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Plenary Session:Screening, Assessing and Treatment Pregnant Women with Substance Use Disorders
Wednesday, July 10, 2019
9:45 am – 11:00 am
Dr. Mishka Terplan, M.D., Professor, Obstetrics and Gynecology And Psychiatry, Associate Director Of Addiction Medicine, Virginia Commonwealth University
Screening, Assessing, and Treating Pregnant Women with Substance Use Disorder
Mishka Terplan MD MPH FACOG DFASAMProfessor Departments OBGYN and Psychiatry
Virginia Commonwealth University
Drug Use is Common
Substance Lifetime UseN
Lifetime Use%
IllicitCannabis
131 mil119 mil
49%44%
Tobacco 169 mil 63%
Alcohol 216 mil 80%
Lifetime Drug Use US
4
20.1 million people in US (7.5%) with SUDNSDUH 2016 (aged 12 and older)
Not everyone who uses drugs becomes addicted
What is the risk of opioid addiction among individuals prescribed opioids for pain?
Rates of misuse 12-29% (95%CI:13-38%)Rates of addiction averaged between 8-12% (95% CI: 3-17%)
Addiction is not only harm of substance use
What happens when women who use drugs become pregnant?
0
10
20
30
40
50
60
Alcohol Cigarettes Illicit
What happens when women who use drugs get pregnant?
Not Pregnant First Trimester Second Trimester Third Trimester
National Survey Drug Use and Health 2017 Past Month Use Data, women ages 12-44
Those who can’t quit or cut back –likely have a substance use disorder
All pregnant women are motivated to maximize their health and that of their baby-to-be
Continued use in pregnancy is pathognomonic for addiction
Addiction: A Brain-Centered Disease Whose Symptoms are Behaviors
Salient Feature: Continued use in spite of adverse consequences
The Pregnancy Box
Outline
• Assessment (screening and testing)
• Treatment
• The 4th Trimester
• Stigma and Discrimination
SAMHSA’s Clinical Guide
https://store.samhsa.gov/product/SMA18-5054
The Clinical Guide consists of 16 factsheets that are organized into 3 sections: Prenatal Care (Factsheets #1–8); Infant Care (Factsheets #9–13); and Maternal Postnatal Care (Factsheets #14–16).
1) Assessment: Universal
• Ask permission– “Is it OK if I ask you some questions about smoking, alcohol and other
drugs?”– Patients are usually not offended by questions about substance use if
asked in caring and nonjudgmental manner
• Consider (Validated) Instrument (ACOG recommended)– Alcohol: T-ACE (Sokol 1989); TWEAK (Chang 1999)– Alcohol and other drugs: DAST and MAST (Kemper 1993); 4P’s Plus
(Chasnoff 1999); CRAFFT (Chang 2011) for pregnant adolescents
• Selective screening based on “risk factors” perpetuates discrimination and misses women with addiction
Urine Drug Testing
Screening:Elisa (Point of Care)
Definitive:Gas Chromatography / Mas Spec
Point of Care Urine Drug Testing
Definitive Testing
https://www.asam.org/resources/guidelines-and-consensus-documents/drug-testing
Limits of Urine Testing
http://www.ezkeycup.com/iCup-Drug-Screen-8-p/i-dud-187-013.htm
• It is not a parenting test
• Toxicology tests for
drugs are not sufficient
for a diagnosis of a
substance use disorder
• Having a substance
use disorder is only
one of many other
factors in determining
child safety
• Urine toxicology
screening and
confirmatory testing
• Patient consent
required before
specimen collection
Toxicology screens are not a substitute for verbal, interactive questioning and screening of
patients about their drug and alcohol use.
