Presentation on theme: "Opioid Dependence in Pregnancy"— Presentation transcript:
1Opioid Dependence in Pregnancy James J. Nocon, M.D., J.D.Indiana University School of MedicineChairman, Indiana Prenatal Substance Abuse CommissionDirector, Prenatal Recovery ClinicWishard Memorial Hospital1001 West 10th Street, F5102Indianapolis, Indiana 46202October 7, 2011
2Objectives Review Opioid Pharmacology Types of Opioid Dependence Managing Opioid DependencePrenatalIntrapartumBreast FeedingEffects on the fetus and newbornWithdrawal
3Pregnancy Enhances Recovery Pregnancy makes a difference in long-term recovery.After one year of treatment:65.7% of women who entered treatment while pregnant used no drugs, whileOnly 27.7% of non-pregnant women remained drug free. (p<0.0005)Peles E, Adelson M. Gender Differences and Pregnant Women in a Methadone Maintenance Treatment (MMT) Clinic. J Addictive Diseases 2006; 25:33
4America Has Never Been Drug-free Most commonly used drugs in order of frequency: 1800 to 200021st Century:Cocaine – the 7% solutionCannabis (THC) (2737 B.C China)Laudanum – tincture of opium;Morphine – from the Civil WarMethadone – developed in Nazi Germany prior to WWIIAlcohol –how the West was wonAmphetamine -1887; used extensively in WWII to keep soldiers alert; the US military uses with airmen today in IraqMethamphetamine -1893Methylenedioxy-methamphetamine (MDMA) Developed by Merck in 1912 as an appetite suppressant; today it’s called ecstasyCocaine 52Cocaine and THC 59THC 49Methadone 42Other Opiates 27Alcohol 10Other Combinations 48(opiates/amphetamines)Based on 287 pregnant patients treated from 2002 to 2007.
5What’s the Difference Between Opioids and Opiates? Alkaloids derived from the opium poppyMorphine, Codeine, ThebaineOpioidsAll Opiates, plus:Semi Synthetics – derived from the alkaloids (thebaine): hydrocodone; oxycodone; heroinSynthetics: methadone; fentanyl; nubain; buprenorphine
6Changes In Opioid UsePercent of pregnant patients dependent on opioids referred to an Indiana Substance Use Program:: 69/287 patients: 24%2008: 69.3%2009: 79.1%2010: 75.5%Includes heroin, opioid dependent chronic pain patients, opioid poly-substance users, methadone and buprenorphine maintenance.
7Opioid Abuse Skyrockets Opioid prescription abuse is the fastest rising addiction and public health problem in the United States.Over 2,000 deaths per week have been attributed to opioid abuse.Most of the fatalities are due to Oxycontin
8What’s Oxycontin? Oxycodone Most abused Rx drug: Made by Perdue Pharma Special coating allows for extended releaseMarketed as safe – low addictive riskPerdue Pharm sued for misbranding, among other issues.East to remove the coating – rapid onsetMost abused Rx drug:Especially in Kentucky and Tennessee: “Hillbilly Heroin”OxyContin's warning label said to not crush the controlled-release tablets because of the potential for rapid release of oxycodone, which led many people to crushing the tablets and injecting or snorting the drug.
9Typical Doses of “Oxy” 10 mg - white 15 mg - grey 20 mg - pink 30 mg – brown – most often prescribed40 mg – yellow60 mg - red80 mg – greenish blueAddicts typically use 250 mg/day to feel normal.And mg to get high.It sells for about $1 per milligram
10PMP Restricts “Oxy” Abuse 47 states have a Prescription Monitoring Program (PMP)Inspect:Florida’s program in jeopardy due to lack of state funding.Lack of effective PMP allows “pill mills” to flourish as “Pain Clinics.”41 million prescriptions for Oxy in Florida (July to Dec 2010)Only 4 million Rx for entire US.
