Post on 26-Jan-2021
PROJECT DOVEImproving Maternal and Neonatal Health
Through Safer Opioid Prescribing
MODULE 3
Partners
SupportBureau of Justice Assistance,
Department of JusticeGrant # PM-BX-Koo4
3Treatment Plan Adjustment and Perinatal Care
MODULE
Monitor pregnant patients in treatment for opioid use disorder
Manage pain and medications during delivery
Identify maternal and neonatal needs following delivery and coordinate with neonatal/pediatric team to assess for NAS
Module 3 provides youwith information and tools to:Learning Objectives
This symbol indicates that the documents referenced are available for download in the Resources section of the online course.
www.brown-cme.com/opioids-pregnancy
Downloadable Resources
https://www.brown-cme.com/opioids-pregnancy
Continuous Monitoring and Treatment Plan Adjustment
Monitoring
Use monitoring tools on a schedule that reflects patient needs
Prescription Drug Monitoring Program (PDMP)
Urine drug testing
Structured screening tools for pain, substance use, mental health
Communication with patient
Review treatment plan at each visit
Affirm and promote positive outcomes:
▪ Focus on the goals the patient has achieved
▪ Offer verbal praise
What if the patient is not meeting her treatment goals?
Reassess and affirm whether the goals are still meaningful to her
Identify barriers
Offer resources to help overcome barriers
Break goals into smaller steps
Work with patient to set more attainable goals
Brief history
At her first visit, Carol presented with:
▪ Pregnancy at 12 weeks gestation
▪ Use of oxycodone 15 mg bid following spinal fusion; no signs of nonmedical use
▪ Moderate depression and anxiety treated with SSRI
At the conclusion of her first visit, Carol:
▪ Decided to taper off opioids
▪ Received referrals to acupuncture, physical therapy, and a pain specialist
Purpose of visit
▪ Follow-up visit
PATIENT 1
Carol
Age 29
Carol is no longer taking oxycodone. She is at 28 weeks
gestation. Carol has completed the pre-appointment
paperwork, which included the PHQ and GAD. Both
indicate increased symptoms of anxiety and depression.
Carol’s PEG score (Pain, Enjoyment of life, General
activity Scale) is steady.
Carol’s status at visit
Reassess pain and functioning
Affirm progress
Acknowledge challenges
Ask about outcomes of alternative treatment referrals
Offer additional options
For patients who have recently tapered from opioids, be sure to:
Carol Video
Dr. Hayes will continue to monitor the screening
scores. She offers Carol suggestions for
medication-free strategies for coping with pain
such as complementary and alternative medicine
and mindfulness options.
Carol’s visit conclusion
Brief history
PATIENT 2
Sarah
Age 30
At her first visit, Sarah presented with:
▪ Pregnancy at 8 weeks gestation
▪ Methadone treatment for 2 years, with relapse 8 months prior to visit
▪ A desire to discontinue methadone out of concern for the fetus
At the conclusion of the first visit, Sarah:
▪ Decided to maintain methadone
▪ Received informational brochures
▪ Scheduled a follow-up visit to discuss methadone recommendations and NAS with the clinician and her boyfriend
▪ Regular prenatal visit
Purpose of visit
Sarah has regularly attended prenatal care. She is at 31 weeks gestation. Sarah has been getting urine toxicology testing, and her screening results have been appropriate for her methadone treatment with no nonprescribed substances.
Sarah’s status at visit
Dosage Adjustments in Pregnancy
Patients on opioid agonist treatment may be concerned about the effect of dosage increases on the fetus.
Clinicians should reassure patients that multiple studies have found no relationship between methadone dosage and NAS severity or other neonatal outcomes.
Cleary et al., 2010; Jones et al., 2013 & 2014
Of great concern are withdrawal symptoms due to inadequate dosage because withdrawal increases risk of relapse and the fetus feels the withdrawal that the mother feels.
Sarah Video
After the ultrasound, Dr. Brown asks Sarah about the referrals her team provided at earlier visits. Sarah tried the prenatal yoga, but has not continued due to transportation issues. She has been attending the mothers in recovery support group.
After the visit, Dr. Brown contacts the methadone treatment provider to alert the treatment provider to the potential need for dosage increase.
Sarah’s visit conclusion
At her first visit, Angela presented with:
▪ Pregnancy at 10 weeks gestation
▪ Signs of nonmedical Rx opioid use in PDMP
▪ History of anxiety
▪ Request for opioid fill
At the conclusion of her first visit, Angela:
▪ Agreed to buprenorphine treatment with another clinician
▪ Accepted information about recovery coach and home visiting services but did not schedule appointments
Age 34
PATIENT 3
Angela
Brief history
▪ Prenatal visit after buprenorphine induction
Purpose of visit
Angela attends a scheduled follow-up visit with Dr. Jones 3 weeks after her initial visit. She has begun buprenorphine treatment with Dr. Burrell. At her initial visit with Dr. Jones, Angela signed a release of information so that Dr. Jones could coordinate with Dr. Burrell.
