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Substance Abuse In the Obstetric Patient Dr. Erika Brandenstein M.D. F.A.C.O.G. Objectives • Identifying the Patient • Maternal and fetal complications • Managing the Patient and Infant • Prevention The Disease: It’s a Medical Condition! • Clearly defined diagnostic criteria in the DSM –IV - Chronic and relapsing condition - Behavior disorder - Affects brain and body functions The Disease: The Role of the Provider • Recognize addiction as a medical issue – Avoid viewing addiction as a moral issue – Not a personal failure of sign of weakness Addiction In the Pregnant Patient • Opioid use in pregnant women double between 1998 and 2011 • Poly-substance use is common • Non-medical use of prescription drugs increasing 2012-2013 National Survey on Drug Use and Health Ages % Current Illicit Drug Users 15-17 14.6 % 18-25 8.6 % 26-44 3.2 % Positive Drug Screens at Reid 2016 70 66 58 60 54 53 50 53 52 46 40 30 20 14 10 0 13 65 2 26%1 12 10 8 6 66 28%0 0 22%0 0 17 16 14 10 56 17%0 2 66 5 26%0 0 30%0 0 78 0 2 Jan Feb Mar Apr May June July # of births 53 46 54 58 52 53 66 total # of pos drug screens 17 14 13 12 10 14 16 % of pos drugs screens 26% 28% 22% 17% 26% 30% # of pos opiate screens 6 6 6 5 6 5 7 # of pos cannibus screens 5 8 6 6 6 10 8 # of pos MDMA (ecstasy) 1 0 0 0 0 0 0 # of pos cocaine screens 0 2 2 1 0 2 0 # of pos amphetamine screens 2 0 0 2 0 0 2 # of pos benzodiazipines 0 2 2 1 0 1 2 # of pos barbituates 0 0 0 1 2 1 3 Aug Sept Oct Nov Dec Identification • All patients should be screened • Consider face to face interview • The 4 P’s, CRAFFT • Urine drug screens Identification The four Ps • Parents: Did any of your parents have a problem with alcohol or other drug use? • Partner: Does your partner have a problem with alcohol or drug use? • Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications? • Present: In the past month, have you consumed any alcohol or used other drugs? • Scoring: Any “yes” answer should trigger further questions Identification • CRAFFT: Substance Abuse Screen for Adolescents and Young Adults • C: Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? • R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? • A: Do you ever use alcohol or drugs while you are by yourself or ALONE? • F: Do you ever FORGET things you did while using alcohol or drugs? • F: Do your FAMILY or friends ever tell you that you should cut down on your drinking or drug use? • T: Have you ever gotten into TROUBLE while using alcohol or drugs? • Scoring: Two or more positive answers indicate the need for further assessment Urine Drug Screens: Patient Selection • Late or no prenatal care • Diagnosis of stillbirth, placental abruption • Always perform with patient’s knowledge and consent • Universal vs. selective screening controversy – No uniform policy – Reporting requirements – Consider consequences of criminalization Consent • General consent for Maternity and Newborn Care – “ I understand that for my safety and that of my infant a blood and/or urine sample will be obtained and can be used to test for…” – Review by hospital legal team Testing the Infant • Urine • Meconium • Cord segment Marijuana Use in Pregnancy • Most commonly used illicit drug in pregnancy (selfreported prevalence of 2-5%) • 48-60% of marijuana users continue in pregnancy (worsening with legalization) • Crosses placenta/ fetal plasma levels 10% of maternal levels • Limited data shows transmission to breast milk Marijuana use in pregnancy: Adverse outcomes • Disruption in brain development in animal models • Mental and behavioral issues • No structural anatomic defects • Addictive in some individuals • Studies limited by confounders – – – – – Polysubstance use Lifestyle issues Self-reporting Recall bias Inconsistent data Marijuana and Lactation • Insufficient data • Encourage discontinuance Medical Marijuana • • • • Not regulated or evaluated by the FDA No approved indications Smoking cannot be condoned Alternative therapy with pregnancy-specific data Opioid Use and Maternal Health: • Heroin is most widely abused opioid and has highest addiction potential • Injecting increases risk for cellulitis/abscess, endocarditis, osteomyelitis, Hep B, Hep C, HIV • Heroin Withdrawal symptoms can develop in 4-6 hours • Obsessive thinking and drug cravings may persist for years • Withdrawal sx: abdominal