11Political Ideology Enables “OXY” Abuse; Intent vs. Impact Intent of Florida GovernorTo reduce federal government and spending.Rejects 15 million in Federal funds for the PMP.Rejects the PMP because of opposition to supporting a “government database.”Attempts to repeal Florida Law creating PMPImpact:Allows pill mills to flourish.More “pain clinics” in Florida than McDonalds.Kills 10 people per day in Florida#1 drug of abuse among year olds
12Others Enable “Oxy” Abuse Organized CrimePharmaciesDoctorsOver $5,000 a day to write prescriptions in “pill mills” in Florida.Can easily make over a million dollars/yearNo nights, no call, just writer’s cramp.And, America has never been drug free!
13What is Addiction?Great question. Like obscenity, hard to define but, I know it when I see it.DependencePsychological: withdrawalPhysical; tolerance and withdrawalAddiction: continuing the behavior in spite of the adverse and illegal consequences of the behavior.
14Relationship View of Addiction If the behavior keeps me from being physically and emotionally present for those I love and those who love me.Then I have a problem with the behavior.May be alcohol, tobacco or other drugs (ATOD)May be eating, sex, gambling, etc.Hoarding?
15Addiction in WomenLate 19th Century: Women accounted for 2/3 of America’s opiate addicts and a large percentage of marijuana, sedative, cocaine and amphetamine addiction.Only 1 in 5 illegal drug addicts during were womenApproximate 15% of all pregnant women today are using alcohol, illegal and illicit drugs during pregnancy.Note: Americans constitute 4% of the world’s population and consume 2/3 of the entire drug supply.
16Psychiatric Gender Issues in Maternal Addiction If sexually abused as a child:6 times more likely to become drug addict (opiates)4 times more likely to become an alcoholicKendler KS, et al. Childhood sexual abuse and adult psychiatric and substance use disorders; an epidemiological and co-twin control analysis. Arch Gen Psychiatry. 2000;57:Major depression more frequent in women substance users.Prescott et al. Sex specific genetic influences on the co-morbidity of alcoholism and major depression in a population-based sample of U.S. twins. Arch Gen Psychiatry. 2000;57:
17Other Women’s Issues in Addiction Alcoholic women usually have alcoholic spouses and less spousal support. (Holds true for opiates, as well)Redgrave, et al, Alcohol misuse by women. Int. Rev. Psychiatry 2003;15:Women more likely to abuse prescription drugs“My mother gave me her Xanax.”Vicodin, Lortab, Xanax and Klonopin.Bardel, et al. Reported current use of prescription drugs and some of its determinants among year old women in mid-Sweden; a population based study. J Clin Epidemiol ;17
18The Pathophysiology of Addiction Just as alcohol, tobacco, and drugs activate the pleasure circuit in the brain, so do many behaviors such as sexual activity, winning a contest, gambling, and being praised.What drugs and behaviors have in common is the release of various neurotransmitters in nucleus accumbens in the brain:Dopamine – creates the “buzz.”Serotonin – sense of well being.Endorphins – euphoria.GABA (gamma amino butyric acid) – satiety and somnolence (sleepy after a big meal or sex)As repeated use of the drug or behavior depletes the dopamine, more activity is required to get the same effect. “Tolerance.”There comes a point when the affected person becomes an addict, as if a switch in the brain is flipped, and the person no longer has the ability to make free choices about the continued use of the drug.Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-471818
19Pleasure in the Brain http://thebrain.mcgill.ca/flash/index_i.html Ventral Tegmental AreaNucleus Accumbens – dopamine rich center in the limbic areaPrefrontal Cortex – short term memoryAmygdala – moderates emotional influences on memory – fear responseMFB: medial forebrain bundleThese are the primary centers involved in pleasurable sensations.Often referred to as “the Pleasure Circuit”
20Continuous Use of Drugs Changes Brain Cells Dopamine SystemCocaine inhibits transportersAmphetamine affects receptor and neurotransmitter releaseSerotoninHallucinogens inhibit receptorsGABA/NMDAEtoh inhibits and facilitates receptor functionOpiates have negative effect (Morphine; Heroin)
21Pathophysiology: Addiction Changes Brain Cells Addiction is a “double whammy.”Tolerance - The brain needs more and more of the drug in order to get the same effect. And in this process, the brain cells are actually altered.Drugs reduce fear response in Amygdala and Prefrontal cortex – person uses more drug with less fear of consequences.McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricaurte GA. Positron emission tomographic evidence of toxic effect of MDMA ("Ecstasy") on brain serotonin neurons in human beings. Lancet 1998 Oct 31;352(9138):Do you have a reference for the picture?
