Substance Use and Addiction in Pregnancy

1
Substance Use and Addiction in Pregnancy

• Michael M. Miller, MD, FASAM, FAPA
• OB GYN Grand Rounds
• March 9, 2006

2
Addiction Medicine

• The specialty of medicine devoted to diagnosis,
  treatment, prevention, education, epidemiology,
  research, and public policy advocacy regarding
  addiction and other substance-related health
  conditions

3
Addiction Medicine

• Its not just for addiction specialists
• There can never be enough addiction specialists
  to address such prevalent/common conditions
• Every physicianincluding OB/GYNs
• encounters patients or family members affected by
  substance-related conditions
• Every physician needs to know some basics about
  recognition and referral

4
The American Society of Addiction Medicine
ASAM
For Attendings, Residents, Students
5
Addiction is only one of the Substance-Related
Disorders

• Addiction (Substance Dependence)
• Problem Use (Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use
• Codependency and ACOA Syndromes

6
Each of these can affect pregnancy

• Addiction (Substance Dependence)
• Problem Use (Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use
• Codependency and ACOA Syndromes

7
Addiction in Women

• Increasing (equality of the sexes)
• 19th Century 2/3 of Americas opiate addicts
  and large age of MJ, sed, coc
• Down to 20 of illegal drug addicts during
  1914-1954
• Possibly 1/3 of current addicts (excluding
  alcohol and prescription drugs!)

8
Substance Use in Women

• In early 1990s,
• DSM IV alcohol dependence
• 2 million women,
• alcohol abuse 2 million women, compared to
• alcohol abuse and dependence 12 million men
• 1-month prevalence of illicit drug use
• 4 of women ages 12 above,
• but in childbearing ages,
• 8 of women ages 18-25 and 6 of women ages
  26-34.
• Regular use (once or more per week)see table

9
Why Relevant

• Since many alcohol/tobacco/other drug-using women
  are of childbearing age,
• Use of substances by women means that there will
  be a significant prevalence of intrauterine drug
  exposure
• Adverse biological effects on development
• Adverse effects during labor of intoxication of
  the fetus
• Adverse effects postpartum from neonatal
  abstinence syndromes
• Adverse long-term effects of exposure

10
But.!

• This doesnt mean a large prevalence / incidence
  of addicted babiesfetuses and infants do not
  have the capacity to manifest the chronic
  behavioral disorder of addiction
• And any intrauterine biological effect of drug
  exposure may be trumped by biological effects of
  the psychsocial aspects of the life of the
  pregnant alcohol/tobacco/drug addicted woman
• And, any post-partum effects on children are more
  likely due to parenting deficits associated with
  ongoing substance use/addiction than with
  long-lasting biological effects of intrauterine
  drug exposure

11
Exposure Rates

• not called use rates since the fetus isnt a
  user and the mother is not a supplier or
  dealer
• 2.5 of babies (80 k/yr USA) opiate exposed
• 5 of babies (160 k/yr USA) cocaine exposed
• 20 of babies (640 k/yr USA) MJ exposed
• 75 of babies (2.4 m/yr USA) EtOH exposed
• The above were 1980s data in 1990s some
  suggest that use rates were only 1/3 of the
  1980s rates.

12
Prenatal Exposure Rate Data from National Survey
on Drug Use and Health (NSDUH), Office of
Applied Studies, SAMHSA, US DHHS

• In 2002 and 2003, 4.3 percent of pregnant women
  aged 15 to 44 used illicit drugs during the past
  month,
• 4.1 percent reported binge alcohol use, and
• 18.0 percent reported smoking cigarettes
• Pregnant women aged 15 to 25 were more likely to
  use illicit drugs and smoke cigarettes during the
  past month than pregnant women aged 26 to 44
• Among pregnant women aged 15 to 44, whites were
  more likely to have smoked cigarettes during the
  past month than blacks or Hispanics

13

• Percentages of Past Month Illicit Drug Use among
  Women Aged 15 to 44, by Pregnancy Status, Age,
  and Race/Ethnicity 2002 and 2003

14
Percentages of Past Month Alcohol Use among Women
Aged 15 to 44, by Pregnancy Status 2002 and
2003(Data from National Survey on Drug Use and
Health, Office of Applied Studies, SAMHSA, US
DHHS)
15
What to make of any data?

