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

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Why Use Opioid Medications?

  • With opioid medications we are not replacing one addiction for another. Opioid medications are long-acting medication that help with:
  • An individual’s cravings are controlled
  • Individual is no longer compulsively using opioids
  • Medication-assisted treatment gives back control to the individual
  • Medication assisted treatment helps the individual focus on rebuilding her life
  • An individual receiving opioid pharmacotherapy must be monitored by a medical team that evaluates adequacy of medication dosage and general health and well-being of the individual.
  • Gerra Long-Acting Opioid-Agonists in the Treatment of Heroin Addiction: Why Should We Call Them “Substitution”? Substance Use & Misuse, 44:663–671
  • Review in Kaltenbach et al., Obstet Gynecol Clin North Am, 1998
  • Pharmacotherapy for Opioid Dependence
  • Prevents erratic maternal opioid levels that occurs with use of illicit opioids, and so lessens fetal exposure to repeated withdrawal episodes.
  • Reduces maternal craving and fetal exposure to illicit drugs.
  • Produces drug abstinence, that in turn allows other behavior changes which decrease health risks to both mother and fetus (for example: HIV, hepatitis, and sexually transmitted infections).
  • Reduces the likelihood of complications with fetal development, labor, and delivery.

Schedule II opioid

  • Schedule II opioid
  • Synthetically derived
  • μ opioid receptor agonist
  • Also uniquely a δ-opioid receptor agonist
  • Antagonist at NMDA receptors
  • Half-life estimated to fall in the range of 24-36 hours
  • It is one part of a complete treatment approach
  • Methadone

Can be provided in inpatient or outpatient settings

  • Can be provided in inpatient or outpatient settings
  • Patients typically begun on methadone when they are in mild withdrawal from opioids
  • Patients cannot be using benzodiazepines and alcohol before beginning methadone treatment in order to minimize chances of over sedation
  • Patients typically begin their methadone dosing under observation; first dose is small; observe for possible negative effects
  • Assuming no negative reactions to initial doses of methadone, dose is systematically increased until it prevents withdrawal, cravings, and possible continued use of illicit opioids
  • Methadone: Starting and Dosing
  • There is no ‘correct’ dose; optimal dose varies greatly between patients
  • Blood concentrations of patients on an equivalent dose, adjusted for body weight, have been estimated to vary between 17- and 41-fold
  • Dosing does not have to be more complicated for pregnant patients

In the 1970s, a positive relationship between maternal methadone dose and NAS severity was reported.

  • In the 1970s, a positive relationship between maternal methadone dose and NAS severity was reported.
  • Recommendations to maintain pregnant women on methadone doses between 20 to 40 mg.
  • 3 decades of research shows an inconsistent relationship between maternal methadone dose and NAS severity.
  • The latest systematic review and meta-analysis concluded that the “Severity of the neonatal abstinence syndrome does not appear to differ according to whether mothers are on high- or low-dose methadone maintenance therapy.”
  • Review in Cleary et al., Addiction, 2010
  • Methadone: Dosing During Pregnancy
  • Split Dosing
  • Maternal Results
    • Increase drug negative urines during treatment
    • Increased adherence with treatment
    • Decrease withdrawal symptoms in mother
    • No change in maternal heart rate, vagal tone or skin conductance
  • Fetal Results
  • Methadone: Dosing During Pregnancy
  • DePetrillo et al., 1995; Swift et al., 1989; Wittmann et al.,1991; Jansson et al., 2009
  • Credit: “Human Fetus” by ddpavumba; “Smiling Pregnant Female Holding Her Tummy” by imagerymajestic
  • Methadone-associated NAS
  • 55-90%
  • ~ 60%
  • 45 to 72 hrs
  • 40 to 120 hrs
  • NAS signs
  • Requiring medication
  • NAS appears
  • NAS peaks
  • Most common medication for treatment is morphine
  • Most common assessment tool is a “modified” Finnegan scale
  • No current standard uniform protocol for treatment
  • Methadone: NAS
  • Image Credit: “Sleeping Asian Baby” by hin255
  • General Recommendations
  • Uninterrupted methadone maintenance treatment
  • Aggressive pain management with behavioral interventions (for example: breathing exercises) and use of non-opioid pain-relief medications (e.g., acetaminophen)
  • Adjust the dose of opioid pain relief medications to achieve adequate pain relief (generally higher doses of opioid pain relief medications administered at shorter intervals)
  • Reduce anxiety of patient and treatment team with clear open communication (especially important in patients with post-traumatic stress disorder as fear of pain is elevated in adults with co-occurring trauma-related stress and social anxiety symptoms)
  • Methadone: Pain Management
  • Alford, et al., 2006; Asmundson et al., 2005
  • Image Credit: “Pills” by amenic181
  • N=101 methadone-maintained pregnant women 2, 6, and 12 weeks postpartum, and compared the incidence of having doses held for over-sedation during pregnancy and postpartum.
  • The average dose at delivery was 83.3mg and mean change from delivery to 12 weeks postpartum was -3.7 mg (95% CI: -6.3, -1.1).
  • After adjusting for benzodiazepine prescriptions, the IRR of an over-sedation event among postpartum women compared to pregnant women was 1.74 (95% CI: 0.56, 5.30).
  • Postpartum dose changes were small in a methadone clinic using clinical assessments to determine dose.
  • The findings suggest that more frequent clinical assessments continuing as late as 12 weeks postpartum may be warranted.
  • Methadone: Postpartum Dosing
  • Pace et al., J Subst Abuse Treat 2014
    • Breastfeeding in
    • Methadone-Stabilized Mothers
    • Methadone detected in breast milk in very low levels
    • Methadone concentrations in breast milk are unrelated to maternal methadone dose
    • The amount of methadone ingested by the infant is low
    • The amount of methadone ingested by the infant remains low even 6 months later
    • Several studies show relationships between breastfeeding and reduced NAS severity and duration
    • Hepatitis C is not a contraindication for breastfeeding
    • Contraindications: HIV+, unstable recovery
  • D'Apolito, 2013; AAP 2012; McQueen et al., 2011; Jansson et al., 2007; Jansson et al., 2010
  • Methadone: Breastfeeding
  • Image Credit: “Mother Is Breast Feeding For Her Baby” by Jomphong
  • Research focusing on the effects of prenatal exposure to methadone has been inconsistent
  • Long-term effects on physical growth have not been demonstrated.
  • Although some research has shown that methadone-exposed school-age children to be less interactive, more aggressive, and showing poorer achievement than children not so exposed, other research has failed to show any differences in either cognitive or social development.
  • The issue is confounded by the fact that children exposed to methadone in utero may experience a nutritional, family, and parenting history quite different than children not so exposed.
  • 2014 meta-analysis of prenatal opioid exposure that included methadone showed “no significant impairments for cognitive, psychomotor or observed behavioral outcomes for chronic intra-uterine exposed infants and pre-school children compared to non-exposed infants and children.”
  • Baldacchino et al., BMC Psychiatry 2014; Behnke et al., Pediatrics, 2013; Farid et al., Curr Neuropharm, 2008
  • Image Credit: “Lady Doctor Measuring Girls Height” by David Castillo 

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