Opioids, Nicotine & Neonatal Abstinence Swati Shivale, MD Senior Resident for Addiction Service Department of Psychiatry SUNY Upstate Medical University, Syracuse, NY April 29 th 2016, Verona, NY
Objectives Screening for depression, drug use Nicotine and neonatal abstinence syndrome Methods to minimize NAS
Patient Profile UNDERSTANDING THE WOMAN THAT WALKS IN TO YOUR OFFICE
Patient Profile Co-morbid psychiatric conditions: Depression, ADHD, Borderline personality disorder Trauma, abuse Dysfunctional families Poor education, learning disabilities
Patient Profile Financial constraints Intimate partner violence Addicted partners Legal issues McQueen KA, Murphy-Oikonen J, Desaulniers L. Maternal Substance Use and Neonatal Abstinence Syndrome: A Descriptive Study. Matern Child Health J. 2015 Aug;19(8):1756-65. doi: 10.1007/s10995-015-1689-y
Screening Fear of losing custody, being judged Under-reporting is norm Urine Cotinine, Urine Drug screen Depression: EPDS, PHQ 9
Why Screen? ACOG Guidelines USPTF Evidence of benefit: Grade B Prevent/minimize NAS DSRIP $$$
Neonatal Abstinence Syndrome Collection of signs and symptoms in a newborn prenatally exposed to opiates Amphetamines Barbiturates Alcohol Benzodiazepines SSRIs http://www.uptodate.com/contents/neonatal-abstinence-syndrome
Cost of NICU Stay In 2009, 55% reduction in LOS= $396 million in annual savings for NAS treatment Patrick SW., Schumacher RE., Benneyworth BD., Krans EE., McAllister JM., Davis MM. Neonatal abstinence syndrome and associated health care expenditures United States, 2000 2009. JAMA.2012;307:1934 1940
Buprenorphine or Methadone? 609 pregnant, opioid-dependent women treated with methadone (n=248) or buprenorphine (n=361) Mothers treated with buprenorphine longer gestation larger infants treatment for NAS less often shorter duration p<0.001 for all the above Meyer MC, Johnston AM, Crocker AM, Heil SH. Methadone and buprenorphine for opioid dependence during pregnancy: A retrospective cohort study. Journal of addiction medicine. 2015;9(2):81-86. doi:10.1097/adm.0000000000000092.
Nicotine and NAS: Why?
Why Not? Placenta previa Abruption Ectopic Pregnancy PROM IUGR Stillbirth Congenital heart defects Thyroid dysfunction Increased risk of SIDS Schizophrenia ADHD Asthma Lowers IQ http://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy
Smoking and opioid use 84%-95% on opioid treatment smoke Buprenorphine/Methadone ensures attendance Is it possible to improve neonatal outcomes by focusing on smoking cessation? Clemmey P, Brooner R, Chutuape MA, Kidorf M, Stitzer M. Smoking habits and attitudes in a methadone maintenance treatment population. Drug Alcohol Depend. 1997;44:123 13 Bailey, B. A., McCook, J. G., Hodge, A., & McGrady, L. Infant birth outcomes among substance using women: Why quitting smoking during pregnancy is just as important as quitting illicit drug use. Maternal and Child Health Journal, 2012;16, 414 422. doi:10.1007/s10995-011-0776-y
What Did We Do? 6 pregnant women with opioid and nicotine use disorder Intensive outpatient individual psychotherapy ± Bupropion Incentives: Buprenorphine & humanrelatedness
Case Series Gestational age at first visit (in weeks) Days to quit (Negative urine cotinine) Other Drugs Spontaneous Vaginal Delivery Neonatal Outcomes *NBN=NewBorn Nursery Morphine? 6 15 Alcohol, Benzodiazepines, Cannabis 4 days NBN No 8.5 15-4 days NBN No 11.4 72 Methadone 4 days NBN. NICU on 3rd day, score of 9 once. No 15.4 23-4 days NICU No 24 12 Cannabis Induced at 42WOG 4 days NICU No 25 Did not quit Cannabis, Methamphetamine 6 weeks NICU Yes
Results Five out six women quit smoking (83%) and stayed quit Our case-series: 4 days, no morphine Current average NICU LOS: 7 to 25 days Brogly SB, Saia KA, Walley AY, Du HM, Sebastiani P. Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis. Am J Epidemiol. 2014;180(7):673 686.
What can I do? Offer Bupropion (Category C; L3) Office based Buprenorphine: Expect dose escalation Offer referral
Questions? shivalsw@upstate.edu Addiction Service: 315-464-3130