22You Know You Are Addicted When you will do anything including breaking the law to obtain the drug,Just to feel normal.
23An Important Digression: Alcohol and tobacco cause more fetal damage than all the other drugs combined including all the known teratogens.
24Strong Link Between Alcohol/Nicotine Use and Use of Illicit Drugs Among Women using BOTH Alcohol and Nicotine in the pregnancy• 20.4% used Marijuana• 9.5% used CocaineWomen NOT using Alcohol or Nicotine• 0.2% used Marijuana• 0.1% used CocaineAlcohol and Nicotine use is also a marker for other drug use.24
25Opiate Use In Pregnancy Derived from Poppy, Papaver Somniferum, 4000 BCMorphine 1806Codeine 1832Heroin 1898 (Bayer) – was the drug of choice for obstetrical analgesia immediately post WWIIMethadone 1930 (Bayer) – synthetic opioidOther Commonly Used drugsMarijuana noted in China 2737 BC – Major Cash crop in Jamestown 1611Cocaine - Spanish taxed it use 1569Amphetamine marketed by Smith Kline in 1887.
26Most Common Opiates Used by Pregnant Patients Hydrocodone: Vicodin; LortabOxycodone: Oxycontin: PercocetMethadoneHeroinOpiates were mostly Category B DrugsAnimal studies appear to pose no risk, butDefinite risk established in humansVisual defects confirmed in human studies with methadone.
27Maternal Treatment with Opioid Analgesics and Risk of Birth Defects National Birth Defects Prevention Study, case-control study for infants born October 1, 1997, through December 31, 2005, in 10 statesTherapeutic opioid use was reported by 2.6% of 17,449 case mothers and 2.0% of 6701 control mothers.Treatment was statistically significantly associated with:conoventricular septal defects (OR, 2.7; 95% CI, 1.1–6.3atrioventricular septal defects (OR, 2.0; 95% CI, 1.2–3.6),hypoplastic left heart syndrome (OR, 2.4; 95% CI, 1.4–4.1),spina bifida (OR, 2.0; 95% CI, 1.3–3.2), orgastroschisis (OR, 1.8; 95% CI, 1.1–2.9) in infants
28Methadone: Visual Problems Reduced acuity (95%),Nystagmus (70%),Delayed visual maturation (50%),Strabismus (30%),Refractive errors (30%), andCerebral visual impairment (25%).Hamilton; Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed substitute methadone in pregnancy. Br J Ophthalmol doi: /bjo
29Opiate Pharmacology Bind to receptors Mu: analgesia; euphoria, respiratory depression, constipation, sedation, miosisKappa: dysphoria, sedation, psychotomimeticDelta: unknownRate of Excretion faster than withdrawalMorphine excreted within 72 hoursMethadone takes 4-5 days.Clinical relevance is patient in withdrawal may have negative UDS.Withdrawal in Adult: 6-24 hours from last doseMorphine: 3-7 days durationMethadone: days or more
30Opiate Agonists Morphine/Codeine/Dilaudid and Derivatives Methadone Specificity for Mu receptorMetabolized by liver½ life 2-4 hours90% excreted in urine/24 hrsMethadone90% bound to protein½ life hoursSlow release into blood
31Opiate Antagonists Naloxone - Narcan Naltrexone - Vivitrol Very strong affinity for Mu receptorRapid competitive antagonist – 2-4 minutesLasts about 45 minutes“Jump starts” withdrawalNaltrexone - VivitrolBinds more slowly½ life 4 hoursUsed in alcohol and opiate treatment.
