Opioid Use Disorders Among MothersOpioid Use Disorders Among MothersDr. Surita RaoDr. Surita Rao

Chairman and Director, Behavioral Health DepartmentSt. Francis Care

Opioid Dependence

• Mu opioid receptors : Responsible for analgesic [ pain control] effect , the euphoria associated with opioids, addictive properties.

• Tolerance and withdrawal• Dopamine: The Reward and re-inforcement

neurotransmitter of the brain. Involved in addiction to any drug including alcohol or prescribed substances.

Addiction : A brain disorder

• The brain does not know the difference between a legal drug [ alcohol, nicotine], illegal drug, prescribed drug or a drug bought on the “street”.

• There is nothing in science or nature that can re-create the effects of addictive substances on the brain!

Addiction : A Brain Disorder• The mesolimbic pathway mesolimbic pathway is the “ reward and

reinforcement pathway of the brain. • It is a dopaminergicdopaminergic pathway.• It mediates drive behaviors [food and sex ].• It is a phylo-genetically ancient pathwayphylo-genetically ancient pathway. You

can also think of it as the “ lizard brain” “ lizard brain” • The reward and reinforcement pathway of the

brain is “hijacked” “hijacked” in addictive illnesses to make the brain think the drug is more important than survival and survival of the next generation [ children]

Women: Stress and hormones.

• In general: Women process stress differently from men.

• Several hormones play a part in the effects of stress on women . These include :

• Cortisone : " stress" hormone of the body. Chronically Higher circulating levels can lead to lowered immune response, abdominal obesity

• Epinephrine/norepinephrine [ also known as adrenalin and nor-adrenaline]: these are the “ flight

or fight hormones of the body. In our prehistoric ancestors they flooded the body and brain when faced with a threat such as a tiger. The heart, rate, blood pressure and pulse go up. We are flooded with energy and an ability to run very fast. Today we are flooded with these with these hormones over and over with no real threat to life or limb. As a result women may develop hypertension, heart disease, anxiety disorders.

• Oxytocin is the bonding hormone, it is associated with lactation and breastfeeding. In women

oxytocin is released in response to stress at times to calm the body down. This can result in us trying to “ make things better” by taking care of people around us at the expense of our own emotional and physical needs.

Women with substance use disorders Relationships

• Abusive relationships [ physical, emotional, sexual, verbal]• The woman engages in sex for drugs or commercial sex to obtain

money for her own drug use as well as that of her significant other.• Codependent Relationships• “Mutual” Abuse : verbal, physical fighting• Loss of relationship : BF or husband without any substance use

disorder leaves and/or takes primary custody of the children. The mother is not able to see the children or has limited, supervised visit.

• A large percentage of women have been introduced to the drug[s] for the first time by a boyfriend or husband. The relationship ends but they are left with the substance use disorder

Women with substance use disorders: Women with substance use disorders: motherhoodmotherhood

• Mothers with substance use disorder love their children but may not be able to get clean and sober in a timely manner to look after them and keep custody.

• That is not a sign that they do not “ love their children enough”.

• Addiction : The brain is “ hijacked” into thinking that the drug is the most important thing in life, more important than staying alive or looking after children[ the next generation]

• SalienceSalience : a brain phenomenon in addiction.

Ongoing heroin or oral opioid use exposes the mother and baby to risks of multiple bad outcomes

• Experiencing the highs and the withdrawal everyday, sometimes multiple times within a 24 hour period

• Drug using lifestyle: • commercial sex, exchange of sex for drugs, unprotected sex , sharing “

dirty “ needles and straws [ for intranasal heroin use] , both of which can cause the mother and baby to contract infectious diseases such as HIV , Hep C and B, herpes.

• Using co-morbid drugs: alcohol, benzodiazepines, nicotine, cocaine, cannabis, hallucinogens, club drugs.