• Because of the high incidence of polysubstance
  use, it is essential to remember the inherent
  difficulties involved in ascribing a specific
  perinatal effect to one specific substance.
• --Finnegan and Kandall, 1997

16
Substance Use and Addiction are Public Health
Problems

• Use direct exposure to toxic effects
• Use exposure to health risks associated with
  route of administration
• Use placing oneself in contexts with health
  consequences (unwanted pregnancy, STDs,
  violence, vehicular crashes)
• Passive exposure poses health risks
• tobacco smoke vehicle passenger gang violence

17
Take-Home Messages Re Substance Use and
Addiction in Pregnancy

• Substance use is widespread.
• Addiction is not uncommon.
• Not all heavy/frequent
• substance users are addicts.
• Not all addicts are daily users
• or users of large quantities of
• substances.

18
Take-Home Messages Re Substance Use and
Addiction in Pregnancy

• Addiction is a stigmatized condition.
• Patients with addiction feel ashamed, and will
  hide the truth (from themselves and others)
  because of shamepregnancy amplifies this.
• Criminalization intensifies shame and
  withholding of information (arrest/ CPS) .
• Addiction is not a desired state.

19
What are the clinical features of addiction?

• Substance use
• Use behaviors and procurement behaviors persist
  despite problems due to use
• Return to use after periods of abstinence,
  despite previous problems
• Inability to consistently control use
• Preoccupation with use/procurement salience of
  use-related behaviors
• Cognitive changes (over-valuation, de-valuation,
  minimization/denial)
• Enhanced cue responsiveness via conditioning and
  generalization

20
What is the natural history of addiction?

• some variants are more malignant in course than
  others
• some variants are pediatric diseases (onset
  before adulthood)
• chronic disease pattern waxing and waning of
  signs/symptoms
• usually progressive
• insidious atrophy of judgment, coping skills,
  relationships, values
• sometimes fatal

21
What is the main clinical feature of addiction?

• Inconsistent control of use

22
DSM IV Criteria for Substance Dependence Disorder

• A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• 1. Tolerance, as defined by either of the
  following
• a need for markedly increased amounts of the
  substance to achieve intoxication or the desired
  effect, or
• b) markedly diminished effect with continued use
  of the same amount of the substance

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DSM IV Substance Dependence

• 2. Withdrawal
• 3. The substance is often taken in larger
  amounts or over a longer period than was intended
• 4. There is a persistent desire or there are
  unsuccessful efforts to cut down or control
  substance use
• 5. A great deal of time is spent in activities
  necessary to obtain the substance, use the
  substance, or recover from its effects

24
DSM IV Substance Dependence

• 6. Important social, occupational, or
  recreational activities are given up or reduced
  because of substance use
• 7. The substance use is continued despite
  knowledge of having a persistent or recurrent
  physical or psychological problem that is likely
  to have been caused or exacerbated by the
  substance

25
Addiction is not Abuse

• Odd words physical abuse, sexual abuse,
  substance abuse
• Substance Abuse -- overarching term
• Substance Abuse -- DSM-IV meaning

26
Addiction is not Dependence

• Physical vs. Psychological Dependence
• Physiological Dependence
• Tolerance
• Withdrawal
• DSM-IV terms

27
Addiction occurs as a result of interactions
among

• Agent factors (substances)
• Host factors (genetics, vulnerabilities,
  comorbidities)
• Environmental factors (culture, neighborhood,
  household)

28
Its not only the agents (self-reinforcing
euphoriants)
29
Its not only the hosts (susceptible individuals)
30
Its not only the environments (cultures,
neighborhoods, homes, settings)
31
Substances

• DRUGS vs. ALCOHOL
• ILLEGAL vs. LEGAL
• HARD vs. SOFT
• STREET vs. PRESCRIPTION
• CLUB DRUGS vs. THERAPEUTIC RXs

32
Its TOBACCO !

• The Killer Drug
• The Gateway Drug
• The Commonest Drug

33
Mortality from Drug Use(direct toxic effects of
intoxication)(medical complications of chronic
use)

• Tobacco 500,000 deaths / year
• Alcohol 125,000 deaths/year
• Drugs

34
Epidemiology

• 10 of adults have a lifetime prevalence of
  addiction to alcohol/drugs, excluding nicotine
• 20 of primary care outpatients have a lifetime
  prevalence of SUD (excl. nicotine)
• 30 of hospitalized inpatients have a lifetime
  prevalence of SUD (excl. nicotine)

