1 Hendrée E. Jones, PhD Executive Director, Horizons Program Professor, Department of Obstetrics and Gynecology School of edicine, !niversity of "orth #arolina at #hapel Hill Perinatal Quality Collaborative of North Carolina $earning Session % &aleigh, "# % ay '(, )*'+ Treating Woen for !ubstan"e #se Disorders$ Considerations during Pregnan"y and the Post%artuPeriod
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8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
Slide ' #redits0 8Husband nd Pregnant 9ife: by David #astillo Dominici; 8Side <ie. Of Pregnant 9oman: by imageryma=estic; 8 other /s&eading >oo- ?or Her >aby: by @omphong
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
Discussing methadone and buprenorphine, labeled by the !S ?ood andDrug dministration 6?D 7 as #ategory # for use in pregnancy for thetreatment of maternal opioid dependence0 8 nimal reproduction studieshave sho.n an adverse effect on the fetus and there are no adeAuate and.ellBcontrolled studies in humans, but potential benefits may .arrant useof the drug in pregnant .omen despite potential ris-sC:
Pregnant .omen .ith opioid use disorders can be effectively treated .ithmethadone or buprenorphineC >oth these medications should not beconsidered 8offBlabel: use in the treatment of pregnant patients .ith opioiduse disorder @ones et alC, & J 'bstet (yne"ol C )*'(
&ec-ittB>enc-iser Pharmaceuticals for donated active placebo tablets andreimbursement for time and travel in )*''C
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
mericans consume 4* percent of the.orldMs supply of pain-illers BB morethan ''* tons of pure, addictiveopiates every yearC 5hat is 2(Percocet or <icodin per every !S#itizenC
#urrent #ontext of Drug !se in the !S
http://www.dailymail.co.uk/news/article-2142481/Americans-consume-8 -percent-worlds-pain-pills-prescription-dru!-a"use-epidemic-e#plodes.html$i#%%&a'"!()oA *+* 1/22/1, pioid painkillers widely prescri"ed amon! reproducti e a!e women
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
retrospective, serial, crossBsectional analysisof a nationally representative sample ofne.borns .ith " SC#linical conditions .ere identified using /#DBIB# diagnosis codesC" S and maternal opiate use .ere described asan annual freAuency per '*** hospital birthsC
♦ lthough less freAuent than alcohol and tobacco use,opioid misuse during pregnancy is nonetheless aserious and gro.ing issue
♦ 5his increase in use of opioids by pregnant .omenappears to be driving an increase in the incidence ofneonatal opioid .ithdra.al
♦ Opioid use by pregnant .omen is often complicated bypolydrug use, and often occurs intert.ined .ithcomplex personal, interpersonal, family, social, andenvironmental factors that can contribute to adverseconseAuences
♦ 9omen have uniAue needs for addiction treatment andmultiBfaceted interventions are needed to help preventand treat opioidBdependence among .omen duringpregnancy and their infants
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
• &educes maternal craving and fetalexposure to illicit drugs
• 9ith drug abstinence, other behaviorchanges can follo. .hich decreaseris-s to mother fetus of infection fromH/<, hepatitis and sexually transmittedinfections
• &educes the incidence of obstetricaland fetal complications and improvesoutcomes
#redit0 /mage in the public domain by SubDural')
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
9HO )*'( Guidelines0 8Pregnant .omen dependent on opioidsshould be encouraged to use opioid maintenance treatment .heneveravailable rather than to attempt opioid detoxificationC Opioidmaintenance treatment in this context refers to either methadonemaintenance treatment or buprenorphine maintenance treatmentC:
Guidance regarding maintenance versus medicationBassisted.ithdra.al has traditionally been based largely on good clinical
=udgmentedication follo.ed by no medication treatment has freAuently been
found to be unsuccessful, .ith relatively high attrition and a rapidreturn to illicit opioid use
aintenance medication facilitates retention of patients and reducessubstance use compared to no medication
>iggest concern .ith opioid agonist medication during pregnancy isthe potential for occurrence of neonatal abstinence syndrome 6" S7 Fa treatable condition
aintenance v C edicationBassisted 9ithdra.al
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
)) 9hy !se Opioid edications 9ith opioid medications .e are not replacing one addiction for anotherCOpioid medications are longBacting medication that help .ith0
#& </"G
n individual s cravings are controlled
#O P!$S/O"
/ndividual is no longer compulsively using opioids
#O"5&O$
edicationBassisted treatment gives bac- control to the individual
#O"SE !E"#ES
edication assisted treatment helps the individual focus on rebuilding her life
&n individual re"eiving o%ioid %har a"othera%y ust be onitored by a edi"al teathat evaluates ade ua"y of edi"ation dosage and general health and )ell1being of theindividual.