• Poor nutrition• Lack of involvement or sporadic adherence with prenatal care

Ongoing heroin or oral opioid use exposes the mother and baby to risks of multiple bad outcomes

• Spontaneous abortion,• Amnionitis, • Chorioamnionitis,• Intrauterine growth retardation, • Placental insufficiency• Premature labor• Premature rupture of membranes• Eclampsia • Toxemia • Septic Thrombophlebitis• Abruptio placentae • Intrauterine death

Finnegan, L.P[Ed][1978]Drug Dependence in pregnancy. Clinical management of mother and child. A manual for medical professionals and paraprofessionals prepared for the National Institute on drug abuse. Services branch, Rockville, MD. Washington DC. U.S government Printing Office

The pregnant woman with an opioid use disorder needs immediate referral to agonist maintenance treatment

[ Methadone or Buprenorphine Maintenance]

• Maintenance treatment helps the pregnant woman to get:

• Regular prenatal care• Stop using illicit substances• Lead a more stable life• Improve her nutritional status• Receive parenting education during her pregnancyRao, S . Schottenfeld ,R. “ methadone Maintenance”. Chapter 29. Sourcebook on substance Abuse

[ Etiology, epidemiology, Assessment and Treatment]. Edited by Ott, P.J. Tarter, R.E. Ammerman, R.T. 1999

Testing the mother and baby for the presence of drugs at delivery.

• The mother being in methadone maintenance treatment by itself is not a reason to refer to DCF

• These mothers often have complex psychosocial issues. The social worker from the hospital to mete with them to help with referrals and anything else they need.

• Urine toxicology is done [ in 24 hours]. Mothers needs to give permission to get Urine Toxicology screen in CT now.

• Sometimes the baby poops in the first 12 hours , sometime later.

• Meconium toxicology results come I [ 5-7 days]. No permission needed for Meconium Toxicity.

MOTHER Study

• In this trial comparing methadone with buprenorphine in opioid-dependent pregnant women, neonates exposed to buprenorphine required less morphine to treat neonatal abstinence syndrome (NAS) and had a significantly shorter duration of hospitalization and of treatment for NAS.

• There are significant public health and medical costs associated with the treatment of neonates exposed to opioids, which in 2009 was estimated at $70.6 million to $112.6 million in the United States alone.

• Just as the use of methadone in non pregnant patients with opioid dependence improves patient outcomes, its use as part of a comprehensive approach to the care of pregnant women improves maternal and neonatal outcomes, as compared with no treatment and with medication-assisted withdrawal.

• However, exposure to methadone in utero can result in a neonatal abstinence syndrome (NAS) characterized by hyperirritability of the central nervous system and dysfunction in the autonomic nervous system, gastrointestinal tract, and respiratory system.

• When left untreated, NAS can result in serious illness (e.g., diarrhea, feeding difficulties, weight loss, and seizures) and death.1 Methadone-associated NAS often requires prolonged hospitalization, pharmacologic intervention, and monitoring.

• Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. Hendrée E. Jones, Ph.D., Karol Kaltenbach, Ph.D., Sarah H. Heil, Ph.D., Susan M. Stine, M.D., Ph.D., Mara G. Coyle, M.D., Amelia M. Arria, Ph.D., Kevin E. O'Grady, Ph.D., Peter Selby, M.B., B.S., Peter R. Martin, M.D., and Gabriele Fischer, M.D. N Engl J Med 2010; 363:2320-2331 December 9, 2010DOI: 10.1056/NEJMoa1005359

MOTHER study Screening, Randomization, and Rate of Treatment Completion, According to Study Group

Jones HE et al. N Engl J Med 2010;363:2320-2331

Mean Neonatal Morphine Dose, Length of Neonatal Hospital Stay, and Duration of Treatment for Neonatal Abstinence Syndrome.

Jones HE et al. N Engl J Med 2010;363:2320-2331.

Opioid Treatment Programs

Opioid Treatment Program (OTP) Survey: 2011

This report presents a census of all SAMHSA-certified OTPs in the United States, both public and private, and presents both highlights and

tabular information from the 2011 OTP survey. The OTP survey was fielded in conjunction with SAMHSA’s 2011 National Survey of Substance

Abuse Treatment Services (N-SSATS).