35
Epidemiology

• Alcohol abuse dependence lifetime prevalence
  14 (males 24, females 5)
• Drug abuse dependence lifetime prevalence 6
• Combined is about 10

36
Substance Dependence or Abuse among Persons Aged
12 or Older 2002 and 2003
Numbers in Millions
22.0
21.6
3.2
3.1
NHSUD
37
Substances

• Sedatives
• Stimulants
• Opioids
• Hallucinogens
• Inhalants

38
Sedatives

• Alcoholic beverages
• Barbiturates
• Benzodiazepines
• Sedative-Hypnotics
• GHB (GBL, 1,4 BD)
• Propofol

39
Stimulants

• Speed
• Cocaine
• Psychostimulants
• Appetite Suppressants
• Designer Drugs (Ecstasy, et al.)
• Nicotine

40
Opioids

• Natural (codeine, morphine, opium, heroin)
• Semi-synthetic
• Synthetic
• Partial Agonists
• --novel delivery systems patches, lollipops,
  nasal sprays

41
Hallucinogens

• LSD
• Mescaline (Peyote)
• Psilocybin (mushrooms)
• Cannabinoids
• NMDA-antagonists
• (PCP, ketamine, dextromethorphan)

42
Inhalants

• Nitrous Oxide
• Nitrates
• Hydrocarbons

43
Routes of Administration

• Oral
• Nasal
• Inhaled/Smoked
• IV
• IM
• Sub-cutaneous
• Transdermal
• Sublingual

44
Range of Conditions

• Use
• Misuse
• Risky Use
• Problem Use
• Addiction
• Disability
• Death

45
Relationship Between Alcohol Use and Alcohol
Problems
Alcohol Use
None
Light
Moderate
Heavy
At Risk
Problem
Dependent
Low Risk
Severe
Moderate
Small
Alcohol Problems
None
46
A bit more on WORDS

• SUBSTANCE ABUSE
• DEPENDENCE
• CRACK BABY
• METH BABY
• ADDICTED BABY
• TOXICOLOGY SCREEN
• DIAGNOSED BY PHYSICAL EXAM AND LAB TESTS
• ASSESSMENT SOCIAL HISTORY

47
Substance Use and Addiction

• in pregnancy
• ... in women who could become pregnant
• For substance using and addicted women, it may be
  several months before she knows shes pregnant
  (irregular menses associated with alcohol or
  other drug use may not prevent the ability to
  conceive!)

48
Substance Use and Addiction

• in pregnancy
• ... in women who could become pregnant
• Surveys suggest that 67 of pregnant women drink,
  and over 10 of pregnant women use illegal drugs
• Tobacco use in young women is about 1/3.
• Black / White, rich / poor, public / private

49
Initial Presentation

• When drug-addicted women present to health care
  facilities for services, some are presenting for
  prenatal care, but others are presenting only to
  deliver their baby
• Access to prenatal care is affected by insurance
  status, lifestyle issues, and also fear of
  referral to legal or child protective services
  authorities
• Access is also affected by delivery system
  issues services unfriendly to women/moms
  (child care, transportation)

50
? Index of Suspicion

• Positive history of addiction in biological
  family
• Positive history of addiction in partner
• Psychiatric co-morbidity
• Personality Disorders
• Affective Disorders (20 of females with
  addiction cf. 1 in 20 males with addiction)
• Frequent legal encounters
• Other substance use

51
Injection Drug Use

• Needle Marks
• Track Marks
• Sclerosed Veins
• Disguised Veins (tattoos, self-scarring)
• Hidden Veins (under breasts, under tongue,
  between fingers/toes)
• Acute cellulitis or endocarditis

52
? Index of Suspicion

• Physical, sexual, verbal abuse in Soc. Hx.
• Hepatitis, cellulitis in P.M.Hx.
• Nosebleeds, cough in R.O.S.
• Nasal septal irritation on P.E.
• Lymphadenopathy, fevers ..
• Labs ? MCV, GGTP
• BUT NOTHING IS AS GOOD AS SCREENING QUESTIONNAIRES

53
Screening Tools

• C A G E
• Control Annoyed Guilt Eye-opener
• T A C E
• Tolerance Annoyed Control Eye-opener
• (How many drinks does it take to
• make you feel high?)