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
• /n the 'I1*s , a positive relationship bet.een maternal methadonedose and " S severity .as reported
• &ecommendations to maintain pregnant .omen on methadonedoses bet.een )* to (* mg
• 3 decades of research sho.s an inconsistent relationship bet.eenmaternal methadone dose and " S severity
• 5he latest systematic revie. and metaBanalysis concluded that the8Severity of the neonatal abstinence syndrome does not appear todiffer according to .hether mothers are on highB or lo.Bdose
methadone maintenance therapyC:
6&evie. in #leary et alC, &ddi"tion, )*'*7
ethadone0 Dosing during Pregnancy
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
6aternal esults – increase drug negative urines during treatment – /ncreased adherence .ith treatment – decrease .ithdra.al symptoms in mother
– "o change in maternal heart rate, vagal tone or s-in conductance
(etal esults – inimizes the reduction in breathing
– inimizes the reduction in movement – ?etal movementBfetal heart rate coupling less suppressed
ethadone0 Dosing during Pregnancy
6DePetrillo et alC, 'II+; S.ift et alC, 'I4I; 9ittmann et alC,'II'; @ansson et alC, )**I; c#arthy7#redit0 8Human ?etus: by ddpavumba; 8Smiling Pregnant ?emale Holding Her 5ummy: by imageryma=estic
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
ethadoneBStabilized othersethadone detected in breast mil- in very lo. levels
ethadone concentrations in breast mil- are unrelated tomaternal methadone dose5he amount of methadone ingested by the infant is lo.
5he amount of methadone ingested by the infant remainslo. even 2 months later Several studies sho. relationships bet.eenbreastfeeding and reduced " S severity and durationHepatitis # is not a contraindication for breastfeeding
#ontraindications0 H/<U, unstable recovery
6DM polito, )*'3; P )*'); c ueen et alC, )*''; @ansson et alC, )**1; @ansson et alC, )*'*7
ethadone0 >reastfeeding
#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
&esearch focusing on the effects of prenatal exposure to
methadone has been inconsistent$ongBterm effects on physical gro.th have not been demonstrated
lthough some research has sho.n that methadoneBexposed schoolBage children to be less interactive, more aggressive, and sho.ingpoorer achievement than children not so exposed, other research hasfailed to sho. any differences in either cognitive or socialdevelopment
5he issue is confounded by the fact that children exposed tomethadone in utero may experience a nutritional, family, andparenting history Auite different than children not so exposed
)*'( metaBanalysis sho.ed 8no significant impairments for cognitive,psychomotor or observed behavioual outcomes for chronic intraButerine exposed infants and preBschool children compared to nonBexposed infants and childrenC:
6>aldacchino et alC, 3*C Psy"hiatry )*'(; >ehn-e et alC, Pediatri"s , )*'3; ?arid et alC, Curr Neuro%har , )**47
ethadone0 #hild Development
#redit0 8$ady Doctor easuring Girls Height: by David #astillo
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
&esearch .ith buprenorphine not as extensive as .ith
methadone9ellBtolerated and generally safe/n contrast to the research .ith methadone, little researchhas compared buprenorphine to an untreated control
group&ather, buprenorphine has been compared in bothretrospective and prospective studies to methadone
a=ority of research .ould suggest that maternaloutcomes are not in any .ay different than for methadone
>uprenorphine0 aternal Outcomes
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7
3) hi 0 ? l O
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
>uprenorphine is found in breast mil- ) hours postBmaternal
dosing#oncentration of buprenorphine in breast mil- is lo.
