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J Weeks- Opiate Addiction - OB Challenges · A Medical Treatment for Diacetylmorphine (Heroin)...
Transcript of J Weeks- Opiate Addiction - OB Challenges · A Medical Treatment for Diacetylmorphine (Heroin)...
Jonathan Weeks, M.D., D.A.B.A.M.Norton Maternal-Fetal Medicine SpecialistsDirector, Prenatal Addiction ProgramOffice (502) 899-6900Google Voice (502) [email protected]
Opiate Addiction in Pregnancy
Opiate Addiction
❖ Epidemiology
❖ Neurobiology of addiction
❖ Treating Opiate Addiction in Pregnancy
❖ Continuing challenges
Opiates-Perinatal M & M
❖ Perinatal
❖ 2-3 fold increase in PTB
❖ LBW
❖ Stillbirth
❖ Neonatal Abstinence syndrome
What’s wrong with those people!$#@*
Illicit Drug Use
Young, dumb & full of…
❖ 12-17 years old: 12%, report prescription opiate abuse
❖ 18-25 years old: 22%
❖ Avg. age of first Heroin .....
❖ 21 years
Addiction - multiple factors
Di Chiara et al., Neuroscience, 1999.,Fiorino and Phillips, J. Neuroscience, 1997.
Natural Rewards Elevate Dopamine Levels
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Brain Reward Pathway
A Medical Treatment for Diacetylmorphine (Heroin) Addiction
JAMA 1965, Dr.s. Vincent Dole and Marie Nyswander
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Methadone Treatment
❖ Prevent withdrawal
❖ Reduce drug cravings
❖ Block euphoria from illicit opiates
❖ Reduce needle-sharing and criminal behavior
❖ HIV, STIs, hepatitis, exposure to violence
Withdrawal in Pregnancy
❖ Rementeria and Nunag AJOG Aug 1973
❖ Perinatal death in 6 of 46 heroin pregnancies acutely withdrawn from heroin or methadone
Methadone Withdrawal
❖ Zuspan AJOG May 1975
Methadone Maintenance in Pregnancy
❖ Compared to untreated (heroin), methadone maintenance therapy...
❖ ⬆prenatal visits
❖ ⬆compliance with HIV meds
❖ ⬇preterm birth
❖ ⬇IUGR
Methadone Treatment
❖ “Methadone maintenance treatment (MMT) is the current standard for the treatment of Opiate dependence in pregnancy” ... Obstetrics: Normal & Problem Pregnancies, 5th Ed
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Buprenorphine❖ Partial agonist
❖ Can produce euphoria
❖ Can precipitate withdrawal in patients on morphine, methadone
❖ Combined with naloxone
❖ Suboxone, Zubsolv, Bunavail
❖ Mono therapy - Subutex
❖ Randomized double-blind, double-dummy
❖ Primary outcome NAS
❖ 175 patients randomized
❖ Discontinuation
❖ 16 of 89 (18%) - methadone
❖ 28 of 86 (33%) - buprenorphine
❖ NAS
❖ methadone 57%
❖ buprenorphine 47%
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Norton Prenatal Addiction Program (502) 559-4375
❖ New Visions for Expectant Mothers
❖ Admission, stabilization and follow up
❖ Norton Maternal-Fetal Medicine
❖ Inpatient care for New Visions admissions
❖ Outpatient consultation & monitoring
Norton Prenatal Addiction Program
❖ New Visions for Expectant Mothers
❖ Admission, stabilization and follow up
❖ Norton Maternal-Fetal Medicine
❖ Inpatient care for New Visions admissions
❖ Outpatient consultation & monitoring
New Visions
❖ Admission & stabilization
❖ No prenatal care ER drop in
❖ Prenatal care… addiction reported or discovered
New Visions
❖ Substances abused?
❖ Severity
❖ Barriers to treatment
❖ Pre-admission counseling
New Visions
❖ No illicit substances for at least 24 hours
❖ Patient presents for admission in withdrawal
❖ Assessment by New Visions staff
❖ Not intoxicated, in withdrawal
❖ Medical evaluation, obstetrical evaluation and treatment
Lab Evaluation❖ CBC, CMP, Urine culture
❖ Witnessed urine toxicology screen daily
❖ Include methadone and buprenorphine
❖ Serum gabapentin level?
❖ Blood alcohol
❖ Hepatitis A, B, C and HIV
❖ TB skin test
❖ Cervical cultures
❖ OB ultrasound, cervical length
Clinical Evaluation
❖ Clinical Opiate Withdrawal scale q 4-6 hours X 48 hours
❖ Fetal monitoring (NST) twice daily
Medications❖ 1/2 NS with 20 KCl plus one ampule multivits daily
❖ EtOH? - thiamine
❖ GI: Antiemetics, antidiarrheal❖ Pain:
❖ acetaminophen
❖ ibuprofen - limit to 48 hours❖ < 32 wks gestation
❖ Omit if oligohydramnios, fetal growth restriction, preeclampsia
Medications❖ gabapentin - for pain, restlessness, agitation
❖ 400 mg P.O. every 6 hrs prn
❖ Buprenorphine (Subutex)
❖ Initial - 4 mg. Consider repeat in 4-12 hours based on COWS and observation
❖ Add 4-6 mg following day, as needed
❖ Methadone - for those planning methadone maintenance
Weaning & Detoxification?
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• Detoxification can be done in pregnancy
• Rapid and slow wean protocols reviewed
• NO excess miscarriage in first trimester
• NO excess preterm birth in thirdJ Kentucky Med Assoc Oct 2010
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• 301 opiate-addicted pregnant patients were fully detoxified during pregnancy with no adverse fetal outcomes
• NAS - 94 newborns treated (31%)• 108 patients acutely detoxified while incarcerated, NAS 18.5%• 23 mothers had inpatient detox with intense outpt follow-up
management, NAS 17.4%• 93 slow output detox, NAS 17.2%• 77 inpt detox without intense outpatient follow up, NAS 70.1%
Challenges
J Adolesc Health. 2009 March ; 44(3): 283–290
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Beyond the womb, beyond the nursery
The Focus on Family Studies
Beyond the womb, beyond the nursery
• J Adolesc Health. 2009 March ; 44(3): 283–290
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• Opiate Addiction
•Social deprivation
•Economic disadvantage
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Is VERTICALLY transmitted!!!!!
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Addiction →Pregnancy
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• High pregnancy rates
• 25% of addicts -- 5 or more pregnancies
• Unplanned
• Poorer pregnancy outcomes, worse infant outcome
• Very low rates of contraception use
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Subs♀ance Abuse