32Opiate Agonist/Antagonists Nalbuphine (Nubain)10 mg. IV or IM q. 3 hours ; onset 2-3 min IVNeonatal half life: 4.1 hoursA favorite of OB nurses – less nauseaButorphanol (Stadol)1-2 mg. IV or IM every 4 h; onset 1-2 min IVNeonatal half life unknownBuprenorphine (Subutex/Suboxone)Long acting; long half lifeUsed for maintenance like methadone
33Pregnancy Increases Metabolism of Specific Opiates Certain enzyme systems increases the metabolism of specific opiates, especially:MethadoneHydrocodoneOxycodoneThis is especially true of MethadoneJarvis, M. A., S. Wu-Pong, et al. (1999). "Alterations in methadone metabolism during late pregnancy." J Addict Dis 18(4):
34Increased Opioid Metabolism Increases with each trimester, especially third30-40 percent of patientsDoses may increase by 50%.May require more drug to treat painMethadone patient may be in chronic withdrawal by third trimester.Higher does methadone actually has better outcome.McCarthy, J. J., M. H. Leamon, et al. (2005). "High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes." Am J Obstet Gynecol 193(3 Pt 1):
35Clinical Management of Opioid Dependence in Pregnancy What is the Evidence?Standard of CareOpiate OverdoseOpiate WithdrawalOpiate MaintenanceChronic pain patientsMethadone maintenanceBuprenorphine maintenanceOpiate analgesia: labor; delivery; CesareanNeonatal Abstinence Syndrome (NAS)Breastfeeding
36Opioid Use in Pregnancy This is the Evidence Four Groups: 213 PatientsPain patients using only opioids – 31Opiate dependent poly-substance patients – 45Methadone Maintenance - 90Buprenorphine Maintenance – 46Subutex – 12Suboxone - 34
37Opioid Dependent Chronic Pain Patients Using Opioids Only Includes opioid/acetamenophen preparations.N = 31Preterm Labor: 4 (12.9%)Positive Meconium (other than opiates): noneMean newborn weight: gramsLOS (newborn): 3.3 days; range 2-21 daysNAS treated: 1Intrapartum complications: 7No overdoses.Nicotine use (> 0.5ppd): 21 (67.7%)
38Opioid Dependent Poly-substance Patients Opioids plus cocaine, or THC or benzodiazepines or all three or moreN = 45Preterm Delivery: 8 (17.7%)Positive Meconium (other than opiates): 12 (26.6%)Mean newborn weight: 2879 gramsLOS (newborn): 7.8 days; range 2-89 daysNAS treated: 5Intrapartum complications: 7One antenatal overdose – mother and fetus survivedOne fatal postpartum overdoseNicotine Use (> 0.5ppd): 30 (66.6%)
39Opioid Only Patients Postpartum Visit Routinely at 4 weeks postpartumN=31Did not return: 3Returned with positive UDS for drugs other than prescribed opioids: 5Returned “negative:” 23 (74.2%)
40Opioid Poly-substance Patients Post Partum Visit Routinely at 4 weeks postpartumN=45Did not return: 13 (28.8%)Returned with positive UDS for drugs other than prescribed opioids: 7Returned “negative:” 25 (55.5%)
41Comparison of Opioid and Opioid Plus Use in Pregnancy Opioid (31) Opioid + (45) p Preterm Delivery 4 (12.9 %) 8 (17.7%) NS Low Birth Weight (<2500g) 3 8 NS Mean Birth Weight 3085 g 2879g NS Positive Meconium 0 12 (26.6%) NAS Treated 1 5 NS Mean Length of Stay Failed to return PP Returned PP “negative” 23 (74.2%) 25 (55.5%) NS
43Methadone Maintenance Post Partum Routinely at 4 weeks postpartumN=90 (92 babies)Did not return: 28 (31.1.%)Returned with positive UDS for drugs other than prescribed opioids: 3Returned “negative:” 59 (65.5%)