54
Addressing Nicotine Dependence

• The Five As
• Ask
• Advise
• Assess Motivation to Change
• Assist
• Arrange Follow-Up

55
Ask !

• Screening patients in a prenatal clinic with
  specific questions about substance use is an
  effective means of reducing substance use in this
  population

56
(No Transcript)
57
Assessing Quantity Backwards

• 6 pack -- 12 pack -- 18 pack -- 24 pack
• 1/2 pt -- pint ---1/5 gal (27 oz or 18 drinks)
• 4/5 quart of wine -- 1/2 gal of wine --
• 1.75 liters 57 oz ( 12 drinks of wine, 38
  drinks of 80-proof, 48 drinks of 100-proof)
• HOW MANY DO YOU BUY PER WEEK?

58
Assessment Taking a History

• Age at First Use
• Age at First Regular Use
• Age of First Problem Use
• Physical symptoms from use
• Alcohol Blackouts
• First O.W.I.
• First complaints from family/friends/employer
• Period of Heaviest Use

59
Assessing for Detox Needs

• Maximum Use in 24 Hours
• Tolerance noted (larger dose required to produce
  given effect)
• First withdrawal symptoms
• Worst withdrawal symptoms

60
Assessing for Rehab Needs

• Days of use per month
• Longest span without use in last one, three,
  twelve months
• Days of intoxication per month
• Ability to stop or cut back as desired
• Salience of use it takes over, becomes 1
  thing of importance
• Assess denialsymptom attribution

61
Remember where this came from.

• Because of preexisting conditions and ongoing
  active drug use, the drug-dependent woman
  frequently suffers from chronic anxiety and
  depression. Lacking self-confidence and hope for
  the future, these women often have interpersonal
  heterosexual difficulties and become victims of
  abuse and battering.

62

• Poverty, homelessness, and the need to engage
  in prostitution or other crimes to support a drug
  habit may overwhelm coping mechanisms.The
  pregnant drug-dependent woman must often indulge
  inthe sale of drugs, prostitution, robbery, or
  forgery. Because most of her day is consumed by
  the two activities of either obtaining drugs or
  using drugs, she spends most of her time unable
  to function in the usual activities of daily
  living.

63
Remember where this came from.

• The opiate addict will have intermittent periods
  of normal alertness and well-being, but for most
  of the day will either be high or sick.
  Because of her lifestyle and because she may fear
  calling attention to her drug habit, the pregnant
  addict often does not seek prenatal care.
• --Finnegan and Kandall, 1997

64
Daily fluctuations in functional state, heroin
user.
65
Methadone Simulated 24 Hr. Dose/ResponseAt
steady-state in tolerant patient
Loaded High
Methadone Maintained Pt
Normal RangeComfort Zone
Dose Response
Bup Maintained
Subjective w/d
Heroin- Using Pt.
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
66

• Alcohol Use
• and Addiction
• in Pregnancy

67
EtOH Pharmacology

• Water solublegoes to total body water
• Readily crosses placenta present in amniotic
  fluid after moderate maternal dose
• Elimination from amniotic fluid is at only ½ the
  rate of elimination from maternal blood, so when
  moms BAC is zero, baby may still be under the
  influence
• Around 3 in 4 pregnant moms exposes her baby to
  ethanol in utero
• Alcohol is a prominent part of many if not most
  drug users lives (Finnegan and Kandall)

68
F A S DFetal Alcohol Spectrum Disorders

• FAS
• Fetal growth retardation (head circumference,
  height, or weight
• Facial dysmorphism
• CNS dysfunction (neurodevelopmental delay, IQ
  averages 68 microcephalycircumference impulsivity/judgment, irritability, memory, motor
  skills, etc.)
• 85 of FAS kids have mental retardation
• FAS is the Leading Cause of Preventable MR

69
FAS Facial Features
70
Fetal Alcohol Syndrome (FAS)

• Prevalence (1997)
• 0.3/1,000 live births
• 7-10 alcohol dependent women who drink during
  pregnancy will have an FASD baby
• Dose Effects
• special risk when 5 drinks or more per day (3 oz
  100 EtOH 5 drinks of 0.6 oz EtOH)
• Risk factors
• Parity, age
• Race, culture

71
Fetal Alcohol Effects (FAE)

• Incidence 1 in 100 live births
• Abnormalities seen depend on when woman drinks
  during pregnancy
• Defects occur before most women know they are
  pregnant
• There is no known safe level of drinking for
  pregnant women
• Binges may be worse than daily drinking
• The higher the blood level of alcohol, the
  greater the chance of damage.