The OTP survey was fielded in conjunction with SAMHSA’s 2011 National Survey of Substance Abuse The OTP survey was fielded in conjunction with SAMHSA’s 2011 National Survey of Substance Abuse

Treatment Services (N-SSATS).Treatment Services (N-SSATS).

National Survey of Substance Abuse Treatment Services (N-SSATS) 2012

Adolescent opioid use disorders : SAMHSA

•In 2007, there were just over 1,600 adolescent substance abuse treatment admissions for heroin abuse

•On average, adolescent heroin admissions were 14.8 years old when they first used heroin and 16.3 years old at admission to treatment, indicating approximately 18 months of use before entering treatment

•More than half (56 percent) of adolescent heroin admissions had at least one prior treatment episode

Among adolescent substance abuse treatment admissions reporting heroin abuse, almost half (48 percent) reported injection as the route of administration, and almost a third (32 percent) reported inhalation

(Figure 1). Male adolescent heroin admissions were less likely than their female counterparts to report injection as the route of administration (43 vs. 56 percent), but were more likely than adolescent female

admissions to report inhalation as the route of administration (36 vs. 27 percent).

Figure 1. Route of Administration of Substance Abuse Treatment Admissions Aged 12 to 17 Reporting Any Heroin Abuse, by Gender: 2007

Trauma issues

• Childhood trauma [ verbal, emotional, physical, sexual , neglect]

• Domestic violence• Trauma as a victim of sexual assault• Multigenerational trauma patterns in families

Severe ongoing stressful , negative experiences

• Exchanging sex for drugs which can leave the woman feeling exploited and coerced even if she entered into it “ willingly”.

• Homelessness• In Childhood : Having to change neighborhoods, schools or

mother changing boyfriends, husbands, significant others• Food insecurity• Lack of a stable income• Father of the baby being uninvolved or under involved• Father of the baby actively suing drugs or being in prison/jail• Lack of emotional support from family or friends

Depression: Epidemiology

• Depression: Women more than menWomen more than men• Depression: Lifetime prevalence of about 15% , maybe as high

as 25% in women• Double Depression [ Dysthymia with superimposed MDD]:

approx 20-25% of people with MDD• Dysthymic Disorder : approximately 6%• Bipolar Disorder I : 0.4-1.6%• Bipolar Disorder Type II: approx 0.5 %• Cyclothymia disorder : 0.4-1.0 %

Depression in women

• PMDD [ Premenstrual dysphoric disorder]• Post Partum depression• Menopause and perimenopause• Pregnancy• Take life issues and circumstances into

consideration

Depression in womenDepression in women

• Women suffer from depression at higher rates than men.

• Research has demonstrated the highest rate of depression is during the childbearing years.

• Some women’s brains may be more vulnerable to the hormonal shifts and changes that occur throughout the reproductive years.

“Baby blues”“Baby blues”

• Post partum Blues [ PPB]: “ Baby Blues”• Generally begin 2-3 days post partum and

last 2 weeks or less.• Affect 50-85% of post partum women• Crying spells, anxiety, mood shifts ,

irritability, sadness.

Post partum depressionPost partum depression

• The symptoms do not resolve within 2 weeks or impact the mother’s functioning.

• 10-15% of post partum women suffer from it• DSM-IV criteria require the symptoms to

begin within a 4 weeks period after birth of the baby.

Post Partum Depression : Multi-factorial causesPost Partum Depression : Multi-factorial causes

Postpartum Risk Factors: Psychosocial/Environmental

Postpartum Risk Factors: Psychosocial/Environmental

• Doubts about parenting ability

• Feeling overwhelmed by caring for new baby

• Lack of emotional/childcare support

• Marital or financial difficulties

• Negative emotions about pregnancy

• Perceived loss of pre-child identity

• Body image issues after childbirth

• Fatigue after delivery • Lack of sleep/disrupted sleep • Stress due to lifestyle

changes.• Unrealistic expectations of

being a "perfect mother.“• Substance abuse

Tree.com

Post Partum Illnesses: Multi-factorial causes

Post Partum Illnesses: Multi-factorial causes

• Past history of mental illness• Family history of mental illness• Interpersonal problems, limited social support• Lack of good coping skills• Environmental problems.