mount of buprenorphine or norbuprenorphine the infant receivesvia breast mil- is only '
ost recent guidelines0 8the amounts of buprenorphine in human
mil- are small and unli-ely to have negative effects on thedeveloping /nfant:85he advantages of breast feeding prevail despite the ris-s of aninfant opiate intoxication caused by methadone orbuprenorphine C:
6 t-inson et alC, 'II*; arAuet et alC, 'II1; @ohnson, et alC, )**'; Grimm et alC, )**+; $indemalm et alC, )**I; @ansson et alC, )**I; Xller et alC, )*''7
>uprenorphine0 >reastfeeding
#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong
3+ > hi 0 #hild D l t
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
• &esearch on the neonatal conseAuences of prenatalexposure to buprenorphine is Auite limited
• "ot enough births have been follo.ed for a sufficientperiod of time to collect convincing data regardingfactors such as cognitive and social development
• Same issue of confounding parental and family factorsin teasing apart developmental effect
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7
>uprenorphine0 #hild Development
32 O5HE&0 Si
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
!niversity of <ienna P/0 GC ?ischer !niversity of 5oronto P/0 PC Selby<anderbilt !niversity P/0 PC artin9ayne State !niversity P/0 SC StineCoordinating Center !niversity of aryland P/0 C rria
31 O5HE&0 > hi C th d
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
neonates, buprenorphineBexposed neonates – &eAuired 4I less&eAuired 4I less
morphine to treat " Smorphine to treat " S – Spent (3 less time in theSpent (3 less time in the
hospitalhospital
– Spent +4 less time in theSpent +4 less time in thehospital being medicatedhospital being medicatedfor " Sfor " S
• >oth medications in thecontext of comprehensivecare produced similar
maternal treatment anddelivery outcomes
&;
Notes$ Significant results are encircledC Site .as a bloc-ing factor in all analysesC 5he O >rienB?leming Y spending function resulted in Y V C**I' for the inferential tests of the edication#ondition effect for the + primary outcome measures at the conclusion of the trialC
6@ones et alC, N Engl J *ed C )*'*7
% V C***')
% V C******')
< >uprenorphine< ethadone
O5HE&0 >uprenorphine v C ethadone
34 O5HE&0 > hi C th d
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
Higher average daily number ofcigarettes smo-ed in the past 3* days.as
U related to in"reasing 0
• 5otal amount of morphine needed to treat" S
• "umber of days neonate .as medicatedfor " S
• "eonatal length of hospital stay
B related to de"reasing 0
• "eonatal .eight at birth
O$S and Poisson regression analyses .ere used to test average daily number of cigarettes smo-ed in the past 3* days at YV C*+, ad=usting for bothedication #ondition and SiteC >elo.Baverage cigarette smo-ing .as defined as 2 cigarettesRday 6B' !D 7, average cigarette smo-ing as '(cigarettesRday 6 ean7, and aboveBaverage cigarette smo-ing as )' cigarettesRday 6U' !D 7C 6@ones et alC, D&D, )*'37
Smo-ing and eonatal bstinence Syndrome 6 S7
SelfBreported past 3*Bday daily average number of cigarettes smo-ed,measured at study entry, .as used to predict neonatal and maternaloutcomes in '3' pregnant participants in the O5HE& studyC
(( >uprenorphine vC ethadone
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
#onsiders the needs of .omen in all aspects of program designand delivery, including location, staffing, program development,program content, and program materials
Provides safe and comfortable environments in .hich .omendevelop supportive relationships that allo. them to address theirrecovery needs
Services need to include0Outreach and engagementScreeningDetoxification#risis intervention
ssessment5reatment planning#ase management
Program #omponents for 9omen
Progra should be a""redited by an outside body li+e C&78 or JH&C'
Substance use counseling and education 5rauma specific and informed services edical and mental health care
Pharmacotherapy Drug monitoring #ontinuing care
(2 Substance !se Disorders during Pregnancy
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
?e. medications are successful in the treatment of anysubstance use disorders, except for alcohol and opioidsC
Opioid medications such as methadone and buprenorphine canbe successful components in treating opioid use disorder, bothin the general population and in pregnant .omenC
Opioid medications are best provided in the context of acomprehensive treatment plan that includes behavioral
treatment li-e individual counselingC comprehensive treatment plan is developed follo.ing anassessment that determines .hich life areas have been affectedby drug use and to .hat extent they have been affectedC
5he patient and provider then develop specific goals for
