Jonathan Weeks, M.D., D.A.B.A.M.Norton Maternal-Fetal Medicine SpecialistsDirector, Prenatal Addiction ProgramOffice (502) 899-6900Google Voice (502) 442-2339mfmdoctor@gmail.com

Opiate Addiction in Pregnancy

Opiate Addiction

❖ Epidemiology

❖ Neurobiology of addiction

❖ Treating Opiate Addiction in Pregnancy

❖ Continuing challenges

Opiates-Perinatal M & M

❖ Perinatal

❖ 2-3 fold increase in PTB

❖ LBW

❖ Stillbirth

❖ Neonatal Abstinence syndrome

What’s wrong with those people!$#@*

Illicit Drug Use

Young, dumb & full of…

❖ 12-17 years old: 12%, report prescription opiate abuse

❖ 18-25 years old: 22%

❖ Avg. age of first Heroin .....

❖ 21 years

Addiction - multiple factors

Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.

Natural Rewards Elevate Dopamine Levels

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Di Chiara and Imperato, PNAS, 1988

Effects of Drugs on Dopamine Release

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Brain Reward Pathway

A Medical Treatment for Diacetylmorphine (Heroin) Addiction

JAMA 1965, Dr.s. Vincent Dole and Marie Nyswander

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Methadone Treatment

❖ Prevent withdrawal

❖ Reduce drug cravings

❖ Block euphoria from illicit opiates

❖ Reduce needle-sharing and criminal behavior

❖ HIV, STIs, hepatitis, exposure to violence

Withdrawal in Pregnancy

❖ Rementeria and Nunag AJOG Aug 1973

❖ Perinatal death in 6 of 46 heroin pregnancies acutely withdrawn from heroin or methadone

Methadone Withdrawal

❖ Zuspan AJOG May 1975

Methadone Maintenance in Pregnancy

❖ Compared to untreated (heroin), methadone maintenance therapy...

❖ ⬆prenatal visits

❖ ⬆compliance with HIV meds

❖ ⬇preterm birth

❖ ⬇IUGR

Methadone Treatment

❖ “Methadone maintenance treatment (MMT) is the current standard for the treatment of Opiate dependence in pregnancy” ... Obstetrics: Normal & Problem Pregnancies, 5th Ed

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Buprenorphine❖ Partial agonist

❖ Can produce euphoria

❖ Can precipitate withdrawal in patients on morphine, methadone

❖ Combined with naloxone

❖ Suboxone, Zubsolv, Bunavail

❖ Mono therapy - Subutex

❖ Randomized double-blind, double-dummy

❖ Primary outcome NAS

❖ 175 patients randomized

❖ Discontinuation

❖ 16 of 89 (18%) - methadone

❖ 28 of 86 (33%) - buprenorphine

❖ NAS

❖ methadone 57%

❖ buprenorphine 47%

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Norton Prenatal Addiction Program (502) 559-4375

❖ New Visions for Expectant Mothers

❖ Admission, stabilization and follow up

❖ Norton Maternal-Fetal Medicine

❖ Inpatient care for New Visions admissions

❖ Outpatient consultation & monitoring

Norton Prenatal Addiction Program

❖ New Visions for Expectant Mothers

❖ Admission, stabilization and follow up

❖ Norton Maternal-Fetal Medicine

❖ Inpatient care for New Visions admissions

❖ Outpatient consultation & monitoring

New Visions

❖ Admission & stabilization

❖ No prenatal care ER drop in

❖ Prenatal care… addiction reported or discovered

New Visions

❖ Substances abused?

❖ Severity

❖ Barriers to treatment

❖ Pre-admission counseling

New Visions

❖ No illicit substances for at least 24 hours

❖ Patient presents for admission in withdrawal

❖ Assessment by New Visions staff

❖ Not intoxicated, in withdrawal

❖ Medical evaluation, obstetrical evaluation and treatment

Lab Evaluation❖ CBC, CMP, Urine culture

❖ Witnessed urine toxicology screen daily

❖ Include methadone and buprenorphine

❖ Serum gabapentin level?

❖ Blood alcohol

❖ Hepatitis A, B, C and HIV

❖ TB skin test

❖ Cervical cultures

❖ OB ultrasound, cervical length

Clinical Evaluation

❖ Clinical Opiate Withdrawal scale q 4-6 hours X 48 hours

❖ Fetal monitoring (NST) twice daily

Medications❖ 1/2 NS with 20 KCl plus one ampule multivits daily

❖ EtOH? - thiamine

❖ GI: Antiemetics, antidiarrheal❖ Pain:

❖ acetaminophen

❖ ibuprofen - limit to 48 hours❖ < 32 wks gestation

❖ Omit if oligohydramnios, fetal growth restriction, preeclampsia

Medications❖ gabapentin - for pain, restlessness, agitation

❖ 400 mg P.O. every 6 hrs prn

❖ Buprenorphine (Subutex)

❖ Initial - 4 mg. Consider repeat in 4-12 hours based on COWS and observation

❖ Add 4-6 mg following day, as needed

❖ Methadone - for those planning methadone maintenance

Weaning & Detoxification?

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• Detoxification can be done in pregnancy

• Rapid and slow wean protocols reviewed

• NO excess miscarriage in first trimester

• NO excess preterm birth in thirdJ Kentucky Med Assoc Oct 2010

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• 301 opiate-addicted pregnant patients were fully detoxified during pregnancy with no adverse fetal outcomes

• NAS - 94 newborns treated (31%)• 108 patients acutely detoxified while incarcerated, NAS 18.5%• 23 mothers had inpatient detox with intense outpt follow-up

management, NAS 17.4%• 93 slow output detox, NAS 17.2%• 77 inpt detox without intense outpatient follow up, NAS 70.1%

Challenges

J Adolesc Health. 2009 March ; 44(3): 283–290

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Beyond the womb, beyond the nursery

The Focus on Family Studies

Beyond the womb, beyond the nursery

• J Adolesc Health. 2009 March ; 44(3): 283–290

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• Opiate Addiction

•Social deprivation

•Economic disadvantage

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Is VERTICALLY transmitted!!!!!

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Addiction →Pregnancy

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• High pregnancy rates

• 25% of addicts -- 5 or more pregnancies

• Unplanned

• Poorer pregnancy outcomes, worse infant outcome

• Very low rates of contraception use

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Subs♀ance Abuse