Number of tests increased 4537% from 2000-2009
2011 – 2014: spending on urine tests increased from c $2 to $8.5 billion/year31 Pain Medicine Practices in US received >80% of total income from urine testing
Comprehensive Pain Specialists (54 clinics: largest pain treatment practice in Southeast)2014: Medicare paid CPS at least $11 million for urine tests2015: Medical Director billed $1.8 million
2) Treatment
Individuals with the Condition of Addiction Need Treatment
Prenatal Care
Medication
Behavioral Counseling
“Gold Standard” is Integration: Comprehensive co-located service delivery
1976
1974
No Addiction Treated Addiction Untreated Addiction
Preterm Birth 8.7% 10.1% 19.0%
Low Birthweight 5.5% 7.8% 18.0
Fetal Death 0.4% 0.5% 0.8%
Neonatal Mortality 0.4% 0.4% 1.2%
Post Neonatal Mortality
0.05% 0.03% 0.1%
Treated vs Untreated Addiction
How effective is treatment?
0
20
40
60
80
100
Pati
en
ts W
ho
Rela
pse,
%
Similar Relapse (or Noncompliance) Rates
for Drug Dependence Versus Other Chronic Diseases
Drug Addiction1,2Type 1 Diabetes3 Hypertension4 Asthma5
Graph adapted from Caron Foundation. http://www.caron.org/pdfs/RelapseRecovery-2003.pdf., 2. Hoffman NG, Miller NS. Psychiatr Ann.1992;22(8):402-408. 3. Graber AL et al. Diabetes Care. 1992;15(11):1477-1483., 4. Clark LT. Am Heart J. 1991;121(2 pt 2):644-669., 5Dekker FW et al. Eur Respir J. 1993;6(6):886-890.
Medications for SUD
Substance Use Disorder Medication
FDA Approved Research Supported
Opioid Use Disorder MethadoneBuprenorphine (+/-naloxone)Naltrexone
Alcohol Use Disorder AcamprosateNaltrexoneDisulfuram
Gabapentin
Nicotine Use Disorder Nicotine Replacement TherapyWellbutrinChantix
Addiction: From Reward Seeking to Relief Seeking
OUD Treatment: Pharmacotherapy
Maternal
• 70% reduction in overdose related deaths
• Decrease in risk of HIV, HBV, HCV acquisition/transmission
• Increased engagement in prenatal care and recovery treatment
• Treatment is platform for delivery of other services
Fetal
• Reduces fluctuations in maternal opioid levels; reducing fetal stress
• Decrease in intrauterine fetal demise
• Decrease in intrauterine growth restriction
• Decrease in preterm delivery
Goal of Pharmacotherapy
• Mu Opioid Receptor Action:
– Decrease or eliminate cravings
– Control physiological withdrawal
– Prevent euphoria from use of other mu agonists
Goal of Pharmacotherapy
• Mu Opioid Receptor Action:
– Decrease or eliminate cravings
– Control physiological withdrawal
– Prevent euphoria from use of other mu agonists
• Stability – platform for recovery
• Improved engagement in behavioral care
• Decrease HIV/HCV
• Psychosocial improvement (employment etc)
• Decrease in overdose
SAMHSA Clinical Guide Recommendations
• Medically supervised withdrawal is not recommended during pregnancy
• Buprenorphine and methadone are the safest medications for managing OUD during pregnancy
• Transitioning from methadone to buprenorphine or from buprenorphine to methadone during pregnancy is not recommended
Methadone and Buprenorphine: Advantages
Methadone Buprenorphine
Advantages
Reduces/eliminates cravings for opioid drugs
Prevents onset of withdrawal for 24 hours
Blocks the effects of other opioids
Promotes increased physical and emotional health
Higher treatment retention than other treatments
Lower risk of overdose
Fewer drug interactions
Office-based treatment delivery
Shorter NAS course
Pharmacotherapy
• Pharmacotherapy supported by:– CDC– WHO– SAMHSA– BOP– NCCHC– ACOG– ASAM– AAP– AAFP– Federal Guidelines for Opioid
Treatment 2015(partial list)
• Pharmacotherapy not supported by:
SAMHSA’s Guidance: Medically Supervised Withdrawal is Not Recommended
• Pharmacotherapy is the recommended standard of care • Pharmacotherapy helps pregnant women with OUD avoid a return
to substance use, which has the potential for overdose or death
• A decision to withdraw from pharmacotherapy should be made with great care on a case-by-case basis.