Angela’s status at visit
Angela Video
Before Angela leaves the appointment, Dr. Jones’ scheduler:
▪ Arranges an appointment for Angela to tour the neonatal nursery and NICU and meet the hospital social worker.
▪ Contacts the home visiting program to schedule an appointment for Angela.
At a later visit, the neonatal care nurse provides Angela with training on:
▪ Signs of NAS
▪ Environmental conditions to reduce NAS
▪ Soothing techniques
Angela’s visit conclusion
Managing Pain and Medication Intrapartum and Immediate Postpartum
Management of intrapartum and postpartum pain poses particular challenges in women physically dependent on opioids or agonist therapy for opioid use disorder
Jones et al. 2009; Meyer et al. 2007 & 2010; Savage & Schofferman, 1995
Long-term exposure to opioid agonists can result in:
Reduced pain tolerance
Reduced analgesic effect from opioids
Greater postpartum pain
Clinicians should aim to reduce patient anxiety about labor and postpartum pain
Use clear communication about the plan for pain management
Remember that breathing and mindfulness techniques can help patients manage anxiety and prepare for pain
Planning for Pain Management
Hofmann et al., 2010, Rosenzweig et al., 2010
To manage pain in childbirth use:
▪ Contact the opioid agonist provider to verify the dose and ensure the patient has medication during and after delivery.
▪ Hospital must be prepared to provide methadone or buprenorphine doses if needed to maintain schedule
Uninterrupted agonist therapy for opioid use disorder
▪ Initiating early in labor may be particularly beneficial in attaining adequate pain relief
Epidural or combined spinal/epidural analgesia
▪ Titrate to achieve pain relief
▪ Generally higher doses of opioid analgesics needed than other patients, administered at shorter intervals, but for the same duration
Opioid analgesics as needed
Caution: Partial agonist/antagonist medications nalbuphine, butorphanol, and pentazocine are contraindicated due to risk of precipitated withdrawal
Preston et al., 1989
For cesarean delivery, multimodal therapy for postoperative pain management can be beneficial:
NSAIDS (beginning with an intraoperative ketorolac dose, if appropriate)
Spinal or epidural morphine
Acetaminophen with or without patient-controlled analgesia for breakthrough pain
Jones et al., 2014
Managing pain after cesarean delivery:
LABOR
▪ Maintain methadone/buprenorphine; consider subdividing dose into 3 or 4 doses administered every 6 to 8 hours
▪ Use epidural analgesia
▪ Do not use partial agonist-antagonists nalbuphine,butorphanol, or pentazocine due to risk of acute withdrawal
▪ Use IV opioids prn
Managing Intrapartum and Postpartum Pain in Patients Receiving Methadone or Buprenorphine
Cesarean Birth
Vaginal Birth ▪ Maintain methadone/buprenorphine
▪ If pain unmanaged with NSAIDS (including ketorolac) or acetaminophen, use short-acting full mu opioid agonists
▪ Maintain methadone/buprenorphine
▪ Can use IV opioids prn for first 24 hours; consider PCA or give short-acting full mu opioid agonists immediately post-op; change to prn after 48 hours
▪ If pain is poorly controlled, change to hydromorphone
POSTPARTUM
NAS Assessment and Treatment
Signs and Symptoms of NAS
Finnegan et al., 1975; Jones & Fielder, 2015; Finnegan & Kaltenbach, 1992
Central nervous system signs
▪ Irritability▪ High-pitched crying▪ Sleep disturbance▪ Tremors▪ Exaggerated reflexes▪ Myoclonic jerks
Autonomic and respiratory signs
▪ Fever▪ Sweating ▪ Yawning▪ Sneezing▪ Nasal stuffiness▪ Rapid breathing
Gastrointestinal signs
▪ Uncoordinated or continuous sucking
▪ Poor feeding ▪ Vomiting▪ Loose stools
Jansson & Velez, 2012, Huybrechts et al., Kaltenbach et al., 2012; 2017; Seligman et al., 2008
NAS severity may be increased by polydrug use, benzodiazepine or SSRI use, smoking, full-term gestation, good birth weight, and genetic factors
The onset of NAS presentation after birth varies by opioid
Gaalema et al., 2012; Zelson et al., 1971
usually
24 to 48 hours
usually
48 to 72hours
unclear
The MOTHER study found that the mean time to pharmacotherapy was 34 hours for methadone-exposed neonates and 71 hours for buprenorphine-exposed neonates
Currently there are no systematic studies of time of onset of NAS due to prescription opioid pain medications
Heroin Methadone Buprenorphine Prescription opioids
slower to present than methadone
Onset of NAS Presentation
Hudak and Tan, 2012
The American Academy of Pediatrics recommends that opioid-exposed neonates be monitored for NAS for 5–7 days to prevent discharge prior to NAS presentation
NAS scoring tools aid in determining need for pharmacotherapy, and in titrating and terminating therapy
Scoring should be performed after feeds, at 3- to 4-hour intervals, when the infant is awake
Kocherlakota, 2014; Sarkar & Dunn, 2006
Research on optimal NAS screening and assessment tools is needed.