44Buprenorphine Patients Subutex N = 12; Suboxone N = 34; Total N= 46Preterm Delivery: 5 (10.9%)Mean newborn weight: gLBW (< 2500g): 5 (10.8%)Positive meconium: 3 (6.9%)Mean LOS: 6.78 days; range 2-49 daysNAS: 8NAS treated: 6Intrapartum Complications 8Nicotine: 29 (63%)
45Buprenorphine Postpartum Routinely at 4 weeks postpartumN=46Did not return: 13 (28.2%)Returned with positive UDS for drugs other than prescribed opioids: 4 (8.6%)Returned “negative:” 29 (63%)
46Methadone vs. Buprenorphine Major Pregnancy Outcomes Bup. (46) Meth (90) pPreterm Delivery 5 (10.9 %) 27 (30%) 0.001Low Birth Weight (<2500g)Mean Birth Weight g 2718gNeonatal Abstinence (NAS)NAS TreatedMean Length of StayFailed to return PP 13 (28.8%) 28 (31.1%) NSReturned PP “negative” 29 (65.1%) 59 (65.5%) NSSee also, Kakko J, Heilig M, Sarman I. Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal growth and neonatal outcomes in two consecutive case series. Drug Alcohol Depend 2008 Jul 1;96(1-2):69-78.
47The Evidence Suggests New Treatment Strategies Prevention of WithdrawalOpioid OverdoseWithdrawalDetoxificationMaintenanceMethadoneBuprenorphineOpioid dependent chronic pain patientPolysubstance Use in Chronic Pain Patient
48Standard of Care: Prevention of Withdrawal Evidence based literature clearly indicates that it is imperative to prevent opiate withdrawal in pregnancy:Increased rate of preterm labor – 41%Increased incidence of abruption 12%Efforts to wean off or “detox” opiates in pregnancy carry an increased risk of harm to the fetus.This represents a shift in the standard of care from “lowest possible dose” to “appropriate” doses to prevent withdrawal.
49Opiate OverdoseCharacterized by pinpoint pupils, respiratory depression, coma, and pulmonary edema.Establish airway.Inject Naloxone – repeat if long acting opiate present, e.g., methadone.Naloxone will not harm fetus.Treatment will precipitate a severe withdrawal.Will need to restart and modify an opioid doseFor maintenance, use methadone or buprenorphineMethadone: start at 20 mg BID and increase 5-10 mg per day until stable.Buprenorphine/naloxone: start at 2 – 4 mg BID; increase by 2-4 mg every 6 hours until withdrawal is abated
50Opiate Overdose Recovery Will need to restart and modify opiate dose to prevent withdrawal.Methadone maintenance – only by a federally certified clinic.But a licensed physician may legally prescribe methadone to treat withdrawal in pregnancy for an inpatient.Buprenorphine – only by a federally certified clinician.
51Opiate Withdrawal Affects Major Systems CNS – tremors, seizuresMetabolic – sweating; yawningVascular – hot flashes and chillsRespiratory – increased rate; respiratory alkalosisGI – cramps, nausea, vomiting, diarrheaDrug specific effects – methadone has a prolonged withdrawal: 10 – 20 days.
52Onset of Opiate Withdrawal Short Acting (heroin; morphine; vicodin):begins 6-24 hours;peak 1-3 days;lasts 5-7 daysMethadone:Begins 1-3 days;peaks 3-6 days;Lasts 2 weeks or more
53Opiate Withdrawal Clinical Picture Patient presents with abdominal pain, cramps and diarrhea and may complain of contractionsAlso has yawning, lacrimation, restlessness; may have tachycardia.UDS may be negative for opiates!Typical history reveals Rx for hydrocodone/acet. 5/500 for injuries in auto accident years agoAdmits taking more than prescription allows – commonly up to pills a dayUDS positive for opiates; often find THC, Benzodiazepines, cocaine.
