Maternal Addiction Treatment

Maternal Addiction

Treatment:Preventing Neonatal Abstinence Syndrome

LAURIE SCOTT, MD

ALBERTO AUGSTEN, PHARMD, BCPP, CPH

CLAUDIA P. VICENCIO, LCSW, LMFT

MEMORIAL HEALTHCARE SYSTEM

American Hospital Association, October 26, 2016

Objectives:

Review the history of treatment of opioid use disorder in pregnant women.

Understand the importance of addressing substance use disorders in pregnancy to prevent Neonatal Abstinence Syndrome (NAS).

Compare efficacy of available drug therapies for the treatment of opioid use disorders in pregnancy.

Present a multidisciplinary, hospital-based, and community involved program for the treatment of substance use disorders in pregnancy.

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Every 25 Minutes…

• Shrill, high pitched cry• Irritability• Hypertonicity• Tremors• Short sleep cycles• Apnea• Stuffy nose• Diarrhea• Vomiting• Sweating• Fever• Sneezing

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Opioid epidemic = NAS

epidemic

$1.5 billion in healthcare expenditures

80% paid by Medicaid

5 fold increase from 2000 - 2012

Up to 50% of total NICU annual hospital days

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A Brief History of

Treatment of Opioid Use

Disorder in Pregnancy

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Laurie Scott, MD

Medical Director of Maternal Fetal Medicine at Memorial

Healthcare System

For over 40 years…

This has been the standard of care for the

treatment of opioid use disorders in

pregnancy.

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The Heroin Epidemic of

the 1970’s: Neonatal Risks

Heroin addiction increasingly recognized as a

fetal / neonatal risk

Possible small increase in congenital

abnormalities

Fetal growth restriction

Abruption

Fetal demise

Preterm delivery and sequelae

NAS

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The Heroin Epidemic of

the 1970’s: Maternal Risks

Infectious disease (Hepatitis, HIV)

Other illnesses (endocarditis, sepsis, osteomyelitis)

Overdose

Domino effect of drug lifestyle (prostitution, criminal records, poverty, family estrangement, malnourishment)

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Methadone Maintenance

Becomes the Standard of

Care Prevent complications of illicit opioid use and withdrawal

Encourage prenatal care and drug treatment

Reduce criminal activity

Avoid association with drug culture

Recommendations against complete withdrawal

High recidivism rate

Fetal distress / demise

“NAS is an expected and treatable condition.”

“Lifestyle of continued use of [illicit Opioids] represents the greatest risk.”

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Prescription Opioid &

Heroin Use Continue to

Increase… Pregnant women: 4.4% illicit drug use in “last 30 days”

0.1% heroin, 1% non-heroin Opioids

2.6% infants screen positive for Opioids

Admissions for substance abuse

4% pregnant

Opioids 2% 1992, 28% 2012

Drug of choice: Opioids 1% 1992, 19% 2012

Overdose deaths increased 500% since 1999

Causes more deaths than MVA

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Today’s Opioid Epidemic:

Demographics

Ages 21-29

Unmarried

Non-Hispanic white

High school educated but unemployed

1/3 have a psychiatric co morbidity

75% are using multiple substances

High cocaine use

100% smoke cigarettes

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Methadone Maintenance

is Not Without Fetal Risk

Increased intrauterine growth restriction (IUGR) – 25%

Increased preterm delivery

Severe NAS and long length of stay post delivery

Emerging information re: long term ocular abnormalities

Long term safety of maintenance therapy not well studied and

uncertain

Neurobehavioral abnormalities related to polysubtance abuse

Adverse maternal impact

Increased risk for C-section

Limited and restrictive access

Social stigma and lifestyle / work challenges

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Buprenorphine Introduced

as Alternative to

Methadone (2002)

Pros and Cons compared to methadone

May be a better choice (decreased overdose risk,

decreased NAS symptoms, less intrauterine growth

retardation, preterm delivery)

Improved access

Less stigma

Increasing acceptance

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New Studies Support Full

Detoxification in Pregnancy

Pregnancy increases motivation of patient, partner and family

Decreased risk for NAS

Safe when controlled

Relapse reduced with appropriate Behavioral Health support

1998 Dashe

34 patients, 59% drug free, 12% maintenance, 29% relapse

No fetal distress, demise, intrauterine growth restriction (IUGR) or preterm delivery (PTD)

2013 Stewart

95 patients, 56% drug free at delivery

No fetal distress, demise, IUGR or PTD

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Detoxification in

Pregnancy, cont’d

2012 Lund

Detoxification and complete withdrawal decreased NAS

Safe for fetus

2014 Haabrekke

Birthweight, head circumference, gestational age at delivery,

NAS all improved with detox and withdrawal

Safe for fetus

2016 Bell

301 patients no adverse fetal outcomes from complete

withdrawal

Total 600 published cases with no report of fetal harm

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Maintenance exchanges

one form of dependency

for another.