cramping, nausea, insomnia, anxiety, and irritability Opioid Use and the Fetus Fetal death with acute withdrawal Possible risk of birth defects Fetal growth restriction Abruptio placentae Preterm labor Intrauterine passage of meconium Opioid Use and the Infant • NAS: hyperactivity of central and autonomic nervous system • Finnegan scoring • Long term affects – Limited data – No proven long term cognitive deficiency up to age 5 Management of Opioid Abuse in Pregnancy Social Services Mental health professionals Physicians and Nurses Management: Maintenance Therapy Prevents acute narcotic withdrawal in mom and fetus Prevents illicit opioid use Reduces criminal activity Encourages prenatal care and comprehensive tx Management: Methadone • Long acting opioid receptor agonist • Daily dosing • Dose change may be required at onset of and after pregnancy • Dose titrated to until patient is asymptomatic Management: Buprenorphine (Subutex) • Partial opioid agonist • Prevents withdrawal symptoms and cravings • Block euphoric effects of other opioids (higher affinity for opioid receptors) • Not a full agonist (less of a high) Management: Buprenorphine • Advantages over methadone – No daily visits – Less severe NAS (89% less morphine/ 58% shorter duration) – Fewer drug interactions Management: Buprenorphine • Disadvantages – No long term data on neurodevelopmental effects – Less structured tx (abuse/selling on the street) – Not effective for all patients Management: Buprenorphine w/ Naloxone (Suboxone) • Naloxone is an opioid antagonist – Binds to opioid receptor but does not activate – Blocks opioids • Causes severe withdrawal if injected • Discourage in pregnancy Buprenorphine General Management • Good communication between obstetrician and addiction treatment program • Know withdrawal symptoms • Can initiate tx as an outpatient or in the inpatient setting • Illegal for physician to write a prescription for any other opioid (including methadone) outside of a licensed tx program. Buprenorphine excluded. • Pt must be informed of fetal effects Medically Supervised Withdrawal • Not recommended due to high relapse rates • It may be considered if needed (unavailability or patient refusal) • Preferably done in the second trimester Intrapartum and Postpartum Management • Treat as if they were not on opioid-assisted therapy • Epidural preferred for Labor and delivery • Notify pediatric staff • Anticipate that requirement for higher doses Management for Infants: NAS • Tremors, seizures/convulsions, overactive reflexes • Stuffy nose or sneezing • Fussiness, excessive crying, high-pitched cry • Poor feeding, poor sucking, poor weight gain • High respiratory rate • Fever, sweating, blotchy skin • Trouble sleeping , yawning • Diarrhea, vomiting NAS • Opiates, benzodiazepines, barbiturates, alcohol, methamphetamines • Assessment through Finnegan scoring – 21 symptoms – Initiating medications Alcohol Use and Maternal Health • 49.8% of women of childbearing age • Directly associated w/ leading causes of preventable death (heart disease, overdoses, accidents, cirrhosis) • Cancer and multiple deficiencies (thiamine, vit C, niacin, pyridoxine) • Increased risk of breast cancer • Alcoholic cardiomyopathy Alcohol Use and the Fetus • Most common teratogen • Leading cause of MR, developmental delay, birth defects • Greatest risk in first trimester • FAS • No established safe level in pregnancy Fetal Alcohol Syndrome Growth restriction (prenatal, postnatal, both) Facial abnormalities ( epicanthal folds, ear abnormalities, smooth philtrum, thin upper lip, upturned nose, flat midface) Central nervous system dysfunction (behavioral disorders, ADD, microcephaly, MR) Fetal Alcohol Syndrome Intrapartum and Postpartum Management • Risk of aspiration w/ acute intoxication • Risk of acute withdrawal w/ associated symptoms (hypertension, delirium, seizures, heart failure) • Malnutrition, coagulopathy, neuropathy should be considered when choosing anesthesia Infant Management • Infant may have withdrawal symptoms (jitteriness, poor feeding, irritability) • Likely to occur within the first 12 hrs of life • FAS from etoh treated w/ barbiturates • No breastfeeding if actively abusing etoh. Limit drinking to equivalent of 8 oz glass of wine or 2 beers and wait 2 hrs until breastfeeding Cocaine Use and Maternal Health Seizures CVA Cardiac Disease Poor Nutrition Psychosis Cocaine Use and the Fetus