improved life functioning in each life area and a plan for ho.and .hen the goals .ill be metC
Part of the plan may eventually include .ellness indicators of.hen patients can taper off of their medicationC
ScreenScreen
ssessssess
PlanRPlanR5reat5reat
EvaluateEvaluate
(1 ?actors to $oo ?or in Good 5 Program
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
Do they use the merican Society of ddiction edicine 6 S 7standards for opioid treatment .ith opioid medications in alldecisions regarding the initiation and continuation of themedication for substance use treatment
Do they use evidenceBbased instruments .hich include at aminimum0
the memberMs report of physical and emotional comfortan instrument to assess for possible .ithdra.al symptomsurine toxicology screen results and any other laboratoryfindingsan instrument for assessing impairment
(4 ?actors to $oo- ?or in Good 5 Program
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
minimum of eight 647 tests per year .ill be performed per patient&andom testing for each patient&eAuires specific drugsRclasses .ill be tested including methadoneand SH s 6sedatives, hypnotics, anxiolytics7; testing should alsoinclude those substances in the memberMs personal history and thosecommon in the region!se certified labs and accepted technologies for appropriateinterpretation of results .ill be used to validly interpret test results
#an they sho. you a staffing plan for recruitment, training anddevelopment
9hat standards can they sho. to document that they are facilitatingrecovery
Do they have a plan for case management in place 9hat are its mainfeatures
(I ?actors to $oo- ?or in Good 5 Program
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
6E9E6 :$ Services for .omenC 5reatment plan includes family issues, 5reatment9ith family involvementC Goal0 improved outcomes for .omenC
6E9E6 $ #hildren accompany .omen to treatmentC 9omen s #hildren participatein child care but receive no 5reatment 9ith therapeutic servicesC Only .omen have#hildren Present treatment plansC Goal0 improved outcomes for .omenC
6E9E6 ;$ #hildren accompany .omen to treatmentC 9omen s and 9omen andattending children have treatment #hildren s plans and receive appropriateservicesC Goals0 Services improved outcomes for .omen and children, betterparentingC
6E9E6 <$ #hildren accompany .omen to treatment; ?amily Services .omen andchildren have treatment plansC Some services are provided to other familymembersC Goals0 improved outcomes for .omen and children, better parentingC
6E9E6 4$ ?amilyB#entered 5reatment Each family member has a treatment planand receives individual and family servicesC Goals0 improved outcomes for.omen, children, and other family members; better parenting and familyfunctioningC
#ontinuum of ?amilyB ased Services
+' odel of #are for 9omen and #hildren
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
> Opioid addiction is a treatable illness> Pregnant .omen .ith opioid use
disorders have medication optionsfrom .hich to choose as a part of acomprehensive treatment program
> 9omenBcentered treatment programsthat focus on the needs of the.omen, her fetus, and her familyoffer the promise of addressing themultiple and complex needs of.omen .ith opioid use disorders
g
#redit0 8balanced stones: by Pa-hnyushchyyC
+( &esources
8/9/2019 PQCNC: Treating Women Substance Abuse Disorders
• Bupropion• arenicline• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,
contingency management• $As (As%, Ad!ise, Assess, Assist, Arrange) as a Brie# &nter!ention
] ery limited data #or NRT and bupropion usein pregnancy, and no data a!ailable #or !arenicline,both o# "hich are ' A pregnancy category C
] oucher based rein#orcement has been pro!ene##icacious as a beha!ioral treatment
Alcohol
• *edication assisted "ithdra"al #rom alcohol use #or pregnant "omen#re+uently uses a benzodiazepine (e g , diazepam) as pharmacotherapy
• -sychosocial treatment should be considered as an integral component o# any "ithdra"al strategy
] -harmacotherapy (e g , acamprosate, naltre.one,disul#iram) should generally not be used inpregnancy due to ris% to the #etus
] Beha!ioral treatments ha!e been #ound to be in#erior topharmacotherapy in non pregnant "omen
Cannabis •
Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management ] No %no"n e##icacious pharmacotherapy
Cocaine • Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,
contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy
Amphetamines/*ethamphetamines
• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy
Benzodiazepines
• 0radual taper "ith a long acting benzodiazepine (e g , diazepam) "ith the goal
o# being benzodiazepine #ree at birth• -sychosocial treatment should be considered as an integral component o# anydose reduction strategy
] Beha!ioral treatments are thought to be in#erior topharmacotherapy