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Pharmacological risks

associated with illicit

opioid use are still present

with maintenance

therapy.

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Medically assisted detox

and withdrawal with

strong follow-up

behavioral health therapy

appears to reduce both

pharmacological risks and

lifestyle risks from Opioid

dependency.

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Maternal Addiction

Treatment (MAT)

Program OverviewALBERTO AUGSTEN, PHARMD, BCPP, CPH &

CLAUDIA P. VICENCIO, LCSW, LMFT

MAT PROGRAM CO-DIRECTORS, MEMORIAL HEALTHCARE SYSTEM

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Case Study: Melodie

32 years old, co-occurring and untreated depression and anxiety

10 years on methadone maintenance (140mg daily) with continuous polysubstance abuse

5 births in those 10 years, all born with NAS, all

removed from her care

Chronic benzodiazepine abuse (high doses), chronic crack cocaine abuse

Partner of 10 years, relationship is abusive

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Assessing Current

Standard of Care

• No prenatal care

• No mental health treatment

• Ongoing domestic violence

Comprehensive care?

• Continued polysubstance abuse

• Partner using drugsAddiction

Treatment?

• 5 babies in 10 years of methadone maintenance, all born with NAS

What about the babies?

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Revising the Standard of

Care Through

Comprehensive Treatment

APPLYING EVIDENCE-BASED APPROACHES THROUGH COLLABORATION

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Primary Goal:

Improving Social Determinants

of Health by Reducing Rates of

NAS ~ $93,000 per infant charges for

NAS hospitalization

2x more likely to be readmitted within 30 days of birth

Children born with NAS are 4.5x more likely to be readmitted to the hospital for maltreatment and 2x more likely to be admitted for mental and behavioral disorders in childhood.

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Creating a New Standard

of Care

1. Universal screening for substance abuse in pregnancy

2. Improved opioid prescribing practices for all women of reproductive age

3. Comprehensive, team-based care

4. Targeted services and outreach for high risk populations

5. Improving access to effective substance abuse treatment

6. Coordinated treatment among all levels of care

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Pharmacology & Birth

OutcomesBuprenorphine Methadone

Mechanism of

Action

Partial μ-agonist Full μ-agonist

Cost Covered by insurance $15 per visit

Availability Certified providers SAMHSA certified

Opioid Treatment

Center

Treatment

Setting

Multiple options Limited

Associated NAS

Rates

~10% ~90%

Fetal Response Reactive nonstress test with

more fetal heart rate

accelerations, ↑ biophysical

profile score

Non-reactive nonstress

test,

↓ biophysical profile

score

Preterm Delivery ~10% ~30%

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Evidence Based Screening:

5 Ps Integrated Screening Tool

Parents: Did any of your parents have a problem with alcohol or other

drug use?

Peers: Do any of your friends have a problem with alcohol or other drug

use?

Partner: Does your partner have a problem with alcohol or other drug use?

Past: In the past, have you had difficulties in your life due to alcohol or

other drugs, including prescription medications?

Present:

In the past month, have you drunk any alcohol or used other drugs?

1. How many days per month do you drink?_______

2. How many drinks on any given day? _______

3. How often did you have 4 or more drinks per day in the last month?

Smoking: Have you smoked any cigarettes in the past three months?

