10/27/2016 Opioids in Pregnancy Megan J. Huchko, MD, MPH Associate Professor in I have no financial or other conflicts of interest to declare Obstetrics and Gynecology and Global Health Duke University UCSF Ob/Gyn Update October 27, 2016 Women, Opioids and Pregnancy Women, Opioids and Pregnancy 1
10/27/2016 Women, Opioids and Pregnancy Learning Objectives • Understand Epidemiology of Substance Use and Opioid Use in Pregnancy • Learn effects of opiate use on mom, baby and pregnancy • Options for treatment in pregnancy • Understand how the current political climate impacts care for pregnant women who use opioids 1. What proportion of pregnant Rates of Substance Use in Pregnancy women use illicit substances? • Most common drugs in pregnant and non- pregnant women are tobacco and alcohol A. 25% • 11.4% of non-pregnant women age 15-44 use 41% B. 10% illicit drugs 31% • 5.4% of pregnant females report use of illicit 21% C. 5% drugs in past month – Many women who report are using more than one D. <1% 7% substance • National Survey on Drug Use and Health, SAMHSA, 2014 • Pregnancy and Substance Use, Drug War Facts, 2015 2
10/27/2016 Rates of Opioid Use in Pregnancy Trends in Illicit Drug Use in Pregnancy • Difficult to find accurate statistics on use versus misuse • Age: Younger women more likely • One in three pregnant women will fill a prescription for to use substances in pregnancy opioid pain medication – 15-17 yrs: 14.6% • Approximately 0.2% pregnant women used heroin and 1% – 18-25 yrs: 8.6% reported using opioid pain relievers non-medically in past month 1,2 – 26-44 yrs: 3.2% – Study showed 2.6% detection of opioids in urine 2 • Duration of Pregnancy: reported • Between 2000 and 2009, number of pregnant women using or misusing prescription opioids increased from 1.2 to 5.6 drug use decreases with each per 1,000 births trimester – NAS increased from 1.2 to 3.4 per 1,000 births • No identifiable relation to SES • 1% of CA-born neonates are exposed to opiates, majority from illicit use in pregnancy • National Survey on Drug Use and Health, SAMHSA, 2014 1. SAMHSA, 2011-2012 • Pregnancy and Substance Use, Drug War Facts, 2015 2. Azadi, Am J Obstet Gyncol 2008 Opioids and mechanism of action Opioid Dependence vs Addiction • Opioids include • – Opiates: Opioid use changes structure and metabolism of brain • Morphine, Codeine, Thebaine • Physiologic dependence means steady dose necessary to achieve – Synthetics: steady state • Oxycodone (OxyContin, Percocet) – Increasing dose necessary for euphoria • Hydrocodone (Vicodin, Norco) • Hydromorphone (Dilaudid) • Once dependence occurs, a withdrawal syndrome occurs when • Heroin* drug not present • Methadone • Addiction to opioids characterized by: • Fentanyl – Inability to abstain • Nubain • Buprenorphine – Significant problems with interpersonal relationships • Taken as pills, suppositories or patches; smoked, inhaled, or – Impaired behavioral control – Cravings injected (ASK!) • Bind to receptors in the pleasure center in the brain (central – Dysfunctional emotional response • tegmental area) Often involves cycles of relapse and – μ-euphoria, respiratory depression, constipation, sedation, miosis remission – Κ- dysphoria, sedation, psychotomimetic • Addic�on ≠ Dependency ≠ Abuse – Δ – unknown • Agonists release dopamine, serotonin and GABA/NMDA 3
10/27/2016 Pregnancy and Opioid Use: A Complex Opiate Withdrawal Dynamic Early Withdrawal Symptoms 6-30hrs Late Withdrawal Symptoms > 72 hrs • 86% of pregnant opioid-using women reported • Excessive tearing • Nausea and vomiting • Diarrhea • Muscle Aches that their pregnancy was unplanned • Pregnancy increases desire and ability to change • Goosebumps • Agitation • Difficulty sleeping • Stomach cramps drug use: – Motivational interviewing in pregnancy promotes • Depression • Anxiety • Drug cravings • Nose running abstention – Compared to non-pregnant women, pregnant women • Sweats are more likely to remain drug free (65.7% vs 27.7%) • Tachycardia/palpitations – 57% of pregnant women who use illicit substances • Hypertension reported