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



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Systemic - impede the development of services that respond to women’s needs.

  • Systemic - impede the development of services that respond to women’s needs.
  • Structural - policies and practices at the service or program level that make it difficult for women to access substance use treatment.
  • Social, Cultural, and Personal
  • Specific Barriers for Women

Adequate treatment period is crucial

  • Adequate treatment period is crucial
  • Individual & group counseling (women only)
  • Co-occurring disorders treated in an integrated way
  • Medication as needed
  • Empowerment model and strengths perspective
  • Recovery is a long term process & frequently requires multiple treatment episodes
  • Elements of Effective Women’s Treatment

The Power Of Words To Hurt Or Heal

  • The Rhetoric of Recovery Advocacy: An Essay On the Power of Language W.L.White; E.A Salsitz, MD., Addiction Medicine vocabulary; Substance Use Disorders: A Guide to the Use of Language Prepared by TASC, Inc. Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (DHHS), rev. 4.12.04
  • Stigmatizing Words
  • Preferred Words
  • Addict, Abuser, Junkie
  • Person in active addiction, person with a substance
  • misuse disorder, person experiencing an alcohol/drug problem, patient
  • User
  • Abuse
  • Misuse, harmful use, inappropriate use,
  • hazardous use, problem use, risky use
  • Clean, Dirty
  • Habit or Drug Habit
  • Substance misuse disorder, alcohol and drug
  • disorder, alcohol and drug disease, active addiction
  • Treatment, medication-assisted treatment,
  • medication
  • Substance Use Disorders During Pregnancy
  • Few medications are successful in the treatment of any substance use disorders, except for alcohol and opioids.
  • Opioid medications such as methadone and buprenorphine can be successful components in treating opioid use disorder, both in the general population and in pregnant women.
  • Opioid medications are best provided in the context of a comprehensive treatment plan that includes behavioral treatment like individual counseling.
  • A comprehensive treatment plan is developed following an assessment that determines which life areas have been affected by drug use and to what extent they have been affected.
  • The patient and provider then develop specific goals for improved life functioning in each life area and a plan for how and when the goals will be met.
  • Part of the plan may eventually include wellness indicators of when patients can taper off of their medication.
  • Screen
  • Assess
  • Plan/
  • Treat
  • Evaluate

Maintenance pharmacotherapy on an opioid-agonist medication such as methadone or buprenorphine is defined as treatment with medication for an indefinite period by fixing and maintaining the level of the opioid in an individual, in order to avoid the craving and withdrawal symptoms that abstinence from illicit opioids would produce.

  • Maintenance pharmacotherapy on an opioid-agonist medication such as methadone or buprenorphine is defined as treatment with medication for an indefinite period by fixing and maintaining the level of the opioid in an individual, in order to avoid the craving and withdrawal symptoms that abstinence from illicit opioids would produce.
  • Medication-assisted withdrawal (sometimes termed ‘detoxification’ or tapering) provides consecutively smaller doses of a medication such as methadone or buprenorphine as well as non-opioid-agonists to provide a ‘smooth’ transition from illicit opioid use to a medication-free state.
  • “Withdrawal from opioid dependence is uncomfortable, but not life-threatening for a woman who is not pregnant. However, for pregnant women who are opioid-dependent, abrupt withdrawal from opioids can be life-threatening to the fetus.” 
  • Kaltenbach et al., Obstet Gynecol Clinics N Am 1998
  • WHO 2014 Guidelines: “Pregnant women dependent on opioids should be encouraged to use opioid maintenance treatment whenever available rather than to attempt opioid detoxification. Opioid maintenance treatment in this context refers to either methadone maintenance treatment or buprenorphine maintenance treatment.”
  • Guidance regarding maintenance versus medication-assisted withdrawal has traditionally been based largely on good clinical judgment.
  • Medication followed by no medication treatment has frequently been found to be unsuccessful, with relatively high attrition and a rapid return to illicit opioid use.
  • Maintenance medication facilitates retention of patients and reduces substance use compared to no medication.
  • Biggest concern with opioid agonist medication during pregnancy is the potential for occurrence of neonatal abstinence syndrome (NAS) – a treatable condition.
  • The SAMHSA/CSAT Principles of Recovery state that there are many roads to recovery.
  • Medications such as methadone or buprenorphine have been used to achieve and sustain recovery. There may also be times when patients want to discontinue their medications.
  • Factors to consider in medication-assisted withdrawal:
  • A complete medical and psychosocial assessment
  • What is motivating the woman to discontinue her medication?
  • Is she pregnant? Is there obstetrical/medical care? Is she post-partum?
  • What positive relationships does she have in place in her life?
  • What is the plan for her and her children if she relapses?
  • What is the plan if she wants to stop the medication-assisted withdrawal?
  • e.g., Jarvis & Schnoll, 1995; Kaltenbach et al., 1998
  • Maintenance v. Medication-Assisted Withdrawal
  • Very slow methadone or buprenorphine taper in pregnancy recommended only if in stable recovery
  • • Taper methadone or buprenorphine by 2 mg on any given day, AND not more than 2–4 mg/week
  • • Stop if signs or symptoms of withdrawal become uncomfortable
  • • Monitor pregnancy
  • • Increase frequency of visits and urine drug screens
  • Maintenance v. Medication-Assisted Withdrawal
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