72
FAS is not treatable.

• Effects persist long after pregnancy
• more realistic expectations for performance
  during childhood and adolescence may result in
  the availability of more appropriate services,
  less frustration, and improved behavioral outcome
  in later adolescence and adulthood Letter to
  the Editor, JAACAP

73
Effect of Pregnancy on Use

• Alcohol Using Women
• Abstinence in 1st Trimester 46
• Abstinence in 2nd Trimester 79
• Abstinence in 3rd Trimester 69
• Abstinence Post Pregnancy 16

74

• Nicotine Use
• and Addiction
• in Pregnancy

75
Effect of Pregnancy on Use

• Tobacco Using Women
• Abstinence in 1st Trimester 28
• Abstinence in 2nd Trimester 36
• Abstinence in 3rd Trimester 47
• Abstinence Post Pregnancy 16

76
Nicotine Use and Pregnancy

• A clear inverse relationship between birth weight
  and of cigarettes smoked per day
• Birth weight averages 200 g lower.
• LBW/SGA resolves itself by 1 year of life
• LBW/SGA are avoided when moms stop smoking during
  first trimester
• But when mom doesnt stop smoking, full-term
  births show increased placenta previa, abruptio
  placentae, and fetal loss

77
Smoking and Pregnancy

• Effects persist long after pregnancy
• SIDS rates are 4.4 times higher for infants born
  to mothers who smoked through pregnancy
• IQ scores are 4 points lower in offspring of
  mothers who smoked through pregnancy
• Stopping Smoking Helps!

78
Nicotine Replacement Therapy

• Serum levels are ½ of those in smokers
• Nicotine gum use enhances success rates for
  smoking cessation in pregnancy
• Fetal/maternal hemodynamics are measurably better
  in the oral NRT patients than in the patients
  continuing to smoke
• 1 mg per cigarette (21 mg patch 1 PPD) 2 mg
  per piece10 Nicorette/day 1 PPD

79

• Sedative Use
• and Addiction
• in Pregnancy

80
Patterns of Sedative Use

• It is unusual to see patients who are abusing
  only prescription medications. Most women who
  abuse sedative-hypnotics take one or more
  benzodiazepines in combination with alcohol,
  along with barbiturates and other sleeping pills.

81
Sedative Withdrawal

• The risk to both mother and fetus from untreated
  sedative-hypnotic withdrawal usually is greater
  than the potential risk to the fetus from
  exposure to either benzodiazepines or
  barbiturates given in a controlled setting.

82

• Illicit Drug Use
• and Addiction
• in Pregnancy

83

• Experimental studies to evaluate the long-term
  effects of intrauterine exposure to drugs are
  limited, so it is difficult to differentiate the
  effects of the actual drug exposure from the
  effects of being raised in an environment of
  ongoing parental drug use.
• Infants born to women who are addicted to alcohol
  or other drugs are at high risk for sequelae such
  as attachment difficulties, behavioral problems
  (disorganization, unpredictability, and
  distractibility), and child neglect or abuse.
  Weaver

84
General Epidemiology

• Data from the 1996 and 1998 National Household
  Survey on Drug Use (now NSDUH)
• 6.4 of non pregnant women of childbearing age
  used illicit drugs
• 2.8 of pregnant women used illicit drugs
• MJ ¾ of illicit drug use, Coc 1/10 of illicit
  use
• Of illicit drug users, 2/3 of non-pregnant women
  of childbearing age also used alcohol and
  tobacco, and ½ of pregnant women used alcohol and
  tobacco

85
Effect of Pregnancy on Use

• Illicit Drug Using Women
• Abstinence in 1st Trimester 28
• Abstinence in 2nd Trimester 76
• Abstinence in 3rd Trimester 93
• Abstinence Post Pregnancy 24