54Opiate Withdrawal in Pregnancy High rate of preterm labor - 41%Increased abruption - 13%Low Birth weight – 27%Increased incidence HIV; Hep B; Hep CCurrent recommendation is to avoid withdrawal during pregnancyThis includes “detoxification” during pregnancy.The risk of adverse events from withdrawal is far greater than from the treatment of neonatal abstinence.Lam SK, To WK, Duthie SJ, Ma HK. Narcotic addiction in pregnancy with adverse maternal and perinatal outcome. Aust N Z J Obstet Gynaecol 1992 Aug;32(3):
55Opiate Withdrawal Treatment Initiate methadone or buprenorphine to stabilize withdrawal: may use oxycodone 10 mg q 4-6h for up to 72 hours to stabilize patient and then switch to methadone or buprenorphine.Phenergan 25 mg q 4-6 H for withdrawal symptoms – best for nausea, vomiting and GI symptomsOr, Phenobarbital, 30 mg TID for neurological withdrawal symptoms.Clonidine 0.1 mg TID – vascular withdrawal symptoms.Check acetaminophen levels in patients using opiate/acetaminophen compounds.
56Opioid Detoxification Must be closely controlled. Benefits rarely outweigh risks.Gradual reduction to minimize withdrawalSymptomatic treatment.Phenergan 25 mg q 4-6 H for withdrawal symptoms – best for nausea, vomiting and gastrointestinal symptomsPhenobarbital, 30 mg TID for neurological withdrawal symptoms.Clonidine 0.1 mg TID – vascular withdrawal symptoms.
57Opioid Maintenance Methadone Encourage patient to remain on methadone during pregnancy.Expect dose to increase up to 50% during pregnancy in about 35% of patients.Doses range from mg. per day.Higher doses not associated with severity of NAS but improve maternal compliance with prenatal care.Patient should be encouraged to breast feed.Note: Methadone is NOT FDA approved for treatment for opiate dependence in pregnancy.McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet Gynecol 2005;193:Philipp BL, Merewood A, O'Brien S. Methadone and breastfeeding: new horizons. Pediatrics 2003;111:
58Opioid Maintenance: Buprenorphine Patient must be in opioid withdrawal to start buprenorphine treatment.Inpatient: some recommend initiating treatment with buprenorphine, 2-4 mg sublingual by either tablet of film.Increase dose by 2-4 mg every 6 hours to stop withdrawal symptoms.Convert to buprenorphine/naloxone for outpatient use.Target doses rage from 4 to 24 mg per dayMost pregnant patients are stable at 8-16 mg per day in divided doses.
59Opiate Dependent Chronic Pain Patient Maintain current opiate regimen – avoid withdrawal (both legal to do and meets standard of care)Hydrocodone 5/325 or 10/325 (up to 2 tabs q 6h)Oxycodone 5/325 or 10/325 (up to 2 tabs q 6h)Low rate of NAS noted with these dosesRequirement of opiate may increasePain moderators may be helpfulAmytryptilene mg h.s.Gabapentin 300 mg TIDPhysical Therapy – maintain mobility
60Polysubstance UseConcomitant use of two or more psychoactive substances, in quantities and frequencies that cause individually significant distress or impairment.In one study, 107/287 or 37.2% of pregnant women presented for prenatal care with polysubstance use.Opiates are a common a component.As are Alcohol and TobaccoCommon conditions with polysubstance use:Chronic pain conditionsFibromyalgiaBipolarAnxiety disorders
62Co-morbid Psychiatric Illness in Chronic Pain Patients Depression most common – 45%Substance Abuse - 19%Many chronic pain patients have been treated with a benzodiazepine and easily become dependent: especially Xanax; KlonopinAnxiety disorders – 16% (Xanax very common)PTSD (grossly under diagnosed)Bipolar – often unrecognized; be aware of aripiprazole – may cause significant HTN and Diabetes.
