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ATTC Center of Excellence on Behavioral Health for Pregnant and Postpartum Women and Their Families www.attcppwtools.org ATTC Regional Center Partners: Great Lakes ATTC Mid-America ATTC New England ATTC Southeast ATTC Purpose: The Center was established to develop a family-centered national curricula, web-based toolkit, and provide support for national training and resource dissemination.
Addressing the Peril of Illicit Drug Use for Pregnancy: Medication Assisted Treatment & Integrated Care Trudee Ettlinger, PhD, APRN, LADC, CCS Maple Leaf Treatment Center 10 Maple Leaf Road Underhill, VT 05489 802-858-7209 tettlinger@mapleleaf.org CoE PPW Webinette 2 March 8, 2016
Webinette Overview Affects an estimated 5 million Americans Health problem does not spare childbearing age women An estimated 225,000 babies are born each year with prenatal drug exposure Opioid addiction is a chronic, relapsing disease Considerations in opiate replacement therapy in correctional settings
Opiate Use and Pregnant Women
Opiate Use and Pregnant Women Prevalence ranges 1-2% with some estimates as high as 21% Maternal Morbidity 6 times more risk for obstetric complications Low birth weight (LBW) 3 rd trimester bleeding Fetal distress Malpresentation of fetus
Opiate Use and Pregnant Women Neonatal Conditions Neonatal abstinence syndrome (NAS) Postnatal growth lags Increased risk for Sudden Infant Death Syndrome (SIDS)
Medication Assisted Treatment
Medication Assisted Treatment Opioid Use Disorder causes both neurochemical and structural brain changes affecting opioid receptors Methadone (a full agonist drug) and buprenorphine (partial opioid agonist drug) are effective in decreasing opiate drug craving Both allow for improved recovery success & prevent opioid withdrawal
Medication Assisted Maintenance Treatment Options Drug Addiction Treatment Act 2000 Opiate Treatment Programs (OTP) Restrictive, daily dosing, earned take-home medication privileges for those free of illicit drugs; serves high risk population Office-based Opiate Treatment (OBOT) Patient meets stability criteria, prescribed buprenorphine; patient contracts with medical practice
Goals for Pregnancy & MAT Reduce illicit drug use exposure for fetus Engage mother in SUD Treatment Prevent opioid withdrawal and its physiologic cascade In correctional setting, MAT is an opportunity for improved public health and safety
Methadone Treatment Medication of choice for pregnancy (more data reporting neo-natal outcomes) Access barriers (i.e., clinic locations, clinic times) Capacity of mother to comply with OBOT clinic requirements & needing OTP care level structure
Buprenorphine Treatment Considerations Formulation Subutex (No Naloxone-buprenorphine monotherapy) Stable on buprenorphine prior to pregnancy Clinical presentation supports stability for OBOT level of care In correctional OTP programs, diversion is sometimes a concern
MAT: Labor and Delivery Continue with scheduled methadone or Subutex for labor and delivery and postpartum Spinal and epidural analgesia is provided for pain control Pain managed with nonsteroidal anti-inflammatory drugs (NSAID s) and short acting opioids (e.g., codeine, morphine, Percocet, Vicodin) Women requiring a Cesarean Section (C-Section) may need decreasing doses of short acting opioids for several days
Neo-Natal Abstinence Syndrome Buprenorphine Vs. Methadone Buprenorphine exposed infants require less withdrawal management treatment (morphine/methadone) and have a shorter stay in the hospital than methadone-maintained mothers
Postpartum Care
Breast Feeding Low bioavailability with methadone and buprenorphine Breast feeding encouraged In correctional settings, diversion has been a concern
Medication Assisted Treatment & Early Postpartum Months Maintain on medications Watch for relapse 3-6 months after birth Discuss contraception: Long Acting Reversible Contraception LARC (IUD or hormonal implant); risk potential for rapid repeat pregnancy No evidence of medication interactions between contraceptives, methadone, or buprenorphine
