Opiate Use in Reproductive Age Females

Transcription

1 Opiate Use in Reproductive Age Females February 15, :00 pm-3:00 pm ET In order to hear the presentation please call +1 (562) , access code All Participant Phone Lines are Muted at This Time

2 Opiate Use in Reproductive Age Females Julia A Riddle DO is a graduate of Michigan State's College of Osteopathic Medicine. She is currently a full time practicing family physician with obstetrics. She works in Northern Michigan's largest obstetrical group caring for their pregnant opiate dependent population. She has had her Buprenorphine waiver for over 6 years. In her free time she carpools her 6 children around, runs and practices yoga on, and off the mat.

3 Opiate Dependence in Reproductive Age Females Julia Riddle D.O. 2/15/2017

4 Objectives 1. Examine the frequency of opiate dependence in reproductive age females and its effects on the entire family unit. 2. Describe current evidence based treatment options for the opiate dependent pregnant female. 3. Review pitfalls to the treatment of the opiate dependant pregnant patient.

5 Epidemic? CDC report ⅓ of medicaid patients ¼ of private insurance patients 1 Deaths from opiate overdose among women have increased 400% since The national Institute of Drug Abuse reports that more than 21,000 infants born in the US experienced symptoms of withdrawal in Apx $50,000

6 Epidemic? 4.4% of pregnant women reported illicit drug use in the past 30 days 4 0.1% pregnant patients use heroin 4 1% opiate use for nonmedical purposes 5

7 What is the concern Gastroschisis H ydrocephaly Glaucoma Congenital heart defects ASD H ypoplastic Left H eart Atrioventricular septal defect Tetralogy of Fallot Pulmonary valve stenosis 6

8 What is the concern? Identifying patients Prevent transmission of disease Prevention of withdrawals in pregnant woman Identifying newborns who could exhibit NAS

9 Treatment Continue treating chronic condition Stop opiate Wean medication Begin maintenance treatment for an Opiate Dependence M ethadone Buprenorphine

10 Continue Treatment M ake sure chronic opiate treatment is ideal for your reproductive age female Discuss risks of opiates in pregnancy before continuing or initiating treatment If you have started them don t stop just because they are pregnant

11 Stop Opiate 1. Infrequent usage 2. No signs of dependence 3. Does not have withdrawals when stopping 4. Many will think the have this control and they actually do not

12

13 Wean Opiate M any are motivated Not recommended SAB PTL meconium passage NE/E6 H igh relapse rates Prefered in second trimester

14 Initiate Treatment Methadone is the gold standard (heroin) reduces fluctuations in opiate levels reduces drug seeking behavior avoid criminal activity and potential for high risk behavior Neonatal abstinence is expected and treated Well studied 1970s

15 Methadone Continued Increase doses in 3rd trimester Split dosing as metabolism increases Dosage does not always correlate with extent of NAS If in methadone treatment it is illegal to write a script for opiate dependence

16 Buprenorphine Lack evidence from long term neurodevelopmental studies Lower risk of overdose or drug interactions Less strict programs ( no daily visits) Hepatic dysfunction Higher dropout rate

17 Buprenorphine Less N AS Shorter hospital stays for infants Less growth restriction in infants Less drug seeking behavior Less exposure to risky behaviors

18 Treatment Programs

19 Buprenorphine Initiate treatment quickly Controlled substance agreement Review longer hospital stay CPS involvement M ethadone is the gold standard Review their past history Review substance of choice Identify co-morbidities

20 During treatment Meet with our NICU staff M eet with patient every 4 weeks, to sometimes twice a week Frequent UDS-confirm abnormals Review their comorbidities, encourage treatment Review infection status- initial treatment

21 Buprenorphine Each appointment Counseling Cravings Support system Side effects Potential dose reduction Safety

22 Constipation Complication of pregnancy Complication of opiates Complication of buprenorphine Encourage lifestyle Encourage colace