abstaining during pregnancy • Fever Withdrawal is a painful, but self-limited process for adults, but can cause Ebrahim, Obstet & Gyencol 2003 permanent damage or death to the fetus Heil SH, J Subs Abuse and Treatment, 2011 Issues facing substance-using women Opioid-Related Pregnancy and their children Complications • Exposure to violence and • Multiple drug exposures • ? CHD • PPROM • Limited parenting skills trauma • Infections • Fetal meconium • Generational drug use and resources – Cellulitis/Abscess • Placental Abruption • Lack of formal education • History of child abuse and – Endocarditis • Fetal death • Lack of job acquisition neglect – Osteomyelitis • Co-morbid psychiatric and maintenance skills – Hepatitis/HIV • Gender inequality/male- issues – Septic thrombophlebitis • Unstable housing focused society • IUGR/LBW Most of these are related • Legal involvement • Lack of positive and to chronic, untreated • Miscarriage • Food insecurity and poor supportive relationships heroin use • Premature labor/PTB nutrition These factors would influence maternal and child outcomes with or without drug use Kaltenbach, K. et al. Obstet Gynecol Clin North Am. 1998 ACOG Committee Opinion. Health Care for Underserved Women and The American Society of Addiction Medicine. 2012 4
10/27/2016 Neonatal Abstinence Syndrome Screening for Opioid Use in Pregnancy • • ACOG recommends screening all pregnant women for Results in approximately 50-90% of babies born to women using opioids in pregnancy • substance use/abuse before pregnancy and in first Defined by alternations in the Neonatal – Central nervous system Abstinence trimester • High-pitched crying, irritability Syndrome is NOT • Exaggerated reflexes, tremors and tight muscles • Be aware of signs and symptoms that may prompt re- • Sleep disturbances Fetal Alcohol – Autonomic nervous system Syndrome: It is screen • Sweating, fever, yawning and sneezes – treatable and there Gastrointestinal distress – Late to care • Poor feeing, vomiting and loos stools are no known long- – – Poor attendance at prenatal visits Signs of respiratory distress term consequences • Nasal stuffiness and rapid breathing • – Signs of sedation, withdrawal or intoxication Can relate in fetal distress and death • Maternal smoking increases risk for and severity of NAS – Physical signs of injection or complications • Protocols vary, but mainstay is supportive care and morphine, some • Substance users come from all SES, race and age: the clonidine or phenobarb necessary – Treatment necessary in approx 50% of NAS cases only way to identify appropriately is to ask ALL • Public health and medical costs for NAS $70.6 to $112.6 million in US in 2009 alone How do you screen? Screening Tools 4 Ps CRAFFT • Normalize the screening • • Have you ever ridden in a CAR driven by – Ask ALL pregnant women at their first visit P arents: Did any of your someone (including yourself) who was parents have a problem with – Explain that you ask to be able to provide the care they high or who had been using drugs? alcohol or drug use? • • require for themselves and their fetuses Do you ever use alcohol or drugs to P artner: Does your partner • Maintain caring and nonjudgmental approach RELAX , feel better about yourself or fit have a problem with alcohol or drug use? in? • Several screening tools work • • Do you ever use alcohol or drugs while P ast: In the past, have you had – 4 Ps (or 5 Ps) you are by yourself or ALONE ? difficulties in your life because – CRAFFT • of medications and drugs, Do you every FORGET things you did including prescription while using alcohol or drugs? • Urine drug testing is an adjunct to detect or confirm medications? • Do your FAMILY or friends every tell you • use P regnancy: In the last month, that you should cut down on your – Should only be used with patient’s consent and in have you drunk any alcohol or drinking or drug use? used any drugs? • compliance with state laws Have you ever gotten into TROUBLE while you were using alcohol or drugs? 5
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