

6 What are appropriate treatment recommendations?

7 Who will tell her the dangers of trying to stop using opiates/opioids?

8 What is informed consent?

9 What barriers exist in coordinating care for her?

10 How do abstinence only philosophies impact her care?

11 Neonatal Abstinence Syndrome What does she need to know?

12 The M.O.T.H.E.R. study, what did we learn?

13 How can stigma impact maternal infant attachment?

14 What are the 8 principles & Finnegan s scale and why should she know about them?

15 Breast is Best Does it apply to her?

16 What does she need during the postpartum period and who helping her?

17 What issues exist with child welfare agencies and issues of child safety?

18 Family planning: special considerations for this population

19 Open discussion

20 Lisa Ramirez M.A. LCDC Women s Substance Abuse Services Coordinator Department of State Health Services Kerby Stewart MD University of Utah Clinical Coordinator SA Services Unit Mental Health and Substance Abuse Division

21 July ,000 Nearly 48,000 women died of prescription painkiller* overdoses between 1999 and % Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men. Prescription Painkiller Overdoses A growing epidemic, especially among women About 18 women die every day of a prescription painkiller overdose in the US, more than 6,600 deaths in Prescription painkiller overdoses are an under-recognized and growing problem for women. Although men are still more likely to die of prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing. Deaths from prescription painkiller overdose among women have risen more sharply than among men; since 1999 the percentage increase in deaths was more than 400% among women compared to 265% in men. This rise relates closely to increased prescribing of these drugs during the past decade. Health care providers can help improve the way painkillers are prescribed while making sure women have access to safe, effective pain treatment. When prescribing painkillers, health care providers can Recognize that women are at risk of prescription painkiller overdose. 30 For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse. Follow guidelines for responsible prescribing, including screening and monitoring for substance abuse and mental health problems. Use prescription drug monitoring programs to identify patients who may be improperly obtaining or using prescription painkillers and other drugs. * Prescription painkillers refers to opioid or narcotic pain relievers, including drugs such as Vicodin (hydrocodone), OxyContin (oxycodone), Opana (oxymorphone), and methadone. www See page 4 Want to learn more? Visit

22 Problem The prescription painkiller epidemic is killing more women than ever before. Prescription painkiller overdoses are a serious and growing problem among women. More than 5 times as many women died from prescription painkiller overdoses in 2010 as in Women between the ages of 25 and 54 are more likely than other age groups to go to the emergency department from prescription painkiller misuse or abuse. Women ages 45 to 54 have the highest risk of dying from a prescription painkiller overdose.* Non-Hispanic white and American Indian or Alaska Native women have the highest risk of dying from a prescription painkiller overdose. Prescription painkillers are involved in 1 in 10 suicides among women. *Death data include unintentional, suicide, and other deaths. Emergency department visits only include suicide attempts if an illicit drug was involved in the attempt. The prescription painkiller problem affects women in different ways than men. Women are more likely to have chronic pain, be prescribed prescription painkillers, be given higher doses, and use them for longer time periods than men. Women may become dependent on prescription painkillers more quickly than men. Women may be more likely than men to engage in doctor shopping (obtaining prescriptions from multiple prescribers). Abuse of prescription painkillers by pregnant women can put an infant at risk. Cases of neonatal abstinence syndrome (NAS) which is a group of problems that can occur in newborns exposed to prescription painkillers or other drugs while in the womb grew by almost 300% in the US between 2000 and Potential risks of combining medications Medicines for treatment of pain and mental illness have benefits and risks. For women, 7 in 10 prescription drug deaths include painkillers. But other prescription drugs play a role in overdoses as well. Women are more likely than men to die of overdoses on medicines for mental health conditions, like antidepressants. Antidepressants and benzodiazepines (anti-anxiety or sleep drugs) send more women than men to emergency departments. Mental health drugs can be especially dangerous when mixed with prescription painkillers and/or alcohol. If you take mental health drugs and prescription painkillers, discuss the combination with your health care provider. 2

23 Prescription painkiller overdose deaths are a growing problem among women. 7,000 6,000 NUMBER OF DEATHS 5,000 4,000 3,000 2,000 Opioids Antidepressants Benzodiazepines Cocaine Heroin 1, SOURCE: National Vital Statistics System, (deaths include suicides) Every 3 minutes, a woman goes to the emergency department for prescription painkiller misuse or abuse. Women between the 50,000 ages of 25 and 54 are most likely to go to the emergency department because of prescription painkiller misuse or abuse. SOURCE: Drug Abuse Warning Network, (Suicide attempts are included for the cases (.03% of total) where opioids were combined with illicit drugs in the attempt.) NUMBER OF EMERGENCY DEPARTMENT VISITS 40,000 30,000 20,000 10,000 0 < AGE GROUP 3