86

• Cocaine Use
• and Addiction
• in Pregnancy

87
Cocaine

• Erythroxylon coca pasteextraction from the
  plant involves solvents such as benzene
• Cocaine HClfurther extraction from the paste
  involves hydrochloric acid
• Cocaine base (crack)extraction from the HCl
  salt involves ether
• The salt is used per nasum or IV it does not
  volatile at the temperatures of a cigarette
• The base is smoked both snorting and smoking
  bypass first-pass metabolism in the liver

88
Cocaine

• Even the HCl salt is an alkaloid
• Cocaine is low MW and water-soluble and crosses
  the placenta readily cocaine base crosses even
  more efficiently. Once there, since the fetal pH
  is lower than the maternal pH, it accumulates on
  the fetal side of the placenta
• In asphyxial episodes, fetal pH drops even more
• And metabolism by the fetus is less than maternal
  metabolism
• So the babys levels are higher than the moms
  serum levels!

89
Cocaine

• It is metabolized to water-soluble products such
  as benzoyl ecgonine while cocaine disappears
  from serum and urine in 12 hours, benzoylecgonine
  is detected in urine drug tests for 2-7 day (or
  even weeks in very heavy daily users)
• EMIT or radio immumo diffusion finds it readily
• Analysis of meconium can find benzoylecgonine in
  an additional 1/3 of cases cf. neonatal urine
  anaylsis

90
The Crack Epidemic

• Up to 5 of babies in 1980s were exposed to
  cocaine in utero
• NYC cocaine-exposed babies rose from 7
• to 21 per 1000 live births from 1983 to 87
  similar 3x increases 85 to 88 elsewhere
• In NYC, it was back to 0.7/100 by 1990, whereas
  crack arrived in Madison (as ready rock) in
  1990.
• Highly over-represented in moms on M.A.(4x
  privately insured moms)
• In 1990s, 8 of black babies were exposed

91
The Crack Epidemic

• The typical cocaine user abuses cocaine
  repeatedly before conception, continues to use
  the drug repeatedly throughout the pregnancy, and
  often combines it with other drugs. (Graham
  textbook, ASAM)

92
The Crack Epidemic

• Assessment of the organic impact of cocaine on
  the human pregnancy must consider confounding
  drug use-associated variables such as poverty,
  homelessness, inadequate prenatal and postnatal
  care, deficient nutrition, varying types of
  cocaine use, multiple drug use, sexually
  transmitted diseases, and the possible presence
  of toxic adulterants that are mixed with or used
  to process cocaine. (Lowinson textbook
  Finnegan Kandall)

93
Cocaine Physiology

• It constricts vesselsin the uterus, cord, and
  placenta
• Deleterious effects on fetal oxygen and nutrient
  exchange outweigh effects on decreased efficiency
  of cocaine delivery to the fetus
• Uterine blood flow and maternal BP vary in
  dose-response relationships to cocaine-induced
  catecholamine serum levels

94
Cocaine Physiology

• It increases uterine contractility
• It precipiates premature labor
• It is associated with increased abruption
• Greater rates of fetal demise
• Even non-tobacco using moms who use cocaine have
  LBW and premature babies
• Lower birth weight and SGA, maybe due to
  utero-placental vasoconstriction, but may be due
  to contextual factors

95
Neonatal Cocaine Intoxication and Withdrawal

• CNS excitation, irritability, insomnia, poor
  feeding in babies born under the influence
  acutely
• CNS depression, irritability, hypersomnia,
  insomnia, poor feeding in babies born with
  exposure just pre-partumthis sluggishness is the
  babys crash

96
Cocaine Pathology

• Maternal strokes
• Fetal strokes (some attribute to context)
• Fetal seizures (some attribute to context)
• No definite teratogenicity
• No definitive persistent behavioral change/ADHD
  that can be linked to direct drug effects vs.
  contextual effects (maternal nutrition/infection
  maternal functioning during infancy/toddler ages)

97
The Reality of the Cocaine Baby

• The most critical aspect of the childs
  development is what happens postpartum.
• Infants with intrauterine drug exposure may be
  difficult to nurture due to behavioral changes,
  which cause problems with bonding between mother
  and infant.
• Mothers who continue to abuse stimulants after
  delivery put their children at risk if they
  breastfeed, because stimulants pass into breast
  milk.
• Maternal drug abuse can have adverse consequences
  for children, such as child neglect and abuse or
  loss of family structure. (Weaver)

