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Treatment of

Pregnant and

Parenting Women with

Substance Use

Disorders

Julia Frew, MD

Assistant Professor of Psychiatry, Obstetrics & Gynecology, and Medical Education

Geisel School of Medicine at Dartmouth

Director, D-H Center for Addiction Recovery in Pregnancy and Parenting

Epidemiology of Substance Use in Pregnancy

Challenges and Opportunities Unique to this Population

Evidence-Based Treatment of SUD in Pregnancy

Role for Integrated Care

Creating a Recovery-Friendly Practice

Resources

Q & A

Substance Use in Past Month among Pregnant Women

14.7

11.5

8.5

7.1

1.4 0.4

TOBACCO ALCOHOL ILLICIT DRUGS MARIJUANA OPIOIDS COCAINE

% reporting past month use

NSDUH, 2017

Cannabis Use in

Pregnancy

Daily or Near-Daily Marijuana Use

1.2

2.7 2.6

2.8

3.1

3.4

PREGNANT NOT PREGNANT

Daily or Near Daily Marijuana Use (%)

2015 2016 2017

NSDUH, 2017

Dickson B, Mansfield C, Guiahi M, et al. Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. Obstet Gynecol.

2018;131(6):1031-1038.

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“Technically with you being pregnant, I don’t think you are supposed to be consuming that, but if I were to suggest something, I’d suggest something high in THC."

“In the context of edibles, start with a low dose and see how it works out for you because those types of things would, um, not cross the blood–brain barrier so even if you have got the CBDs and the other good parts of the plant would get in your baby’s blood system but the psychotropic properties, the THC molecule, would not get near your baby, so basically would not be getting your baby stoned.”

“The doctor will probably just tell you that ’marijuana is bad for kids and will just try pushing pills on you.’ Maybe you have a progressive doctor that will not lie to you. All the studies done back in the day were just propaganda.”

“Google it first. Then if you feel apprehensive about it, you could ask.”

“Most of them out here tell them not to smoke weed. Even the cancer doctors. It is so messed up. I do not know how the baby doctors work, if they are chill or not. Just do not go stoned when you talk to them.”

Safe?

Effective? Elicit reasons for use

Assess for marijuana use disorder

Recommend treatments with more data for

nausea, appetite, pain, sleep, anxiety

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Opioid Use Disorder in

Pregnancy

Overdose Death among Women in Northern New England

0

20

40

60

80

100

120

140

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

NH

VT

ME

Data source: Kaiser Family Foundation

Rural and Urban Differences in Neonatal Opioid Withdrawal (NAS/NOWS) and Maternal Opioid Use

Vilapiano, et al. JAMA Pediatrics 2017;171;2:194-196.

Impact of Opioids on Maternal-Child Health

Anesthesiology 2014 121:1158-65

Ko, et al. Incidence of Neonatal Abstinence

Syndrome — 28 States, 1999–2013 MMWR

Weekly / August 12, 2016 / 65(31

Smith, K. Carsey School of Public Policy Regional Brief 51. 2017

Consequences of Untreated Substance Use Disorders for Mother and Baby

Mother Baby

• Limited prenatal care

• Tobacco, alcohol, other polysubstance use

• Infectious disease

• Perinatal complications/loss

• Short inter-pregnancy interval

• Unemployment, housing, and food insecurity

• Dental problems

• Risk for overdose

• Prematurity

• Low birth weight

• Vertical transmission of infectious disease

• Neonatal Opioid Withdrawal

• Developmental delay

• Risk for Sudden Infant Death Syndrome

• Adverse childhood events

Treatment Transforms Outcomes

Adjusted OR

Perinatal Outcome Untreated SUD Treated SUD No SUD

Low birth weight

(<2,500g)

1.8 (1.1-3.1) 1.0 (ref) 0.7 (0.6-0.9)

Preterm delivery 2.1 (1.3-3.2) 1.0 0.8 (0.7-1.0)

Placental abruption 6.8 (3.0-15.5) 1.0 1.1 (0.7-1.7)

Fetal demise 16.2 (6.0-43.8) 1.0 1.5 (0.7-3.3)

Adapted from: Goler, et al. J. Perinatology 2008 1-3.

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What is known about Treatment of OUD during Pregnancy?

• Research strongly favors opioid agonist treatment

• Reduces risk of morbidity and mortality

• Prevents relapse compared to abstinence based approaches

• Allows women to concentrate on self-care and raising a family

• Methadone and buprenorphine both safe during pregnancy

• Neonatal abstinence less severe with MAT than illicit drug use

• Buprenorphine equivalent in effectiveness, with decreased duration and severity of NOWS/NAS

• Data on detoxification are not reassuring

• Promoted in some practice environments

• Low rates of completion (9-100%) and high rates of relapse (0-100%)

• High rates of loss to follow up in some studies

Terplan, M, et al. Obstetrics and Gynecology 2018; 0;0:1-12; Mcarthy, J, Leamon, M, Finnegan, L, Fassbender, C. AJOG 2017

“Treatment that addresses the full range of a woman’s needs is associated with increased abstinence and improvement in other measures of recovery, including parenting skills and overall emotional health. Treatment that addresses alcohol and other drug abuse only may well fail and contribute to a higher potential for relapse.” Center for Substance Abuse Treatment, 2007

IOP/PHP

Outpatient

Residential

SUD Treatment

Prenatal Care

Psychosocial

Support

Mental Health

Treatment

?

