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Moms on Meds. Substance Abuse During Pregnancy: Jennifer Anderson Maddron , M.D. Prescription Painkiller Overdoses. July 2013. - PowerPoint PPT Presentation


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Moms on MedsSubstance Abuse During Pregnancy: Jennifer Anderson Maddron, M.D.

1 Prescription Painkiller Overdoses. July 2013Approximately 18 women die every day of a prescription painkiller overdose in the US. More than 6,600 deaths in 2010Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% increase among menPrescription painkillers are involved in 1 in 10 suicides among women. For every woman who dies of a prescription painkiller overdose, 30 go to the ER for painkiller misuse or abuse

Prescription Painkiller Overdoses. (2013). Retrieved on August 4, 2013, from


Prescription painkiller overdose deaths are a growing problem among women

32010 National Survey on Drug Use and Health4.4% of pregnant women reported use of an illicit substance within the past 30 days

Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: summary of national findings. NSDUH Series H-41. HHS Publication No. (SMA) 11-4658. Rockville (MD) SAHMSA: 2011

4 Deliveries at LeConte Medical Center5NICU Transfers To East Tennessee Childrens Hospital6

7Maternal Complications of Substance Abuse Many barriers exist for pregnant substance abusers

Lifestyle issues may result in pregnant women engaging in high risk behaviorProstitutionSharing of IV needlesIntimate Partner ViolenceTheft and other criminal activities

8Maternal Complications of Substance Abuse Confounding variables of substance abuseSocioeconomic statusEthnicityAccess to prenatal carePoly-substance abuseCumulative effect of poly- substance abuse may be dramatically worse than the outcome predicted by the use of individual drugs during pregnancy. Marijuana use is often present with tobacco and alcohol use. Women reporting regular tobacco use are 4-9 times more likely to report marijuana use.

9Substances Most Commonly Abused During PregnancyTobaccoAlcoholMarijuanaOpiatesCocaineBenzodiazepinesAmphetaminesHallucinogens

10Opioid AddictionOxycodoneHydrocodoneMethadoneRoxicodoneHeroinFentanylMeperidineHydromorphonePropoxyphene

11Opioid use in Pregnancy: Maternal ComplicationsAltered Mental StatusSomnolenceRespiratory DepressionDeathIV Use may result in Hepatitis B & CHIVSkin infectionsEndocarditisSepsis

12Opioid Effects on PregnancyAntenatal ComplicationsPreterm DeliveryGrowth RestrictionLow Birth WeightPlacental AbruptionFetal Death

Neonatal EffectsNeonatal Abstinence Syndrome (NAS)

13Neonatal Abstinence Syndrome (NAS)

Constellation of withdrawal symptomsCentral Nervous SystemInconsolability, high-pitched crying, skin excoriation, hyperactive reflexes, tremors, seizuresGastrointestinal SystemPoor feeding, excessive sucking, feeding intolerance, loose or watery stoolsAutonomic/metabolicSweating, nasal stuffiness, sneezing, fever, tachypnea, mottling1415 Treatment optionsHolistic Multidisciplinary Approach to treatment of Neonatal Abstinence SyndromeNon-pharmacologicalCuddlerEnvironmental DietPharmacologicalNarcoticsNon-narcotics

16 Pharmacological TreatmentApproximately 67% of babiesAre weaned from opioid in about 20 daysDo not require adjuvant treatmentStay in the NICU approximately 24 days

Approximately 33% of babiesRequire weaning time of 60 days (range up to 155 days)Require adjuvant treatment with up to two additional medicationsStay in the NICU for about 68 days (some up to 155 days)

Do 17Mothers TennCare status at time of delivery for NAS children

18TennCare cost associated with treatment of NAS infants

19Treatment of Substance Abuse During Pregnancy20ScreeningUniversal Screening of all women before and during pregnancy

Identify women currently using illicit substances & women at risk

Toxicology testing: Urine Drug Screens 21InterventionMultidisciplinary approach needed to address Physical, Psychological and social issuesObstetrical and Neonatal CareAddiction Medicine SpecialistMental Health ServicesSocial Services22Treatment of Opioid Addiction in PregnancyFor Opioid addicted Pregnant patients:DetoxificationRelapse rates are high and dangerousOpioid Replacement TherapyMethadone versus BuprenorphineAlcohol and Drug CounselingTreatment of Co-existing Mental Health Disorders23Treatment of Opioid Addiction in PregnancyComprehensive care provided at one location is cost effective and produces better outcomes for both mother and child.Early Start Program at Kaiser Permanente, CaliforniaPatients who were screened, assessed and treated had lower rates of preterm delivery, low birth weight, and neonatal-assisted ventilation

Wong, S. (2011, April). Substance Use in Pregnancy. Journal of Obstetrics and Gynaecology Canada. 33(4): 367-38424American College of Obstetrics & Gynecology Committee Opinion in 2004

wrote that using a protocol for universal screening, brief intervention, and referral to treatmentresults in a mean net savings of $4644 in medical expenses per mother/ infant pair.

25Treatment Cost Considerations

One year in prison$51-$73/day$25,900 Outpatient$15/day x 120 days$1,800Intensive Outpatient9 hrs/week x 6 months maintenance$2,500Methadone Maintenance$13/day x 300 days$3,900Short term residential treatment$130/day x 30 days + $400 x 25 weeks$4,400Long term residential treatment$49/day x 140 days $6,800Reference: Position Paper on Drug Policy published by the Physician Leadership on National Drug Policy January, 2000. Data source: Center for Substance Abuse Treatment, Federal Bureau of Prisons. 1997 National Treatment Improvement Evaluation StudyAnnual treatment cost for a person with drug addiction26Pregnancy is an ideal time to provide intervention to women with substance abuse problems, as motivation to modify harmful behavior is increased.