98

• Opiate/Opioid Use
• and Addiction
• in Pregnancy

99
A Few Words about Urine Drug Testing

• Not toxicology
• Not screening
• Know whats being tested for
• Know the method (TLC, RIA, GC/MS)
• Opiates vs. Opioids
• Confirmatory testing / Adulterant testing
• A POSITIVE TEST ONLY PROVIDES INFORMATION ABOUT
  RECENT USE, NOT ABOUT DIAGNOSIS OF ADDICTION

100
Heroin Addicted Women

• Heroin causes fetal growth retardationin animal
  lab research, and in humans addicted to heroin
• 35 years ago, researchers found that initiation
  of methadone maintenance eliminated maternal
  deaths, fetal demise, and reduced several
  complications of pregnancyfirst trimester MMT
  dosing is directly linked to birth weight
• Meconium staining is vastly less on MMT patients
  vs. active heroin addicted mothers birth weight
  approaches normal

101
Continue Opioids During Pregnancy

• Medical withdrawal of the pregnant
  opioid-dependent woman is not recommended because
  of high rates of relapse to heroin use and the
  increased risk to the fetus of intrauterine
  death. Methadone maintenance is the treatment of
  choice (CSAT, 1993).

102
Use of Methadone General

• Recall, methadone can be prescribed
• for treatment of narcotic addiction
• for treatment of narcotic withdrawal
• for treatment of pain, whenever indicated
• for treatment of pain, even in addicts ! !
• Methadone, when used for pain, can be prescribed
  by any physician with DEA registration for C-IIs
  
• Methadone, when used for pain, can be tapered by
  any physician with DEA registration for C-IIs

103
Use of Methadone Pregnancy

• Must be ordered and dispensed through
  licensed/accredited methadone clinic (OTPopioid
  treatment program)
• If admitted to general hospital / OB unit already
  on MMT, can be continued
• If pregnant, an OP or IP facility can start MMT
  themselves if a hand-off to a licensed OTP is
  pending within 72 hours

104
Rationale for Methadone Maintenance

• Methadone maintenance reduces use of illicit
  opioids by blocking withdrawal symptoms and
  cravings. Use of a stable methadone dose reduces
  fluctuations in maternal opioid level, which
  reduces stress on the fetus (fluctuations between
  intoxication and withdrawal result in adverse
  fetal effects, such as premature labor and
  spontaneous abortion).

105
Daily fluctuations in functional state, heroin
user.
106
Methadone Simulated 24 Hr. Dose/ResponseAt
steady-state in tolerant patient
Loaded High
Methadone Maintained Pt
Normal RangeComfort Zone
Dose Response
Bup Maintained
Subjective w/d
Heroin- Using Pt.
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
107
Dosing of Methadone

• Low Dose strategies are ineffective
• Pregnant women especially should be dosed at over
  60 mg, probably over 120 mg daily.
• Dosage requirements rise in the third trimester
• larger plasma volume / total body water
• decreased plasma protein binding
• increased methadone metabolism
• increased clearance by the mother

108
Late Pregnancy Dosing

• Methadone half-life is shortened
• Watch for breakthrough withdrawal sx in mom as
  methadone levels drop need to adjust dose upward
• Splitting dosage (BID) may be required, if
  possible

109
Advantages ofMethadone Maintenance

• Methadone maintenance enhances the ability of the
  woman to participate in prenatal care and in
  addiction treatment, thus allowing her to better
  prepare for the arrival of the infant.
• There are measurable reductions in criminal
  activity.
• The pregnant mom is more functional overall
  there are decreased disruption of the
  maternal-child unit, especially if shes avoiding
  incarceration.
• Elimination of heroin use with adequate doses of
  methadone prevents harm to the fetus from
  exposure to adulterant compounds in street
  heroin.
• Improved maternal health and nutrition reduce
  obstetrical complications and improve the health
  of the infant at delivery.

