Treatment of Opioid Use Disorder During Pregnancy
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1 Treatment of Opioid Use Disorder During Pregnancy Cheyenne Johnson RN, MPH, CCRP Director Clinical Activities and Development, British Columbia Center on Substance use
2 Disclosure No conflict of interest
3 Outline Review opioid use during pregnancy Overview guideline supplement development process Review guideline recommendations Perinatal Services BC forthcoming tools and activities
4 Opioid Use in Pregnancy Non-medical opioid use during pregnancy is associated with: Fetal growth restriction Fetal demise Neonatal opioid withdrawal (aka NAS) If injecting drugs, going harms related to injection drug use (overdose, HIV, Hep C, infection etc.) 1. Lund IO, Fitzsimons H, Tuten M, Chisolm MS, O'Grady KE, Jones HE. Comparing methadone and buprenorphine maintenance with methadone-assisted withdrawal for the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes. Substance abuse and rehabilitation. 2012;3: McCarthy JJ, Leamon MH, Finnegan LP, Fassbender C. Opioid Dependence and Pregnancy: Minimizing Stress on the Fetal Brain. American journal of obstetrics and gynecology
5 Engaging in Care Opportunity! OUD care during pregnancy, intrapartum and post partum: Eliminate or reduce non-medical opioid use Significantly improve pregnancy outcomes Benefits of OAT (opioid agonist treatment) 3. WHO Guidelines Approved by the Guidelines Review Committee. Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. Geneva: World Health Organization Copyright (c) World Health Organization 2014.; Lind JN, Interrante JD, Ailes EC, et al. Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review. Pediatrics Zedler BK, Mann AL, Kim MM, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction (Abingdon).2016.
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8 Provincial Opioid Addiction Treatment Support Program (POATSP) 71 New Full Exemptions Issued (since June 2017) CPSBC 2016/ new exemptions CPSBC 2015/ new exemptions 8
9 Guideline Supplements Two forthcoming Pregnancy and Youth Supplement to the main provincial OUD guideline Released Feb
10 Supplement Development Process Guideline Development Committee Ronald Abrahams, MD, CCFP, FCFP, M.S.C. (Committee Co-chair) Andrea Ryan, MD, CCFP, Dip. ISAM (Committee Co-chair) Jola Berkman, RN, BScN, BSc(med)Hons Eric Cattoni, MD, CCFP Sonia Habibian, MD, CCFP, FASAM, MRO Janine Hardial, MD, CCFP Georgia Hunt, MD, CCFP Cheyenne Johnson, RN, MPH, CCRP Tamil Kendall, PhD Annabel Mead, MBBS, Dip. ABAM, FAChAM Jill Pascoe, MSW, RSW Nitasha Puri, MD, CCFP, dip. ABAM Nancy Poole, PhD Christy Sutherland, MD, CCFP, Dip. ABAM Meaghan Thumath, RN, BSN, MScPH Lani Wittmann, RN, MN, IBCLC, PNC
11 Supplement Review Process External Reviewers Kate Bodkin, BA, MD, CCFP Andrew Gaddis, Fulbright Scholar Hendrée Jones, PhD Lorena Marcellus, RN, BSN, MN, PhD Alice Ordean, MD, CCFP, MHSc, FCFP, FASAM Launette Rieb, MD, MSc, CCFP, FCFP, Dip. ABAM, CCSAM
12 Summary Table of (Draft) Recommendations
13 Care Principles (Recommendations #1-4) Clinicians caring for pregnant individuals with opioid use disorder should: apply the principles of trauma-informed and culturally safe practice assess each patient s basic medical and psychosocial needs (e.g., mental wellness, security, stable housing) and make necessary referrals to secure social determinants of health Offer integrated and individualized care programs which are essential to fostering stability and improving treatment and pregnancy outcomes Provide/facilities access to the full scope of harm reduction supplies and services available to the general patient population.
14 Prenatal Screening and Assessment (Recommendation #5) All individuals who are or may become pregnant should be offered regular screening for alcohol, tobacco, and non-medical drug use, and informed of the risks and risk reduction strategies. Screenings should be accompanied by brief support.
15 Overview of the continuum of care for OUD
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17 Pharmacological Treatment (Recommendations 6-10) #6: Withdrawal management alone is not recommended due to high rates of relapse and subsequently elevated risk of fatal and nonfatal overdose, infections, and negative pregnancy outcomes.