NAS Assessment Tools
Non-NASS MeasuresNASS Measures
▪ Neonatal Abstinence Scoring System (NASS)aka the Finnegan tool is the most widely known, though challenging to administer
▪ MOTHER NAS Scale (MNS) improved the NASS, and a short form has been developed
▪ Neonatal Drug Withdrawal Scoring System (NDWSS) aka the Lipsitz scale is commonly used
▪ Neonatal Narcotic Withdrawal Index(NNWI)
▪ Neonatal Withdrawal Inventory (NWI)
▪ Withdrawal Assessment Tool (WAT-1)
Jansson & Velez, 2012
Hospital protocols and practices related to nonpharmacological and pharmacological treatment approaches can affect NAS severity and duration.
Avoid the NICU setting in favor of “rooming in” mother and baby or a neonatal nursery.
Optimal environmental conditions for neonates exposed to opioids in utero include minimal stimulation, dim light, and low noise. Low music may help some newborns.
Rooming in allows for skin contact and breastfeeding(shown to reduce NAS) and improved maternal bonding.
Rooming In
Abrahams et al., 2007, 2010; Hodgson and Abrahams, 2012; Newman et al., 2015
Active Caregiver Participation
Hudak & Tan, 2012; Kocherlakota, 2014
Active maternal participation in care and handling by caregivers is beneficial:
▪ Skin-to-skin contact (kangaroo care)
▪ Holding, cuddling, gentle handling
▪ Pacifiers, swaddling
▪ Frequent feeding, breastfeeding
Early detection of and response to NAS symptoms is important: at first sign of irritability neonates should be soothed.
Breastfeeding
Evidence suggests that breastfeeding decreases NAS scores,the need for treatment, length of pharmacological therapy, and length of hospital stay in infants prenatally exposed to methadone or buprenorphine.
Abdel-Latif et al., 2006; Pritham et al., 2012; Welle-Strand et al., 2013
Abdel-Latif et al., 2006; Pritham et al., 2012; Wachman et al., 2013; Welle-Strand et al., 2013.
Breastfeeding is contraindicated if the mother is HIV positive or using illicit drugs or select prescribed medications.
If the patient is taking short-acting opioids for pain, advise breastfeeding before taking the medication.
The FDA recommends caution in use of tramadol or codeine when breastfeeding with ultrarapidmetabolizers.
Special considerations:
Opioids and Adjunctive Medications
Morphine sulfate is the most common medication used to treat NAS.
Methadone is also common. Can be more difficult to titrate than morphine due to longer half-life.
Buprenorphine is a newer addition. In a recent clinical trial, buprenorphine showed shorter treatment and hospital stay duration than morphine.
Opioids are the first-line NAS treatment:
Adjunctive medications can reduce NAS treatment duration:
Clonidine aids in treating the signs and symptoms of NAS.
Phenobarbital lowers the cumulative dose of opioids needed.Brown et al., 2014; Kraft et al., 2017
Historically, treatment protocols have used weight-based or symptom-based dosing. Comparative studies are needed. Evidence suggests that adherence to a treatment protocol shortens length of treatment and length of stay.
Patrick et al., 2016
Maternal Postpartum Care
After Delivery
Monitor the patient for sedative effects of agonist and other postpartum medication
Coordinate hospital release with the opioid agonist provider so the patient does not have an interruption in medication
.
If dosage increased during pregnancy, plan for decreasesbased on symptoms
Remind the patient to return on schedule to her methadone or buprenorphine provider
Immediate Postpartum Period
Discuss contraceptives and sexually transmitted infection prevention plans
Rescreen and reassess needs, including screening for postpartum depression and anxiety
Revisit treatment plan especially related to substance use supports, mental health care, and pain management
Ensure that the patient has a postpartum care plan and that linkages to other services have occurred
Continue to monitor for need for dosage decrease
Ongoing Routine Care
Ask about breastfeeding
Screen for postpartum depression
Screen for substance use, cravings, and withdrawal symptoms
Continue to offer or ask about in-home support such as home visiting and recovery coach services
MODULE 3
KEY POINTS
For monitoring and treatment plan adjustment:
Continue use of monitoring tools
Use affirmations to support patient’s progress
Provide additional resources and referrals as patient’s needs change
Be conscious of dosage adjustment needs, especially in patients on methadone
Key Point
For pain management in delivery and postpartum, expect that patients will need:
Clear communication about plan for pain management in childbirth
Multimodal pain management, including epidurals, and higher opioid dosage (prn)
Uninterrupted opioid agonist treatment, if applicable
Key Point
Optimal neonatal care includes:
Promote rooming in to provide a low-stimulation environment and maternal bonding
Skin-to-skin contact, soothing, breastfeeding, frequent feeding
If needed, opioids as the first-line pharmacological treatment
Key Point
For maternal postpartum care:
Monitor for sedative effects of opioid agonist therapy
Screen for postpartum depression, substance use, and pain management
Revisit referral and resource needs
Key Point
Sarah’s Summary (Video)
Dr. Jones’ Summary
congratulations!you have completed Module 3