110
Methadone Maintenance

• reducing illegal drug use, removing the woman
  from a drug-seeking environment, preventing
  fluctuations of drug levels throughout the day,
  improving maternal nutrition, increasing the
  likelihood of prenatal care, enhancing the
  womans ability to prepare for the birth of her
  baby, reducing obstetrical complications, and
  offering the pregnant heroin addict an
  opportunity restructure her life. Finnegan and
  Kandall

111
Management of Labor

• Generally, the same as for any L D
• May choose to start conduction anesthesia
  earlier to minimize need for narcotic therapy
• Tolerance will be higher, so higher opioid doses
  will be needed when those agents are chosen
• If mom is in some degree of acute withdrawal,
  give more methadone before delivery
• Dont give Narcan ! !

112
Opioid Overdosage in Pregnancy

• Naloxone should not be given to a pregnant woman
  except as a last resort for severe opioid
  overdose, because withdrawal precipitated by an
  opioid antagonist can result in spontaneous
  abortion, premature labor, or stillbirth.

113
Opioid Withdrawal

• Abrupt withdrawal in the non-pregnant individual
  usually causes physical effects no worse than a
  bad case of influenza.
• However, opioid withdrawal during pregnancy can
  lead to fetal distress and premature labor
  because of increased oxygen consumption by both
  mother and fetus.
• Even minimal symptoms in the mother may indicate
  fetal distress, since the fetus may be more
  susceptible to withdrawal symptoms than the
  mother. Weaver

114
Neonatal Opioid Withdrawal

• Neonatal opioid withdrawal syndrome occurs in 60
  to 80 of infants with intrauterine exposure to
  heroin or methadone
• But its easy to manage!

115
Breastfeeding

• Breastfeeding should be encouraged to promote
  mother-infant bonding and to provide optimal
  nutrition and passive immunization to the child.
• Women can breastfeed while on methadone
  maintenance as long as they are not abusing any
  drugs and are not HIV-positive.
• Weaver (2003)

116
Other issues

• Research has been unable to link either illicit
  heroin or prescribed methadone to any genetic
  damage in offspring
• There do seem to be tendencies toward multiple
  births in women exposed to opioids regularly
  around the time of conception
• The risk of SIDS is greater in births from
  heroin-dependent moms, and possibly greater in
  births from MMT-treated moms

117
Intravenous Drug Use and Pregnancy

• It may not be the substance (heroin, cocaine,
  speed, downers) those poses the health risk
• Maybe its the route of administration
• Maybe its the associated behaviors (trading
  sex for drugs, prostitution)
• And maybe its nutrition (intake, absorption, or
  hepatitis effects)

118
Medical Complications in Pregnant IV Drug Users
(IVDUs)

• Anemia
• Cellulitis
• Dental decay
• Edema
• Endocarditis
• HBVacute / chronic
• HCVacute / chronic
• HIV

• Hypertension
• Phlebitis
• Pneumonia
• STDs
• Septicemia
• TB
• UTIscystitis, pyelonephritis

119

• Inhalant Use
• and Addiction
• in Pregnancy

120
Anne Marie Pagliaro, Ph.D., R.N.Louis A.
Pagliaro, Ph.D.

• Toluene embryopathy
• Case reports of FAS-like syndrome with growth
  retardation, developmental delays, and
  craniofacial anomalies.

121
From Zebras Back to HorsesAddressing Drug
Dependence

• The Five As
• Ask
• Advise
• Assess Motivation to Change
• Assist
• Arrange Follow-Up

122
Arrange Follow-Up

• Its a CHRONIC disease
• If its addiction, it wont go away with brief
  advice only
• It must be addressed again and again over the
  course of the condition, whether its getting
  worse or better
• If you give an assignment, you must follow up or
  else the patient will know that this isnt really
  important

123
To wrap it all up.

• Appropriate support should be available to
  addicted women after delivery to help them meet
  the challenge of dealing with their newborn,
  especially if older children are present and
  require care. Support can come from the womans
  family, a Twelve Step self-help group, or health
  care practitioners with appropriate advice. Lack
  of support can lead to relapse, which may result
  in neglect of the infant. Weaver

124
Weaver (ASAM Textbook, 2003)

• Continuation of addiction treatment postpartum,
  coupled with appropriate social support for new
  mothers, is essential to prevent relapse after
  delivery. Basic knowledge of perinatal addiction
  allows health care providers to improve the
  health and welfare of mothers and their children.