Treating Pregnant and Parenting Women for Substance Use Disorders: Behavioral and Medication Strategies



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Treating Pregnant and Parenting Women for Substance Use Disorders: Behavioral and Medication Strategies

  • Hendrée E. Jones, PhD
  • Executive Director, Horizons Program
  • Professor, Department of Obstetrics and Gynecology
  • School of Medicine, University of North Carolina at Chapel Hill
  • This product is supported by Florida Department of Children and Families
  • Substance Abuse and Mental Health Program Office funding.

Objectives

  • 1.      Examine different behavioral interventions and medication assisted treatments for increasing treatment engagement and reducing drug use among pregnant and/or parenting women
  •  
  • 2.      Identify the issues that increase neonatal abstinence signs and symptoms and examine different evidence-based strategies to help support resilience among children who have been prenatally opioid-exposed
  •  
  • 3.    Articulate Block Grant requirements for pregnant and parenting women
  • First page credits: “side view of pregnant woman” by imagerymajestic; “mother-child-family-happy-love-1039765/” by the danw; “family eating at the table” by skeeze

Acknowledgements

  • Study patients and infants
  • National Institute on Drug Abuse
    • R01 DAs: 015764, 015738, 017513, 015778, 018410, 018417, 015741, 15832
  • Maternal Opioid Treatment: Human Experimental Research (MOTHER) Site PIs and investigative teams

Disclosures

  • Discussing 2 medications, methadone and buprenorphine, currently labeled by the US Food and Drug Administration (FDA) as Category C for use in pregnancy for the treatment of maternal opioid dependence: “Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.”
  • Pregnant women with opioid use disorders can be effectively treated with methadone or buprenorphine. Both these medications should not be considered “off-label” use in the treatment of pregnant patients with opioid use disorders.
  • Reckitt-Benckiser Pharmaceuticals for donated active placebo tablets and reimbursement for time and travel in 2011.
  • Substance use during pregnancy in the USA has been a long-standing important health issue. In the 1800s:
  • 66–75% of individuals with opium use disorders were women.
  • Women’s most common opium source was medical prescriptions to treat pain.
  • Physicians recognized neonatal opioid withdrawal and the need to treat in utero opium exposure with morphine in order to prevent morbidity and mortality.
  • Following the1914 Harrison Narcotic Act, the treatment of substance use disorders was segregated from mainstream medical practice.
  • Kandall, Substance and shadow, 1996. Earle, Medical Standards, 1888
  • Credit: Still from The Dividend, 1916. public domain.
  • By the 1900s physicians became better educated about the drawbacks of prescribing narcotics, and legitimate supplies of narcotics then shrank.
  • Women unable to stop using substances were forced to seek them from illegitimate sources.
  • Passage of the Harrison Narcotic Act of 1914 greatly changed narcotic prescribing and dispensing practices, requiring that addictive substances needed to be prescribed by a licensed health professional.
  • Some enlightened physicians treated opioid addiction with morphine.
  • In 1919, this practice was prohibited by the Supreme Court.
  • Result: Segregation of the treatment of substance use disorders from general medical practice
  • Kandall, Substance and shadow, 1996

