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

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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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Page 1: Moms on Meds

Moms on MedsSubstance Abuse During Pregnancy:

Jennifer Anderson Maddron, M.D.

Page 2: Moms on Meds

Prescription Painkiller Overdoses. July 2013 • Approximately 18 women die every day

of a prescription painkiller overdose in the US. More than 6,600 deaths in 2010

• Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% increase among men

• Prescription 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 http://www.cdc.gov/vitalsigns/PrescriptionPainkillerOverdoses/

Page 3: Moms on Meds

Prescription painkiller overdose deaths are a growing problem among women

Page 4: Moms on Meds

2010 National Survey on Drug Use and Health

4.4% 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

Page 5: Moms on Meds

Deliveries at LeConte Medical Center

2011 2012 2013 (through June)0

200

400

600

800

1000

1200

938 Births 960 Births

98 Moms+ UDS 62 Moms

+ UDS

25 Mec +babies 25 Mec +

babies

465 Births

15 Moms +UDS

5 Mec +babies

81 Babies + UDS 51 Babies

+ UDS 13 Babies+ UDS

Page 6: Moms on Meds

NICU Transfers To East Tennessee Children’s Hospital

2011 2012 2013 (through June)

0

5

10

15

20

25

30

35

40

TotalDrug Related

38 Transfers

19 Drug RelatedTransfers

34 Transfers

13 Drug Related Transfers

14 Drug RelatedTransfers

17 Transfers

82%50% 40%

Page 7: Moms on Meds
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Maternal Complications of Substance Abuse

• Many barriers exist for pregnant substance abusers

• Lifestyle issues may result in pregnant women engaging in high risk behavior– Prostitution– Sharing of IV needles– Intimate Partner Violence– Theft and other criminal

activities

Page 9: Moms on Meds

Maternal Complications of Substance Abuse

Confounding variables of substance abuse• Socioeconomic status• Ethnicity• Access to prenatal care• Poly-substance abuse

Page 10: Moms on Meds

Substances Most Commonly Abused During Pregnancy

• Tobacco• Alcohol• Marijuana• Opiates• Cocaine• Benzodiazepines• Amphetamines• Hallucinogens

Page 11: Moms on Meds

Opioid Addiction• Oxycodone• Hydrocodone• Methadone• Roxicodone• Heroin• Fentanyl• Meperidine• Hydromorphon

e• Propoxyphene

Page 12: Moms on Meds

Opioid use in Pregnancy: Maternal Complications

• Altered Mental Status• Somnolence• Respiratory Depression• Death• IV Use may result in

– Hepatitis B & C– HIV– Skin infections– Endocarditis– Sepsis

Page 13: Moms on Meds

Opioid Effects on PregnancyAntenatal Complications

• Preterm Delivery• Growth Restriction• Low Birth Weight• Placental Abruption• Fetal Death

Neonatal Effects• Neonatal Abstinence

Syndrome (NAS)

Page 14: Moms on Meds

Neonatal Abstinence Syndrome (NAS)

Constellation of withdrawal symptoms Central Nervous System

Inconsolability, high-pitched crying, skin excoriation, hyperactive reflexes, tremors, seizures

Gastrointestinal System Poor feeding, excessive sucking, feeding intolerance, loose or watery stools

Autonomic/metabolic Sweating, nasal stuffiness, sneezing, fever, tachypnea, mottling

Page 15: Moms on Meds
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Treatment options

• Holistic Multidisciplinary Approach to treatment of Neonatal Abstinence Syndrome– Non-pharmacological

• Cuddler• Environmental • Diet

– Pharmacological• Narcotics• Non-narcotics

Page 17: Moms on Meds

Pharmacological

Treatment• Approximately 67% of babies

– Are weaned from opioid in about 20 days

– Do not require adjuvant treatment– Stay in the NICU approximately 24

days

• Approximately 33% of babies– Require weaning time of 60 days

(range up to 155 days)– Require adjuvant treatment with up to

two additional medications– Stay in the NICU for about 68 days

(some up to 155 days)

Page 18: Moms on Meds

Mother’s TennCare status at time of delivery for NAS children

Page 19: Moms on Meds

TennCare cost associated with treatment of NAS infants

Page 20: Moms on Meds

Treatment of Substance Abuse During Pregnancy

Page 21: Moms on Meds

Screening• Universal Screening of all

women before and during pregnancy

• Identify women currently using illicit substances & women at risk

• Toxicology testing: Urine Drug Screens

Page 22: Moms on Meds

Intervention• Multidisciplinary approach

needed to address Physical, Psychological and social issues– Obstetrical and Neonatal Care– Addiction Medicine Specialist– Mental Health Services– Social Services

Page 23: Moms on Meds

Treatment of Opioid Addiction in Pregnancy

• For Opioid addicted Pregnant patients:– Detoxification

• Relapse rates are high and dangerous

– Opioid Replacement Therapy• Methadone versus Buprenorphine

– Alcohol and Drug Counseling– Treatment of Co-existing Mental

Health Disorders

Page 24: Moms on Meds

Treatment of Opioid Addiction in Pregnancy

• “Comprehensive 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): 367-384

Page 25: Moms on Meds

American College of Obstetrics & Gynecology Committee Opinion in 2004

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

Page 26: Moms on Meds

Treatment Cost Considerations

One year in prison

$51-$73/day $25,900

Outpatient $15/day x 120 days

$1,800

Intensive Outpatient

9 hrs/week x 6 months maintenance

$2,500

Methadone Maintenance

$13/day x 300 days

$3,900

Short term residential treatment

$130/day x 30 days + $400 x 25 weeks

$4,400

Long 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 Study

Annual treatment cost for a person with drug addiction

Page 27: Moms on Meds

Pregnancy is an ideal time to provide intervention to women with substance abuse problems, as motivation to modify harmful behavior is increased.