Traditional Care

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SUD Treatment

Prenatal Care

Psychosocial

Support

Mental Health

Treatment

?

Coordinated Care Integrated Care SUD Treatment

Prenatal Care

Mental Health Treatment

Psychosocial

Support

Dartmouth-Hitchcock Moms in Recovery

Beh

avio

ral

Hea

lth S

ervic

es

• MAT for SUD

• Perinatal psychiatry

• Group therapy

• Individual therapy

• Trauma-informed care

• IOP and OP

Med

ical

Ser

vic

es

• Prenatal care

• Women’s health care

• Contraception

• Hepatitis C treatment

• Pediatric care

• Dental collaboration

Support

ive

Ser

vic

es

• Peer support

• Case management

• Parenting classes

• Diaper bank

• Food shelf

• Playtime

• Health education

Demographics

32.1

67.9

Residence (%)

Vermont NH

88.3

7.3 4.4

Payor Source (%)

Medicaid Private Insurance Uninsured

64

36

Stable Housing During Pregnancy (%)

Yes No

52.6

22.6 21.9

2.2 0.7 0

10

20

30

40

50

60

Heroin Non-prescribed buprenorphine Prescription Opioids Cocaine Fentanyl/Synthetic Opioids

Primary Substance at Admission (%)

Heroin Non-prescribed buprenorphine

Prescription Opioids Cocaine

Fentanyl/Synthetic Opioids

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Co-occurring Disorders 83.9% current tobacco users

67.2% current cannabis users (? % with Cannabis Use Disorder)

74.5% with psychiatric diagnosis

• Depression 65.0%

• Anxiety 23.4%

• PTSD 21.9%

• ADHD 8.8%

• Borderline PD 4.4%

• Bipolar Disorder 4.4%

45.6% prescribed psychotropic medication

Infant Outcomes Infants (n=131)

Length of gestation (weeks), m(sd) 38.4 (2.5)

Birthweight (grams), m(sd) 3054 (553)

Requiring NAS pharmacologic treatment, n(%) 15 (12.8%)

Length of stay (days), m(sd) 6.8 (7.0)

Delivery Type, n(%) Vaginal delivery Cesarean delivery VBAC Operative vaginal delivery

74 (56.5%) 42 (32.1%) 2 (1.5%) 13 (9.9%)

Normal admission to the nursery, n(%) 107 (82.3%)

Admission to the NICU, n(%) 25 (19.1%)

Documented active child protection involvement at

discharge, n(%) 46 (34.9%)

Maternal Outcomes Pregnancies

(n=137)

Estimated gestational age (weeks) at entry to: Obstetrics (OB) care, m(sd) Addiction treatment, m(sd)

11.0 (5.8)

13.0 (10.5)

Number of OB visits, m(sd) 14.8 (5.7)

Number of OB vists at PATP, m(sd) 6.4 (5.0)

Pregnancy weight gain (pounds), m(sd) 24.9 (19.8)

Postpartum OB visit, n(%) 102 (75.0%)

[VALUE] %

[VALUE] %

[VALUE] %

Umbilical Cord or Meconium Toxicology

(%)

Negative/prescribed only THC Only

Illicits other than THC

Becoming Recovery-Friendly

Trauma and SUD

Trauma

SUD PTSD

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Trauma and SUD

Trauma

SUD PTSD

95% of those with SUD have

lifetime trauma hx

25-50% of those with SUD

have PTSD

30-50% of those with PTSD

have SUD

Trauma Informed Care

≠

PTSD Treatment

Trauma Informed Care

TIC is a strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.

https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/key_terms.html

Safety

Trustworthiness and

Transparency

Peer Support and Mutual Self-

Help

Collaboration and Mutuality

Empowerment, Voice, and

Choice

Cultural, Historical, and Gender Issues

TIC

https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/guiding_principles.html

Words Matter

https://www.samhsa.gov/capt/tools-learning-resources/sud-stigma-tool

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Flexibility Requirements

Independence

Accountability

Change

Support

Validation

Acceptance

Honesty

Attendance

Addressing

life

problems

Urine drug

testing

Caring for

medical

problems

It Takes a Team!

Resources

https://store.samhsa.gov/system/files/sma18-5054.pdf

https://store.samhsa.gov/system/files/sma18-5071fs2.pdf

https://med.dartmouth-hitchcock.org/carpp.html

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Questions?

CARPP@Hitchcock.org

603-653-1800

Julia.R.Frew@Hitchcock.org