63Reconditioning Physical Therapy in Chronic Pain Management The sine qua non of good pain management.Components: Strengthening, aerobics, etcPainful activities become comfortableRehabilitates physically and psychologicallyReduces depression and anxietyEnhances self efficacyEmpowers patient to become functional
64Red Flags for Abuse Lost/stolen Rx Early refills Calling unfamiliar physiciansUse for psychoactive effect
65Benzodiazepines Used in patients for musculoskeletal spasm and pain. Most often used for anxiety/panic disorder.Alprazolam and Clonazepam are Category DHowever, abrupt cessation will cause withdrawal, often severe.More prudent to prevent withdrawal.Neonatal withdrawal will often occur.Best to avoid starting benzodiazepine in pregnancy.
66Analgesia and Anesthesia for Methadone Patients Epidural – labor/delivery/cesareanSpinalCan use intrathecal opiates/cainesPost op pain managementUse standard opiates – morphine, dilaudidUse % more or double the dose for a morphine or dilaudid pumpIbuprofen; 800 mg q 8 h as soon as toleratedLots of stool softener
67Buprenorphine Maintenance Note: Methadone is NOT FDA approved for treatment for opiate dependence in pregnancy.Buprenorphine has been found safe and effective in world-wide studies and recent studies indicate it is also safe for use in neonatal withdrawal.Easy to treat opiate withdrawalsHas become standard of opiate dependency management in Scandinavia, Europe and the United Kingdom.
68Buprenorphine History France 1996: buprenorphine registered to treat opiate dependencePhysicians allowed to dispense by prescription2002: Drug Addiction Treatment Act amended to allow qualified physicians to dispense buprenorphine by prescription
69Buprenorphine Initial Observations Thousands treated with increasing numbers of pregnant patientsNeonatal withdrawal noticed to be absent or mildLess preterm birthNormal birth weightsFischer G, Etzersdorfer P, Eder H, Jagsch R, Langer M, Weninger M. Buprenorphine maintenance in pregnant opiate addicts. Eur Addict Res 1998;4 Suppl 1:32-6.
70Buprenorphine Subutex and Suboxone Buprenorphine – used for INPATIENT initiationHigh abuse potential for IV useSuboxoneBuprenorphine/naloxone – created to eliminate IV abuseMajority of outpatients currently treated with suboxone
71Buprenorphine Issues for Pregnant Patients Initial recommendation to use Subutex only – fear of effects of naloxone on fetus, specifically “intrauterine withdrawal.”Subsequent pharmological evidence reveals naloxone absorbed in extremely low dose with no evidence of harmAlmost all current outpatients are treated with Suboxone.Majority of those pregnant conceived under Suboxone treatment.
72Buprenorphine and NASRecent evidence indicates buprenorphine safe and effective in weaning newborn from methadone with reduced length of stay when compared to morphine.Kraft WK, Gibson E, Dysart K, et al. Sublingual Buprenorphine for Treatment of Neonatal Abstinence Syndrome: A Randomized Trial. Pediatrics 2008;122:e
73Using Opiates In L&DUse of agonist/antagonist opiates popular because of reduced nausea and vomiting.However, Nalbuphine (Nubain) noted for excess sedation.Butorphanol (Stadol) may increase blood pressure – avoid in hypertension.Morphine best tolerated by largest group of patients.
74Opioid Effects in Obstetrics Analgesic effect in labor is limited.Sedative effect is excellent.Major factor in prolonging latent phase labor.Ironically, morphine is the drug of choice for treating prolong latent phase – heavy sedation effect.Best analgesic effect is at beginning of active phase – use longer acting opiate MORPHINEChange drugs when ineffective (incomplete cross tolerance).Use adequate amounts; whatever it takes.