24 What Can Be Done The US government is States can Tracking prescription drug overdose trends to better understand the epidemic. Educating health care providers and the public about prescription drug misuse, abuse, suicide, and overdose, and the risks for women. Developing and evaluating programs and policies that prevent and treat prescription drug abuse and overdose, while making sure patients have access to safe, effective pain treatment. Working to improve access to mental health and substance abuse treatment through implementation of the Affordable Care Act. Health care providers can Recognize that women can be at risk of prescription drug overdose. Discuss pain treatment options, including ones that do not involve prescription drugs. Discuss the risks and benefits of taking prescription painkillers, especially during pregnancy. This includes when painkillers are taken for chronic conditions. Follow guidelines for responsible painkiller prescribing, including: Screening and monitoring for substance abuse and mental health problems. Prescribing only the quantity needed based on appropriate pain diagnosis. Using patient-provider agreements combined with urine drug tests for people using prescription painkillers long term. Teaching patients how to safely use, store, and dispose of drugs. Avoiding combinations of prescription painkillers and benzodiazepines (such as Xanax and Valium) unless there is a specific medical indication. Talk with pregnant women who are dependent on prescription painkillers about treatment options, such as opioid agonist therapy. Use prescription drug monitoring programs (PDMPs) electronic databases that track all controlled substance prescriptions in the state to identify patients who may be improperly using Take steps to improve PDMPs, such as real time data reporting and access, integration with electronic health records, proactive unsolicited reporting, incentives for provider use, and interoperability with other states. Identify improper prescribing of painkillers and other prescription drugs by using PDMPs and other data. Increase access to substance abuse treatment, including getting immediate treatment help for pregnant women. Consider steps that can reduce barriers (such as lack of childcare) to substance abuse treatment for women. Women can Discuss all medications they are taking (including over-the-counter) with their health care provider. Use prescription drugs only as directed by a health care provider, and store them in a secure place. Dispose of medications properly, as soon as the course of treatment is done. Do not keep prescription medications around just in case. (See preventiontips.htm) Help prevent misuse and abuse by not selling or sharing prescription drugs. Never use another person s prescription drugs. Discuss pregnancy plans with their health care provider before taking prescription painkillers. Get help for substance abuse problems ( HELP); call Poison Help ( ) for questions about medicines. prescription painkillers and other drugs Clifton Road NE, Atlanta, GA Publication date: 7/2/2013 CS238899B www www For more information, please contact Telephone: CDC-INFO ( ) TTY: Web: Centers for Disease Control and Prevention

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26 Dose Response Methadone Simulated 24 Hr. Dose/Response At steady-state in tolerant patient Loaded High 0 hrs. Normal Range Comfort Zone Subjective w/d Time Sick Objective w/d 24 hrs. FIGURE 1 OPIOID AGONIST TREATMENT OF ADDICTION - PAYTE

27 MAT MAT Mechanism at Opiate Receptor Pregnancy Methadone (Methadose) Buprenorphine (Subutex) Agonist Synthetically manufactured, produces increasing effects until the receptor is fully activated and maximum effect is reached. Partial Agonist Maximum effect is less than a full agonist, there is a ceiling effect. Safe/NAS Safe*/NAS Buprenorphine + Naloxone (Suboxone) Partial Agonist-Antagonist Combination of partial agonist and antagonist. no Naltrexone & Naloxone (Depade, ReVia, Vivitrol) Antagonist Bind to receptor to block the effect of agonists. no *based on preliminary studies and should only be offered to pregnant women already taking buprenorphine