Placental abruption Preterm birth Low birth weight Microcephaly, cognitive and motor disorders Intrapartum and Postpartum Management • Maternal complications – Thrombocytopenia – Hypo or hypertension – Cardia arrhythmias • Pain control issues • No acute neonatal withdrawal syndrome • No breastfeeding if actively abusing Methamphetamines and Maternal Health • Most frequently used after alcohol and marijuana • Arrhythmias, HTN, Seizures, hyperthermia • Increased high risk sexual activity • Insomnia, anxiety, confusion, memory loss, and psychotic features w/ long term use • Severe dental issues Methamphetamine Use and the Fetus • • • • • CNS Defects Cardiac defects Oral cleft and limb defects GI defects Long term effects on attention, memory and visual motor integration • No case-control or prospective studies Intrapartum and Postpartum Management • Consider maternal complications • Anticipate problems with infant – Decreased arousal, increased stress, poor quality of newborn movement • Breastmilk 2.8-7.5 x higher than maternal plasma • Do not breastfeed! Pregnancy Management Pearls • Meds alone will not be successful – Prenatal care – Chemical dependency counseling – Family therapy – Group therapy – Psychosocial services Pregnancy Management Pearls Education Goal not to judge (Affect on baby and treatment) Monitoring (high risk) Minimize maternal and fetal separation Barriers to Identification and Treatment • Poverty – Transportation – Education – Inability to afford tx • Fear – Losing baby – Jail • Illness Our Plan: Early Detection Face to face interview Office urine drug screen Hospital urine drug screen Our Plan: Management • • • • • Patient education Treatment referral Medications Correspondence Close follow-up/ surveillance (office visits, DCS) • Support (WIC, transportation, classes) • Encouragement and compassion Our Plan: Prevention Contraception • Free clinic • LARCs Postpartum treatment • Supervised withdrawal Postpartum support • Early follow-up • Inpatient or transitional facility Our Plan: Prevention • Hospital wide and unit based discussions with multidisciplinary teams. • Community outreach Resources • • • • • • • American Congress of Obstetricians and Gynecologists. Patent safety update: routine urine drug screens on our pregnant patients?. Available at:://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/January-2015/Patient-Safety. Retrieved on Sept 19, 2015. Center for Adolescent Substance Abuse Research, Children’s Hospital Boston. The CRAFFT Screening Interview. (2009). Boston: CeASAR; 2009. Available at: www.ceasar.org/CRAFFT/pdf/ CRAFFT_English.pdf. Retrieved September 19, 2015. Daniel J et al, Fetal alcohol spectrum disorders, National Human Genome Research Institute, National Institutes of Health, Bethesda Maryland, Am Fam Physican, 2005 July 15; 72 (2): 279-285. Ewing H, A practical guide to intervention in health and social services with pregnant and postpartum addicts and alcoholics: Theoretical framework, brief screening tool, key interview questions, and strategies for referral to recovery resources, Martinez, CA: The Born Free Project Contra Costa Dept of Health Services, 1990. How buprenorphine works. Available at https://advancedpainmanagementclinic.com /addiction/suboxone-pharmacolo . Retrieved Oct 3, 2016. Marijuana use during pregnancy and lactation. Committee Opinion No. 637. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:234-8. Methamphetamine abuse in women of reproductive age. Committee Opinion No. 479. Americn collete of Obstetricians and Gynecologists. Obstet Gynecol 2011:117:751-5. Resources cont. • • • • • • Neonatal Abstinence Syndrome. Available at: http://www.marchofdimes.org/baby/neonatal-abstinence-syndrome-(nas).aspx Retrieved Oct 4, 2016. Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; 119:1070-6. Reece-Stremtan S, Marnelli A, Academy of Breastfeeding Medicine. AMB clinical protocol #21: Guidelines for breastfeeding and substance use or substance use disorder. Breastfeeding medicine 2015, 10: 3. Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist. Committee Opinion No. 473. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011; 11:200-1. Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Substance Use Disorders in Pregnancy Consensus Statement Executive Summary 2007.Indiana perinatal Network. www.indianaperinatal.org. Retrieved October 4, 2016. Thank You!!!