• A pregnant woman receiving treatment for OUD may decide to move forward with medically supervised withdrawal if– It can be conducted in a controlled setting– The benefits to her outweigh the risks
Pregnant patients should be advised that withdrawal during pregnancy increases the risk of relapse without fetal or maternal benefit
Detoxification:
No increased risk of fetal demise
No difference in NAS
Recurrence more common among those who receive detoxification
Detoxification: Acute Intervention for a Chronic Condition:Clinical Mismatch
The Pregnancy Box
3) The 4th Trimester - Postpartum
• Critical Period– Newborn care, breastfeeding, maternal/infant bonding– Mood changes, sleep disturbances, physiologic changes– Cultural norms, “the ideal mother” in conflict with what it is actually like to
have a newborn– Insurance and welfare realignment
• Neglected Period– Care shifts from frequent to infrequent– From Mom-focused (PNC provider) to Baby-focused (Pediatrician)– From “medical” to “social” (WIC)– Continuity of Care: Addiction Provider
The 4th Trimester: Contraception
https://www.colorado.gov/pacific/sites/default/files/PSD_TitleX3_CFPI-Report.pdf
Colorado LARC Experiment
Maternal mortality in the past and its relevance to developing countries today
Am J Clin Nutr. 2000;72(1):241S-246S. doi:10.1093/ajcn/72.1.241S
The 4th Trimester:Maternal Mortality
Opioid Crisis: Hepatitis C
4) It’s more than opioids
Our response to the opioid crisis must not be opioid-exclusive
FETAL ALCOHOL SPECTRUM DISORDERS (FASDS)
AS IDENTIFIED BY
THE NATIONAL ORGANIZATION ON FETAL ALCOHOL SYNDROME (NOFAS)
“……..an umbrella term describing the range of effects that can occur in an individual who is exposed to alcohol during the nine month prenatal period before birth. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis.”
Diagnostic terms under the FASDs umbrella include:
▪ Fetal Alcohol Syndrome (FAS)
▪ Partial Fetal Alcohol Syndrome (pFAS)
▪ Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)
▪ Alcohol Related Neurodevelopmental Disorder (ARND)
▪ Alcohol Related Birth Defects (ARBD)
https://www.nofas.org/about-fasd/
Opioid Use During Pregnancy Alcohol Use During Pregnancy
Prevalence of use 1.6%-8.5% of pregnant women
use opioids; however, it’s on the
rise1
Approximately 8.5% of pregnant women
drink alcohol at some point during
pregnancy1
Likelihood of
developing
NAS is seen in 30-80% of infants
born to women who used
opioids in the third trimester2
2-5% of school age children may have FASDs3
Negative
effects/Disabilities
Neonatal Abstinence Syndrome
(NAS) 4
Fetal Alcohol Spectrum Disorders (FASDs)1
Duration of effects Unknown4 FASDs last a lifetime 5
COMPARING AND CONTRASTING ALCOHOL USE AND OPIOID USE
DURING PREGNANCY
Comparing and Contrasting Alcohol use and Opioid use During
Pregnancy (Continued)
Opioid Use During Pregnancy Alcohol Use During Pregnancy
Cost of Care Average of $90,000 per case of NAS6 Estimate $1.2-2.5 million per case of
FAS7
Screening and Brief
Intervention
Universal screening using the 5 P’s
tool, and brief intervention8
Universal screening using the AUDIT (US)
tool, and brief intervention9
Ethics Avoid separation of mother and
child10
Avoid separation of mother and child 10
Treatment Medication-assisted therapy (MAT)2 Appropriate treatment referral for
alcohol use disorder **See treatment resource directories on ACOG website: https://www.acog.org/About-ACOG/ACOG-Departments/Tobacco--Alcohol--and-Substance-Abuse/Fetal-Alcohol-Spectrum-Disorders-Prevention-Program/Provider-Resources/FASD-Resource-Directory
Conclusion
• Assessment for Substance Use should be universal in PNC
• Urine Drug Testing: poor test characteristics, poorly interpreted, lead to patient discharge from practice (in pain clinics)
• Treatment Works – women with treated SUD have birth outcomes similar to general population
• Need to continue attention past delivery: the 4th Trimester
• Public Health demands a broad response to opioid crisis