28 Informed Consent for Pregnant Opioid/Opiate Dependent Individuals Seeking Treatment Your diagnosis is opioid/opiate use disorder. Having a diagnosis of opioid/opiate use disorder means that you have or are currently experiencing problems related to your use of prescription pain killers or heroin. When you are pregnant and have a diagnosis of opioid/opiate use disorder it means that you are in a high risk category or that your disease is more severe. You have the following three options: 1. Recommended treatment for you includes a daily dose of medication (methadone or buprenorphine) that will prevent you from experiencing withdrawal symptoms or cravings. In addition, chemical dependency counseling, prenatal care, and any other care you might need are recommended. Benefits: Provides better outcomes for your baby such as higher birth weight and lower risk of complications. Provides a steady and stable dose of medication throughout the day so that your baby is not at risk for complications associated with withdrawals including death. Reduces the risk of using needles which reduces the risk of transferring diseases to your baby. Reduces the risk of problems during pregnancy and delivery. Risks: It is likely that your baby will experience withdrawal symptoms after birth. These symptoms are called Neonatal Abstinence Syndrome or NAS. NAS can be treated in the hospital. The presence of NAS does not mean that your child will continue to have problems later. 2. You could choose medically managed detoxification which means you will be slowly taken off or tapered off of opioids/opiates over a period of days in a treatment setting: Trying to detox by yourself is extremely dangerous for you and your baby. Benefits: Your baby may not experience withdrawal symptoms after birth. You will not have to take medication daily. Risks: The risk of miscarriage or your baby (the fetus) dying is much higher. Your risk of relapsing or returning to using opioids/opiates illegally is much higher. 3. You could also choose to not accept treatment and keep using opioids/opiates. Risks: The risk of miscarriage (the fetus dying) is much higher. Every time you experience withdrawal symptoms or cravings to use your baby (the fetus) is at risk of dying. The problems you are experiencing will get worse. It is likely that your baby will experience withdrawal symptoms after birth. Please circle the option you have chosen. 1.Opioid Substitution Therapy 2.Medically managed 3. No treatment Detoxification The risks and benefits of all options have been explained to me. Client Signature Date Signed Staff Signature Date Signed

29 OPIOID/OPIATE USE IN PREGNANT WOMEN WHAT ARE OPIOIDS/OPIATES? Drugs such as heroin, morphine and codeine are considered opiates as they are derived from opium while certain prescription painkillers are considered opioids including drugs such as oxycodone, hydrocodone, methadone, etc. WHY IS IT IMPORTANT TO KNOW MORE ABOUT PREGNANT OPIATE/OPIOID DEPENDENT WOMEN? OPIOID USE IS CLIMBING. In 2009, there were more than 23,000 pregnant women using opiates or opioids when they delivered, nationwide, up 475% from The incidence of neonatal abstinence syndrome (NAS) has tripled in 10 years. Nationally, about one child every hour is born with NAS. NAS is a group of problems that occur in a newborn who was exposed to addictive illegal or prescription drugs while in the mother s womb. From 2007 to 2011 the number of Medicaid related NAS cases in Texas increased from 536 to 852. DID YOU KNOW THAT TREATMENT RECOMMENDATIONS FOR PREGNANT OPIATE/OPIOID DEPENDENT WOMEN ARE DIFFERENT THAN FOR THOSE WHO ARE NOT PREGNANT AND THOSE WHO ARE DEPENDENT UPON OTHER DRUGS? Although heroin withdrawal is rarely fatal to healthy adults, fetal death is a significant risk in pregnant women who are not treated for opioid addiction. If not given information regarding the risks and benefits of treatment options an individual may unintentionally engage in behaviors that create complications to pregnancy including fetal death. Both The American College of Obstetrics and Gynecology, (ACOG), and The American Society of Addiction Medicine, (ASAM,) recommend against medically supervised withdrawal or detoxification from heroin or opioids during pregnancy because of the high relapse rate and the increased risk of fetal distress and death. Chronic untreated opioid use during pregnancy is associated with fetal complications including fetal death. WHAT ARE THE TREATMENT RECOMMENDATIONS FOR PREGNANT OPIOID/OPIATE DEPENDENT INDIVIDUALS? Accurate information regarding the benefits of engaging in appropriate treatment services as well as the risks of not engaging in services or engaging in contraindicated services should be communicated immediately as to ensure timely referral and admission to appropriate treatment services. A comprehensive package of medication-assisted treatment, (methadone in particular unless the individual is already established on buprenorphine), along with chemical dependency counseling, prenatal care, and other medical and psychosocial services are recommended by ACOG and ASAM as the best treatment option for these individuals and have shown to improve outcomes for both mother and child. OTHER THINGS TO CONSIDER Stigma affects all opioid-dependent patients to some degree, but prejudice toward those who become pregnant is especially high. Breast feeding is not contraindicated in a methadone-maintained patient if she is known to be free of other drug use and is known to be HIV seronegative. There are known and effective treatments for NAS. Appropriately treated NAS has not been associated with longterm developmental problems for the child. Appropriate opioid substitution therapy (OST), the prescribing of methadone or buprenorphine as indicated, normalizes brain function. Sedation is most often a result of overmedication and is a signal the dosage needs to be changed. Case workers and other advocates can provide valuable assistance to prescribing physicians by sharing observations made during their work with parents who are on OST.

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