23 St orage This is not a lock box This is a lock box

24 Mental health support Counseling What are they asking Depression/Anxiety fluoxetine/buspirone Sleeping Eating Shelter Abuse

25 Co-Morbidities Primary substance use disorder and secondary co-occurring disorder. Primary co-occurring disorder and secondary substance use disorder. Common pathway. Bidirectional model. 8

26

27 Intrapartum Ensure prompt care Ensure facilities capable of handling NAS Initiate social work referrals Remind pts of longer stays UDS...UDS...UDS

28 Intrapartum Breastfeed THC? Other substances Treatment labor pain/post surgical pain M ay need higher doses of pain medication May continue buprenorphine

29 The Newborn Breastfeed! There are no studies that confirm a dose relationship to withdrawals M econium screening Expect a CPS investigation Alert Pediatrician opiate dependence infections

30 Newborn Neonatal Abstinence Syndrome uncoordinated sucking irritable high pitched cry Buprenorphine hours peek M ethadone 2 weeks, but usually within 72 hours 10

31

32 Postpartum Tendency to stop counseling Switching from buprenorphine to buprenorphine plus naloxone M edicaid programs only fund one year of treatment Residential treatment program

33 Postpartum Initiation of Birthcontrol M ay go home with CPS M ay need reduction of their dose (methadone)

34 Michigan Center For Rural Health Snapshot Free Buprenorphine Waiver Course by The American Society of Addiction Medicine and Spectrum Health A Buprenorphine waiver training is available for providers interested in seeking their waiver to prescribe buprenorphine in office-based treatment of opioid use disorders. To obtain the waiver to prescribe, physicians are required to take eight hours of training and NPs/PAs are required to take 24 hours of training. Date: Friday, March 24, 2017 Time: 1 p.m.- 5:30 p.m. Location: James N. Tucci Community and Conference Center, Lower Level 2750 East Beltline Avenue NE Grand Rapids, MI Presenters: John Hopper, MD, DFASAM and Cara Poland, MD, MEd, FASAM Cost: FREE Organization: American Society of Addiction Medicine

35 Summary Opiate dependence is an escalating issue Initiate treatment early Closely monitor Inform patients so they know what expect Counseling M ental health issues Watch infant for withdrawals Encourage effective birth control

36 Bibliography 1. Briggs, Bill Jan 22, 2015 Pill-Popping Mommas Many Pregnant Women Take Opioids, CDC Finds. NBC News. 2. Office of Applied Studies NCBI Bookshelf. Chapter 13 Medication-Assisted Treatment for Opioid Addiction During Pregnancy. Rockville (MD):Substance Abuse and Mental Health Services administration To Help Newborns Dependent on Opioids, Hospitals Rethink Mom s. National Public Radio Broadcast 3/26/ Broussard, C.S et. al. Maternal treatment with Opioid analgesics and risk for birth defects. AM J Obstet gynecol April Azadi A. Didy GA 3rd. Universal Screening for substance abuse at the time of parturition. AM J Obstet gynecol 2008;198:e Substance Abuse and Mental Health Services Administration. Results from the 2010 National Drug Use and Health: summary if national findings. NSDUH Series H-41, HHS Publication No. (SMA) Rockville (MD): SAHMSA: When opiate abuse complicates pregnancy. Prasad, M, Contemporary OB/GYN. 2/01/ NCBI Bookshelf. Chapter 12 Treatment of CO-Occurring disorders. Rockville (MD):Substance Abuse and Mental Health Services administration Johnson RE, et. al. Use of buprenorphine in pregnancy: patient management and effects on the neonate. Drug Alcohol Dependence 2003;70:S Kaltenbach K, Finnegan Lp. Developmental outcome of children born to methadone maintained women: a review of longitudinal studies. Neurobehav Toxicol Teratol Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No.524. AM J Obstet gynecol 2012;119:

37 Cont act Julia Riddle D.O. Grand Traverse Women's Clinic (231) work (517) cell