First Medication to Treat Opioids

  • Methadone was developed and first used as an analgesic in Germany prior to World War II.
  • First utilized in the United States in the 1940s for medication-assisted withdrawal for heroin-addicted individuals, using decreasing doses over a 7-10 day period.
  • Follow-up research found relapse rates exceeding 90%.
  • In the 1960s, Dole and Nyswander found that heroin-dependent patients could be safely maintained on methadone.
  • Effective dosing leads to tolerance and a reduction or elimination of craving for heroin.
  • In 2012, an estimated 23.9 million Americans age 12 or older – 9.2% of the population – had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month.
  • This number is up from 8.3% in 2002.
  • Current Context of Drug Use in the USA
  • National Survey on Drug Use and Health (NSDUH),  2012
  • Most common medications that are misused
  • Painkillers containing:
    • Hydrocodone, such as Vicodin, 
    • Oxycodone, such as Percocet 
    • Oxycontin
  • Benzodiazepines:
    • Lorazepam (Ativan)
    • Alprazolam (Xanax)
  • Americans consume 80 percent of the world's supply of painkillers – more than 110 tons of pure, addictive opiates every year. That is 64 Percocet or Vicodin per every US Citizen.
  • Current Context of Drug Use in the USA
  • http://www.dailymail.co.uk/news/article-2142481/Americans-consume-80-percent-worlds-pain-pills-prescription-drug-abuse-epidemic-explodes.html#ixzz3a6bgFNoA CDC 1/22/15 Opioid painkillers widely prescribed among reproductive age women
  • Opioid Painkiller Prescribing: Where You Live Makes a Difference
  • July 2014
  • Each day, 46 people die from an overdose of prescription painkillers in the US.
  •                
  • Health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills.
  • 10 of the highest prescribing states for painkillers are in the South.
  • Where You Live Matters
  • Florida has worked hard to reduce this rate!
  • Where You Live Matters: Florida
  • Until recently Florida was known as the “OxyContin Express.” Florida became the epicenter of prescription drug diversion because of a proliferation of “pill mills.”
  • Florida instituted “Strike Forces” to reduce the supply of diverted medications, and it implemented a Prescription Drug Monitoring Program (PDMP) in 2009.
  • Image credits and credits: Florida Statewide Task Force on Prescription Drug Abuse and Newborns: 2014 Progress Report
  • Where You Live Matters: Florida
  • Neonates and Prescription Medication Misuse in Florida
  • The number of newborns diagnosed with drug withdrawal symptoms quadrupled over the past five years, while the number of all live births in Florida has steadily decreased.”
  • Image credit and credits: Florida Statewide Task Force on Prescription Drug Abuse and Newborns: October 2012
  • Where You Live Matters: Florida
  • Neonatal Abstinence Syndrome
  • “In Florida, NAS has increased from 592 (of 231,417) live births in 2008 to 1,411 (of 213,237) live births in 2011.”
  • “The number of hospital discharges of newborns diagnosed with NAS has increased 10-fold in Florida since 1995, far exceeding the 3-fold increase observed nationally.”
  • “… reporting of NAS varies by hospital because there is no statewide standardization for the diagnosis and reporting of substance exposed newborns. Consequently, statewide NAS data are likely underreported.”
  • Credits: Florida Department of Health MCH Brief
  • Where You Live Matters: Florida
  • Florida is in the process of implementing a number of health and public health campaigns to reduce the occurrence of NAS, including outreach efforts to encourage pregnant women who are using substances to enter treatment.
  • These efforts are vitally important given that only 10.3% of mothers of babies with confirmed NAS received a referral for or counseling for substance use or use disorders.
  • Credits: Lind et al., 2015 MMWR by the CDC
  • Prescription Painkiller Overdoses
  • A growing epidemic, especially among women
  • July 2013
  •                                                                         
  •                                   
  •              
  • Nearly 48,000 women died of prescription painkiller* overdoses between 1999 and 2010.
  • Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% among men.
  • For every woman who dies of a prescription painkiller overdose, 30 go to the emergency department for painkiller misuse or abuse.
  • Chronic Pain Relative to Other Chronic Issues
  • A retrospective, serial, cross-sectional analysis of a nationally representative sample of newborns with NAS.
  • Clinical conditions were identified using ICD-9-CM diagnosis codes.
  • NAS and maternal opiate use were described as an annual frequency per 1000 hospital births.
  • 2000 2003 2006 2009
  • 2000 2003 2006 2009
  • Low Respiratory Medicaid
  • Birthweight Diagnoses Coverage
  • in the United States – one infant every hour – suffers from neonatal abstinence syndrome (NAS)
  • Why are more individuals, including pregnant women, using opioids?
  • There has been an increase in the access to these medications.
  • Pain became the 5th vital sign in the early 21st century.
  • Federal prosecutors allege in documents filed in U.S. District Court that Chris and Jeff George from Florida dramatically increased the numbers of pain clinics in Florida and routed opioid pain medications to Kentucky, Ohio and South Carolina.
  •  
  • Current Context of Opioid Use During Pregnancy
  • Image Credit: “Back Pain During Pregnancy” by imagerymajestic
  • The two most common drugs used by non-pregnant women have been alcohol and tobacco.
  • This same statement is true for pregnant women.
  • Among pregnant women in the United States, approximately 16% used tobacco products, 9.4% drank alcohol, and 5% used illicit drugs in the past month.
  • National Survey on Drug Use and Health 2012/13 Past Month Use
  • SAMHSA Office of Applied Statistics, 2011-2012
  • Because it is very unusual for a women to initiate new drug use during pregnancy, it is important to ask all women about substance use:
    • Before pregnancy
    • In their family
    • By their partner
    • By their peers
  • Current Context of Opioid Use During Pregnancy
  • Prenatal Opioid Exposure and Neonatal Withdrawal
  • Neonatal Abstinence Syndrome (NAS) often results when a pregnant woman uses opioids (e.g., heroin, oxycodone) during pregnancy.
  • Defined by alterations in the:
    • Central nervous system
      • high-pitched crying, irritability
      • exaggerated reflexes, tremors and tight muscles
      • sleep disturbances
    • Autonomic nervous system
      • sweating, fever, yawning, and sneezing
    • Gastrointestinal distress
      • poor feeding, vomiting and loose stools
    • Signs of respiratory distress
      • nasal stuffiness and rapid breathing
  • NAS is not Fetal Alcohol Syndrome (FAS)
  • NAS is treatable
  • NAS and treatment are not known to have long-term effects; interactions between the caregiver and child can impact resiliency/risk with potential long-term effects in some cases.
  • Finnegan et al., Addict Dis. 1975; Desmond & Wilson, Addict Dis. 1975
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