Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Opioid Dependence During Pregnancy Michelle Lofwall, M.D. University of Kentucky © AMSP 2009 1 Challenging to Treat MDs have inadequate training Medical & legal system prejudices State reporting requirements Doctor-patient alliance problems © AMSP 2009 2 What You Need to Know Punishment ≠ effective deterrent Comprehensive treatment works! 3x in mom’s opiate use Prenatal care 3x low birth weight (LBW: <2500 grams) Perinatal HIV transmission to <2% 2x maternal custody in 1st yr © AMSP 2009 3 This Lecture Reviews Definitions Causes, course, prevalence & comorbidity Medical complications Treatment © AMSP 2009 4 © AMSP 2009 5 Abuse & Dependence Abuse ≥ 1 of: Obligations Hazardous use Legal Interpersonal problems Dependence ≥ 3 of: Tolerance Withdrawal Amounts or more time Desire or unable cut down Time get, use, or recover Non-drug activities Physical/psychological problems © AMSP 2009 6 Opioid Withdrawal Occurs with /no opioid use OR opioid antagonist ≥ 3 of: Dysphoria (unhappy) Nausea or vomit Muscle aches Lacrimation (watery eyes) or rhinorrhea (runny nose) Diarrhea © AMSP 2009 Yawning Fever Insomnia Mydriasis (big pupils), piloerection (goose bumps), or sweating 7 This Lecture Reviews Definitions ✓ Causes, course, prevalence & comorbidity Medical complications Treatment © AMSP 2009 8 Etiology 50% Genes 50% Environment Availability Peer use Drug-using partners Hx victimization © AMSP 2009 9 Chronic Relapsing Course >50% relapse >90% use opioids before pregnancy 20x mortality vs. Ø substance disorder dx © AMSP 2009 10 Prevalence of Opiate Use % Opiate + 10 8.6 8 6 4 2 1 0 Maternal selfreport © AMSP 2009 Meconium 11 Other Drugs & Psych Dxs > 90% Cigs >10% Axis I • LBW •LBW with •Premature >10% Cocaine mood •SIDS disorder • Placental •Stillbirths abruption • Premature © AMSP 2009 12 Complex Social Problems >50% single moms & unemployed >25% hx of physical/sexual abuse Low socioeconomic status Adversely affects pregnancy Prenatal care Direct harm © AMSP 2009 13 Risky Behaviors Sharing needles, unprotected sex, dealing Mom’s infections risk of: Premature contractions & labor Breakdown fetal membranes & abortion Difficult to separate out opioid effects © AMSP 2009 14 This Lecture Reviews Definitions ✓ Causes, course, prevalence & comorbidities ✓ Medical complications Treatment © AMSP 2009 15 Maternal & Fetal Problems Multifactorial etiology HIV: 25% transmit Hep C: ~5% transmit Endocarditis heart failure hypoxia Nutritional deficiency – e.g., 25% Fe-defic © AMSP 2009 16 Fetal Hypoxia Intoxication Withdrawal Unstable fetal environment © AMSP 2009 17 Newborn Birth Outcomes ~50% LBW (~20% with rx) Death ~25% HIV (<2% with rx) Meconium aspiration (stool inhaled into lungs) ~10% Microcephaly (small head) © AMSP 2009 18 Neonatal Abstinence Syndrome (NAS) © AMSP 2009 19 NAS Definition Central nervous system excitability Autonomic nervous system GI system malfunction Respiratory distress © AMSP 2009 20 NAS Time course depends on: Opioid Fetal half-life (T ½) opioid storage & metabolism Risk factors: Opioid dependent mom 70% chance NAS Smoking severity Prematurity severity © AMSP 2009 21 © AMSP 2009 22 This Lecture Reviews Definitions ✓ Causes, course, prevalence & comorbidities ✓ Medical complications ✓ Treatment © AMSP 2009 23 4 Treatments Reviewed Psychosocial rx without medication Methadone maintenance (MM) Methadone-assisted withdrawal Buprenorphine (Subutex®) maintenance © AMSP 2009 24 Psychosocial Interventions Cornerstone Therapeutic alliance Expect demanding & resistant behavior Complete assessment Assist with all problems © AMSP 2009 25 Methadone Maintenance Long T ½ (27 hrs), synthetic opioid agonist Strict federal regulations Opioid > dependent > 1 yr (unless preg) 18 yrs unless parental consent/failed rx Daily visits x 90 days © AMSP 2009 26 Many Treatment Goals Mother: /stop withdrawal /stop drug use Prenatal/med/psych rx Psychosocial probs Supportive network Parenting skills © AMSP 2009 27 Many Treatment Goals Fetus/neonate Stable intrauterine environment Stop intox/withdrawal cycles Deliver term/healthy newborn + maternal/fetal bond © AMSP 2009 28 Components of MM Treatment Multidisciplinary team Individual & group counseling Parenting classes Daily oral methadone dosing Start at 30 mg (40 mg max day 1) > 50 mg maintenance dose Blocks + illicit opioid effects Prevents withdrawal © AMSP 2009 29 MM Benefits 3x in mom’s opiate use Prenatal care 3x LBW Perinatal HIV transmission to <2% 2x maternal custody of newborn © AMSP 2009 30 MM Limitations Availability Limited patient acceptance Does not incidence of NAS Report of fine motor skill problems © AMSP 2009 31 Methadone-assisted Withdrawal 1970’s = standard rx until fetal deaths Utilized if MM not available or accepted Goals: Mother/fetus opioid withdrawal Achieve Deliver opioid free state in mom/fetus term, healthy fetus with no NAS © AMSP 2009 32 Components of Withdrawal Treatment Inpatient OB monitors fetus daily for distress Stabilize on methadone then taper dose If fetal distress – slow taper, dose 3 & 7 day tapers at specialty units Discharge Con’t outpatient rx to maintain abstinence © AMSP 2009 33 Withdrawal Outcomes >50% relapse Problem > opioid withdrawal Problem = medical & psychosocial Compared to MM, detox alone results in: 2x + urine drug test at delivery 5x days in trt 6 fewer OB appts No diff in NAS or birth outcomes © AMSP 2009 34 Buprenorphine Maintenance 2002 approved rx for non-preg opioid depend Partial opioid agonist Enhanced safety profile T ½ = 37 hrs Office-based © AMSP 2009 35 Buprenorphine Maintenance Must become qualified to prescribe Potential advantages Similar outcomes as MM Large on-going clinical trial © AMSP 2009 36 This Lecture Reviewed Definitions ✓ Causes, course, prevalence & comorbidities ✓ Medical complications ✓ Treatment ✓ © AMSP 2009 37