Risky Life Profile Generational familial drug use High exposure to violence Limited education Psychiatric cooccurring disorders Justice system involved Unsuccessful work history Unsafe housing Multiple hardships
Wrap Around Care
Clinical Treatment & Support Services Interrelated Elements include... Birth plan (correctional settings) Childcare Housing Life management skills Nutrition Transportation
Psycho-Social Care Package Parenting groups Individual counseling Group counseling Stress management skills
Cornerstones of Treatment Motivational Therapeutic Strategies Optimal Care Care Continuum Navigation Skills Building
Connecting Navigator Helper Counseling Services Departments relating to Children & Families Economic Services Field Correctional Services Medication Assisted Treatment Clinic Obstetric Care Women, Infants, Children (WIC)
Treatment Challenges
Higher Level of Care Indicators (i.e., OTP or residential setting) Evidence of benzodiazepines, cocaine, and alcohol in urine screening Not attending substance use disorder counseling Diverting prescribed MAT medication (also a concern in correctional settings)
Summary Message Board Keep Both Safe Understand: OTP and OBOT community resources Methadone is the preferred choice for pregnancy Opioid addiction is a relapsing chronic brain disease Women/mothers need full wrap-around care
Trudee Ettlinger, PhD, APRN, LADC, CCS Maple Leaf Treatment Center 10 Maple Leaf Road Underhill, VT 05489 802-858-7209 tettlinger@mapleleaf.org CoE PPW Webinette 2 March 8, 2016 To access recorded webinette: www.attcppwtools.org
References (1 of 3) ABM Clinical Protocol #21. (2009). Guidelines for breastfeeding and drug-dependent women. Academy of Breastfeeding Medicine, 4(4). Abuse, O. (2012). Dependence, and Addiction in Pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists. Obstetrical Gynecology, 119, 1070-6. Amaeda, A., Bateman, B.T., Clancy, C.R., Creanga, A.A., & Leffert, L.R. (2014). Opioid abuse and dependence during pregnancy: Temporal trends and obstetrical outcomes. Anesthesiology, 121, 1158-65. Brown, H.L., Britton, K.A., Mahaffey, D., Brizendine, E., Hiett, A.K., Tumquest, M. A. (1998). Methadone maintenance in pregnancy: A reappraisal. American Journal of Obstetrics and Gynecology, 170, 459-463. Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.)
References (2 of 3) Goler, N.C., Armstrong, M.A., Taillac, C.J., Osejo, V.M. (2008). Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. Journal of Perinatology, 28, 597-603. Heil, S. H., Jones, H. E., Arria, A., Kaltenbach, K., Coyle, M., Fischer, G., Martin, P. R. (2011). Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment, 40(2), 199 202. Jones, H.E., Fischer, G., Heil, S.H., Kaltenbach, K., Martin, P.R., Coyle, M.G., Selby, P., Arria, A.M. (2012). Maternal opioid treatment: Human experimental research (MOTHER)--approach, issues, and lessons learned. Addiction, 107, 28-35. Jones, H.E., Johnson, R.E., Jasinski, D.R., O Grady, K.E., Chisholm, C. A., Choo, R.E., Crocetti, M., Milio, L. (2005). Buprenorphine versus methadone in the treatment of opioid-dependent patients: Effects on neonatal abstinence syndrome. Drug & Alcohol Dependence, 79, 1-10.
References (3 of 3) Kaltenbach, K., Silverman, N., & Wapner, R. (1992). Methadone maintenance during pregnancy. State Methadone Treatment Guidelines. Treatment Improvement Protocol (TIP) Series, 1, 85-94. Keegan J., Parva, M., Finnegan, M., Gerson, A., Belden, M. (2010). Addiction in Pregnancy. Journal of Addictive Diseases, 29(2), 175-191. Winklbaur, B., Kopf, N., Ebner, N., Jung, E., Thau, K. & Fischer, G. (2008), Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction, 103, 1429 1440. Young, J. L., & Martin, P. R. (2012). Treatment of opioid dependence in the setting of pregnancy. Psychiatric Clinics of North America, 35(2), 441-460.
Thanks for Participating! You will be eligible to receive a.5 NAADAC contact hour if viewed prior to April 1, 2016 Please send your request to receive a certificate of attendance to: info@attcppwtools.org no later than April 1, 2016. www.attcppwtools.org