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Dimensions of Treatment

1. Acute Intoxication and Management of Perinatal Withdrawal (including fetal monitoring during process)

2. Biomedical Conditions and Complications (Hep C, HIV, etc.)

3. Emotional, Behavioral or Cognitive Conditions and Complications (All patients served had co-occurring mood or thought disorder)

4. Readiness to Change (alcohol, drugs, tobacco, explore internal/external motivating factors)

5. Relapse, Continued Use or Continued Problem Potential (prenatal and post partum, psychosocial risk factors)

6. Recovery Environment (social and family support, barriers to engagement: substance-using partner, abusive environment, lack of housing/transportation, legal issues, access to prenatal care/insurance)

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A MAT Program Tracer 28

ER Admission

• Outreach

• Initial OB Work-up

• Initiate social work Involvement

Inpatient Induction

•Average 7 days

•Psychiatric stabilization

•Setting up outpatient resources & support

Outpatient Stabilization

• 14-21 days for detox

• Supportive housing

• Intensive Outpatient Program

• Dialectical Behavior Therapy

• Coordination with outpatient OB/GYN

Goal:

Collaboration &

Coordinated Care

Emergency department, inpatient & outpatient

OB, Psychiatry, Pharmacy, Nursing, Social Work, Peer Support, Administration

Residential treatment programs, OB clinics, child welfare, smoking cessation, Medicaid

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Treatment Consideration:

Intrapartum Concerns

Obstetric pain management/ anesthesia adjunct

Methadone Maintenance – risk of inducing acute Opioid withdrawal

Avoid partial agonist:

Nubain (nalbuphine)

Stadol (butorphanol)

Talwin (pentazocine)

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Postpartum Concerns

Psychological & physiological effects of reintroducing opioid

Consider injectable nonsteroidal anti-inflammatory agents (kertorolac)

Goal is Opioid-free discharge

High risk of relapse

Sober support, structure

Aftercare treatment

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MHS MAT Program Results

to DateOPTIMIZED, INTEGRATED TREATMENT FOR IMPROVED MATERNAL & FETAL OUTCOMES

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MAT Patients Served by

Substance of Choice

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Total Patients Served n=52

Opioid/ Polysubstance

n=48

Methadone n=3

Heroin n=45

Non-Opioid

n=4

Alprazolam n=1

Alpha PVP (Flakka)

n=2

Kratomn=1

MAT Patient Demographics

by Race/Ethnicity (n=52)

90%

4% 6%

White, Non-Hispanic Hispanic/ Latino

Black or African-American

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Birth Outcomes,

May 2015 to Present (n)

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3126

3 2

TOTAL BIRTHS DRUG FREE

BABIES/MOMS

BABIES BORN

EXPOSED

LOST TO

FOLLOW-UP

Drug Free Babies/MomsBabies Born

ExposedLost to Follow-up

84% 10% 6%

Maternal Post-Partum Recovery Rates (%) 36

92

7975

1 1 10

10

20

30

40

50

60

70

80

90

100

3 Months 6 Months 12 Months

MAT Program Mthadone Maintenance

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Chase: born 10/01/2015

Hurricane Matthew

Questions?Alberto Augsten, PharmD, BCPP, CPh

[email protected]

Zeff Ross, FACHE

[email protected]

Laurie Scott, MD

[email protected]

Tammy Tucker, PsyD

[email protected]

Claudia P. Vicencio, LCSW, LMFT

[email protected]

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References1. Association of State and Territorial Health Officials. Neonatal Abstinence Syndrome: How States

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3. Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. 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. 2008;103(9):1429-1440. doi:10.1111/j.1360-0443.2008.02283.x.

4. Jones HE, Martin PR, Heil SH, et al. Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues. doi:10.1016/j.jsat.2007.10.007.

5. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. doi:10.1056/NEJMoa1005359.

6. Kakko J, Heilig M, Sarman I. Buprenorphine and methadone treatment of Opioid dependence during pregnancy: Comparison of fetal growth and neonatal outcomes in two consecutive case series. Drug Alcohol Depend. 2008;96(1-2):69-78. doi:10.1016/j.drugalcdep.2008.01.025.

7. Salisbury AL, Coyle MG, O’Grady KE, et al. Fetal assessment before and after dosing with buprenorphine or methadone. Addiction. 2012;107(SUPPL.1):36-44. doi:10.1111/j.1360-0443.2012.04037.x.

8. Patrick SW, Burke JF, Biel TJ, Auger KA, Goyal NK, Cooper WO. Risk of Hospital Readmission Among Infants With Neonatal Abstinence Syndrome. Hosp Pediatr. 2015;5(10):513-519. http://hosppeds.aappublications.org/content/5/10/513.abstract.

9. Uebel H, Wright IM, Burns L, et al. Reasons for Rehospitalization in Children Who Had Neonatal Abstinence Syndrome. Pediatrics. 2015;136(4):2014-2767. doi:10.1542/peds.2014-2767

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