18 Safety Considerations Withdrawal Management Alone Detox can potentially be an important first point of contact and a bridge to other treatment options However, detox as a standalone intervention associated with: High rates of relapse (Strang et al., 2003) 90% relapse most within 7 days HIV-transmission (MacArthur et al., 2012) Morbidity and Mortality (Luty 2003, Simpson and Friend, 1988)
19 Pharmacological Treatment (Recommendations 6-10) #7 All pregnant individuals with opioid use disorder should be offered opioid agonist treatment (OAT) OAT has been shown to eliminate or substantially reduce nonmedical opioid use, leading to improved maternal and neonatal outcomes in comparison to untreated opioid use disorder and/or withdrawal management strategies.
20 Overview of the continuum of care
21 Pharmacological Treatment (Recommendations 6-10) #8: The type of OAT to be initiated should be selected based on patients individual circumstances and with consideration of access and availability. Methadone is traditionally recognized the first-line option for OAT during pregnancy. Buprenorphine/naloxone is an alternative first-line medication for this population. Recent studies have found this medication to be as safe and effective as methadone and buprenorphine monotherapy during pregnancy. Slow-release oral morphine may be considered for patients who are not successfully retained in treatment with buprenorphine/naloxone or methadone. Injectable opioid agonist treatment (ioat). Caution should be exercised when prescribing ioat for individuals who are pregnant or may become pregnant. This caution should be exercised with consideration of the potential harms of denying access to ioat for a pregnant person who otherwise meets eligibility criteria.
22 Methadone in pregnancy Most frequently prescribed OAT during pregnancy For the mother Prevents relapse, minimizes fluctuations in serum opioid levels (eliminates fetal stress) For the neonate: Longer gestation, higher live birth rates, greater birth rates, early discharger from hospital Methadone prescribing information in the main guideline
23 Buprenorphine (+ buprenorphine/naloxone) Growing evidence supports equal efficacy & potential superiority of buprenorphine in pregnancy Neonatal outcomes similar to methadone However, NOWS may be less severe
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26 Pharmacological Treatment (Recommendations 6-10) #9 Unless clinically indicated, transitioning between methadone, buprenorphine/naloxone, and slow-release oral morphine during pregnancy and postpartum periods is not recommended for patients who are stable on one of these medications prior to becoming pregnant.
27 Pharmacological Treatment #10: For patients stable on buprenorphine/naloxone prior to becoming pregnant, transition to buprenorphine monotherapy during pregnancy is not necessary.
28 What about the naloxone (in buprenorphine)? Naloxone: theoretical risk that naloxone may pose to the fetus by elevating maternofetal cortisol levels Several recent studies have found no statistically significant differences between the two formulations in terms of pregnancy and treatment outcomes 6. Debelak K, Morrone WR, O'Grady KE, Jones HE. Buprenorphine + naloxone in the treatment of opioid dependence during pregnancy-initial patient care and outcome data. The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions. 2013;22(3): Wiegand S, Stringer E, Seashore C, et al. 750: Buprenorphine/naloxone (B/N) and methadone (M) maintenance during pregnancy: a chart review and comparison of maternal and neonatal outcomes. Vol Lund IO, Fischer G, Welle-Strand GK, et al. A Comparison of Buprenorphine + Naloxone to Buprenorphine and Methadone in the Treatment of Opioid Dependence during Pregnancy: Maternal and Neonatal Outcomes. Substance Abuse: Research and Treatment. 2013;7:61-74
29 What about the naloxone (in buprenorphine)? In Canada available as buprenorphine/naloxone (Suboxone ) Recently remove pregnancy as contraindication in product monograph Buprenorphine mono-produce available via Special Access Programme (SAP)
30 Post partum recommendations #11 Rooming-in is recommended as the standard of care for opioid exposed infants as it facilitates care for the mother-child dyad as one unit while alleviating neonatal opioid withdrawal symptoms. Assessment and treatment of neonatal opioid withdrawal symptoms should be conducted in rooming-in settings. #12 Breastfeeding should be encouraged in mothers who are stable on OAT.
31 Summary Release date: Spring 2018 NEW! Perinatal RACE Line April 1 st Stay tuned for more practice support and educational
32 Educational Online addiction medicine diploma program Nursing modules coming Summer 2018! Interdisciplinary fellowship program Nursing Social Work Physicians Provincial opioid addiction training support program Visit under the Training
33 Summary Guideline recommendations highlights: Withdrawal management alone is dangerous OAT should be offered for all pregnant individuals Methadone (1 st line) Buprenorphine/naloxone (alternative 1 st line) Slow release oral morphine (SROM) (2 nd /3 rd line) Injectable OAT (caution) Transitioning OAT is not recommended including transition to buprenorphine mono-therapy
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