75Dose of Opiates: Whatever It Takes. Morphine2-5 mg. I.V. every 4 hours; onset 5 min.10-15 mg. I.M. every 4 hours; onset minNeonatal half life: 7.1 hours but less sedating than NalbuphineNalbuphine (Nubain)10 mg. IV or IM q. 3 hours ; onset 2-3 min IVNeonatal half life: 4.1 hoursButorphanol (Stadol)1-2 mg. IV or IM every 4 h; onset 1-2 min IVNeonatal half life unknown
76Analgesia and Anesthesia for Methadone and Buprenorphine Patients Epidural – labor/delivery/cesareanSpinalCan use intrathecal opiates/cainesPost op pain managementUse standard opiates – morphine, dilaudidUse % more or double the dose for a morphine or dilaudid pumpIbuprofen; 800 mg q 8 h as soon as toleratedLots of stool softener
77Opiate Effects on Newborn All Opiates cause some depression but significant depression is rare.Meperidine (normeperidine): dose dependent neurobehavioral depression up to 63 hours.Nalbuphine - reduces neonatal perception to sound and tone for more than 24 hours.Morphine has the least toxic effect on fetus.Naloxone (Narcan) is the drug of choice for neonatal depression secondary to opiate sedation.
78Neonatal Abstinence Syndrome (NAS) Hydrocodone babies rarely have NASMorphine: Heroin – acute, severe but rapid – over in 72 hoursMethadone – prolonged – days with 6-8 weeks not uncommonBuprenorphine – mild and often not requiring treatmentBreastfeeding assists NAS recovery
79Assessment of Newborn with NAS Four Key Neurobehavioral Signs CNS signs:Irritability, excessive crying; voracious appetiteSeizuresGI signs: vomiting; diarrheaRespiratory signs: tachypnia; hyperpneaANS signs: sneezing, yawning, tearingFinnegan ScaleFinnegan and Kaltenbach (1992) in Hoekelman (ed) Primary Pediatric Care. St. Louis; CV Mosby
80Current Treatment NAS Combination therapy Oral clonidine; phenobarbitalDilute morphine dropsIncrease morphine dose until signs of withdrawal controlledMaintain controlling dose for 2 daysThen wean morphine dose every 1-2 days.AAP Committee on Drugs. Neonatal Drug Withdrawal. Pediatrics 1998; 101:
81Drug Concentration in Breast Milk Milk to plasma ratio.Varies over time.When the amount of drug ingested from the milk, per unit of time, is less than the therapeutic dose (clinical effect),Then the level of exposure is low.Regardless of the milk to plasma ratio.
82Methadone Long half life BUT, transfer to milk is minimal. Maternal dose of 80 mg. per day (typical) yields infant dose about 2.8% of maternal.Some studies indicate concentrations in breast milk unrelated to maternal methadone dose.Appears to have mitigating effect on NAS – shorter LOS of breast-fed infants.Phillip BL, Merewood A, O’Brien S. Methadone and breastfeeding; new horizons. Pediatrics 2003;111:
83Buprenorphine Suboxone and Subutex Suboxone: buprenorphine and naloxone.Oral Rx for opiate dependent maintenance.Substantially reduced NAS.Minimal to no effect on breastfeeding.Most recent literature indicates using buprenorphine to treat NAS in newborn: improved efficacy and shortened LOSKraft WK, et al. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Pediatrics; published online August 11, 2008.
84Opiate Dependent Chronic Pain Patients and Breastfeeding Hydrocodone, oxycodone and fentanyl.Usual doses for pain relief appear to have minimal to no effect on infant.However, many of these patients also use pain moderators which may depress infant:Benzodiazapines: Xanax; KlonopinGabapentin: NeurontinAmytryptilene: Elavil (generally safe)Cyclobenzaprine: FlexorilHigh rate of tobacco use in these patients.
85Methamphetamine Documented High dose in Breast Milk Resulted in infant death.Breast feeding contraindicated.
86Recovery, Relapse and Breastfeeding Does breastfeeding enhance or detract from ongoing recovery in the postpartum patient?The most common cause of relapse is stress, and it doesn’t take much.If breastfeeding is not going well and the patient is experiencing significant stress, she is ripe for relapse.Plays into low self esteem - “I’m a failure”Baby always crying – “I need some peace and quiet.”Despair – using drugs to “numb out.”
87Treating Addiction in Pregnancy What works - just about anything:Identifying the problem - 50% will abstainMotivating the patient - 85% will abstainWhat doesn’t - ignoring the problem.