Massachusetts general hospital. Psychiatry update & board preparation. 2nd edition. Theodore A. Stern, John B . Herman. Chapter 28. Psychiatric disorders associated with the female reproductive cycle. Helen G. .Kim, Adele C. Viguera, Benita Dieperink

Post Partum PsychosisPost Partum Psychosis

• Very rare condition: 1-2 of every 1000 post partum women

• Symptoms usually begins within 48-72 hours of delivery.

• It is a medical emergency• Immediate hospitalization is needed

PsychotherapyPsychotherapy• Always make a referral to a therapist/ counselor specializing in dual diagnosis

and substance use disorders.• The patient will get some psychosocial therapies at the methadone

maintenance program or in the suboxone provider's office. Always find out the details , especially in the suboxone [ buprenorphine] provider’s office. Asses to see if the pregnant woman needs any additional level of care and make a referral.

• Consider referring to a residential treatment program or an intensive outpatient program.

• Parenting classes for the mother and the father or her family members or significant other.

• Domestic violence issues. Does the woman need help with a safe place to live• Referral to prenatal care [ usually at a high risk Ob-Gyn clinic]. Monitoring

and support to ensure optimal adherence to prenatal care appointments and recommendations.

• Work with the patient to have appropriate release of information signed so that you can communicate with members of the extended treatment team.

Bipolar Disorder: Epidemiology

• Lifetime prevalence of classic bipolar disorder is approximately 1%• Studies that carefully estimate milder forms of mood elevation and

include cyclothymia and Bipolar Disorder NOS : 2-5% lifetime prevalence.

• Only 1/3rd have been diagnosed by a physician• Only 27% have ever received treatment• This rate of under-treatment is one of the worst among any

psychiatric illness

Chapter 14. Bipolar Disorder. . Perlis, Roy H. Ghaemi, S. NassirMassachusetts General Hospital. “Psychiatry, Update & Board Preparation” Second Edition. Editors: Stern, Theodore A. Herman, John B

Medications for the treatment of substance use disorders

Medications for the treatment of substance use disorders

• Alcohol: Acamprosate 333 mg , 2 tabs , 3 times a day. Naltrexone 50 mg daily [ LFT’s should be within 3 times normal]. Topiramate.

• Opioids: Naltrexone: blocking agent for opioids• Agonist maintenance agents: [ these are also used for

detoxification from opioids]• Methadone • Buprenorphine [ Suboxone] : partial agonist. Acts as a blocker

at higher dosages. In the united states Suboxone is mixed with naloxone , so it will induce opioid withdrawal if crushed and injected.

DAWN Statistics

• This publication presents national estimates of drug-related visits to hospital emergency departments (EDs) for the calendar year 2011, based on data from the Drug Abuse Warning Network (DAWN).

• DAWN is a public health surveillance system that monitors drug-related ED visits for the Nation and for selected metropolitan areas. The Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), is the agency responsible for DAWN. SAMHSA is required to collect data on drug-related ED visits under Section 505 of the Public Health Service Act.

• DAWN relies on a nationally representative sample of general, non-Federal hospitals operating 24-hour EDs, with oversampling of hospitals in selected metropolitan areas. In each participating hospital, ED medical records are reviewed retrospectively to find the ED visits that involved recent drug use.

• All types of drugs—illegal drugs, prescription drugs, over-the-counter pharmaceuticals (e.g., dietary supplements, cough medicine), and substances inhaled for their psychoactive effects—are included.

• Alcohol is considered an illicit drug when consumed by patients aged 20 or younger. For patients aged 21 or older, though, alcohol is reported only when it is used in conjunction with other drugs.

DAWN : Non Medical Use of Pharmaceuticals

Drugs and Alcohol Taken TogetherEd Visits DAWN

Adolescent drug use : NIDA

Adolescent drug use : NIDA

Adolescent drug use : NIDA

Questions, comments and discussionQuestions, comments and discussion