Conflict of interest. History. Objectives

Transcription

1 Conflict of interest th Annual Perinatal Conference : The Opioid Crisis Women and Opioid Use Disorder; Supporting recovery and optimizing care during pregnancy The speaker has no conflict of interest to declare Susanne Astrab Fogger, DNP, PMHNP-BC, CARN-AP, FAANP University of Alabama at Birmingham Friday September 21 Objectives 1. Increase understanding of opioid use disorder (OUD) during pregnancy 2. Discuss medication assisted treatment (MAT) for pregnant women with OUD 3. Highlight the management of women on MAT during pregnancy and the postpartum period 4. Review implications for neonates History The opioid epidemic in the United States affects many Americans number of deaths from opioids since 1999 to present more than 500,000 deaths Leading cause of death -under 50 Misuse of pain medications and heroin speak to the underlying issues of a substance use disorder fueling the overdose deaths 1

2 Marked Geographic and Temporal Variation in Overdose Deaths : Estimated Age-adjusted Death Rates for Drug Poisoning by County Alabama Opioid overdose death rate (age-adjusted): 7.7 per 100, year percent change: 166% increase Most impacted age group: years Most impacted county: Jefferson County Opioid prescriptions per person Average number of prescriptions per 100 people in the US is 67 Two congressional districts rank among the five highest in the U. S. for number of opioid prescriptions 4 th Congressional District Franklin, Colbert, Marion, Lamar, Fayette, Walker, Winston, Cullman, Lawrence, Marshall, Etowah, & DeKalb with bits of Jackson 166 prescription per 100 people 1 st Congressional District-Washington, Mobile, Baldwin, Escambia and Monroe 131 prescriptions per 100 people Lyndsey A.Rolheiser,JackCordes, BSPH, ands.v.subramanian, Opioid Prescribing Rates by Congressional Districts, United States, 2016, American Journal of Public Health: published online before print July 19, 2018 DOI: /AJPH Addiction A primary chronic disease brain reward, motivation, memory and related circuitry Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations Reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors American Society of Addiction Medicine (2015) 2

3 Differences Dependence: syndrome of specific withdrawal symptoms following reduction or cessation of drug use does not equal a substance use disorder Addiction: must meet DSM-5 criteria 4 C s of Addiction Loss of Control Compulsive use Continued use despite harm Craving Opioid use and Women % of pregnant who use opioids Tripled in past 10 years 1.2% of all pregnant women used in 2012 # of infants nearly fivefold annually from 1.19 to 5.63 per 1,000 births Knopf, A. Opioid use among women of childbearing age detailed. Alcoholism & drug Abuse weekly, (2/20/2017) , 29 (8) p. 3. Women and Risk Women s risk of overdose and Opioid used disorder (OUD) higher than men often have more chronic conditions treated with opioids more exposure to opioids become addicted more often than men on a smaller dose over a shorter period of time. 3

4 Opioid Use in Pregnancy Pregnant women with OUD seek care late in pregnancy, if at all are often sicker than men Medical, behavioral, psychosocial and social Stigma, fear of judgement and loosing child custody barriers to treatment Common signs of opioid intoxication Drooping eyelids Constricted pupils Reduced respiratory rate Scratching (due to histamine release) Head nodding High Risk Behavior Screening tools for drug use S Screening B -Brief I Intervention R Referral T Treatment DAST Quick Screen 4

5 Brief Intervention Referral to Specialized Treatment Brief intervention is a single session or multiple sessions of motivational discussionfocused on increasing the patient s insight and awareness regarding substance use The effectiveness of the referral process to specialty addictions treatment is a strong measure of SBIRT success A proactive and collaborative effort SBIRT providers and those providing treatment Ensures access to the appropriate level of care motivation toward behavioral change Women s Recovery Treatment Goals : 1. Total long term abstinence 2. Risk reduction-use of MAT Blocks effect of the drug Decreases high risk drug use 3. Support maternal infant bonding Pregnancy Considerations Abrupt discontinuation of opioids in pregnancy associated with increased risk Abruptio placentae Intrauterine growth restriction Preterm labor and birth Intrauterine passage of meconium and neonatal aspiration Fetal distress Fetal death American College of Obstetricians and Gynecologists (ACOG) Committee on Health Care for Underserved Women & American Society of Addiction Medicine (2016); Kocherlocota(2014) 5

6 Someone in opiate withdrawal, how can you tell? Withdrawal symptoms within 8-24 hours: Restlessness, anxiety, drug craving & irritability Lacrimation Rhinorrhea Increased BP & P Muscle pain Shivering Sweating Nausea/ vomiting Abdominal cramping Diarrhea Abstinence/Risk Reduction Although patient may commit to abstinence: Powerful unconscious internal signals may override goal Signals hijack the brain often below the person s awareness Individual seeks relief through return to chemical use Medications to assist recovery How is this not adding to the problem? Medication for stabilization is not just giving legal narcotics but offering stabilization Brain changes are long term Behavior changes Changes in neurochemistry Neurochemical effects are long lasting continue after the detoxification period when the person is no longer using Endorphins Chronic illness model 6

7 Medication Assisted Treatment Methadone-highly regulated only provided by Opioid Treatment Program Naltrexone daily or monthly IM All prescribers within their scope of practice Buprenorphine or buprenorphine with naloxone MDs with DEA license and SAMHSA waiver to prescribe to 30 patients initially (July 16) request to increase practice up to 275 patients CARA act July 2016,-NPs and PAs Rationale for Pharmacotherapy Substance use disorders are a chronic condition. Medications can target neurotransmitters involved in the reinforcing and anxiolytic effects. Beneficial in combination with non-pharmacologic therapy including counseling and other behavioral therapies Can reduce relapse and help maintain abstinence. Reduces the risk of HIV, HepC & B transmission. Choices Methadone and Buprenorphine Effective-opiate dependence in pregnant women Little risk to fetus similar pregnancy outcomes Benefit of MAT for the safety of the mother and health of the neonate. In some states Medicaid will only cover buprenorphine Martin, P.R. & Finlayson A.J. (2015) Methadone Full opioid agonist Slow (oral) absorption Slow elimination (long half life 24 ) Agonist substitution strategy Titrated to effective dose range (80mg/day) Reduces tolerance in opioid system, results in blockade of effect of the illicit opioids 70% retention in treatment 50% sustained abstinence 7

8 Methadone: pregnancy related changes In the second and third trimester, methadone doses may require increasing: Increased metabolism and circulating blood volume As the advancing gestational age, plasma levels of methadone progressively decrease and clearance increases Risk and severity of NAS are not correlated with methadone doses taken by the mother at time of delivery. Dose will be adjusted after birth ASAM National Practice Guideline, 2015 Methadone: pregnancy related changes The half-life of methadone falls Average of hours in nonpregnantwomen Average of 8.1 hours in pregnant women As a result, increased or split methadone doses may be needed as pregnancy progresses to maintain therapeutic effects Dividing the methadone dose twelve hours apart may produce more adequate opioid replacement ASAM Clinical Guidelines 2015 Fetal and Neonatal Effects of Methadone Low rates of teratogenic outcomes Small relative risk of congenital malformations Neonatal opioid withdrawal syndrome occurs in 94% of newborns born to women who use methadone Higher doses of medication required to treat neonatal opioid withdrawal syndrome when methadone used in pregnancy over buprenorphine No known correlation between methadone dose and neonatal opioid withdrawal syndrome Kocherlakota(2014) Buprenorphine Partial opioid agonist. Can be used for tapering protocol for detox or opioid therapy. Less stigma than Methadone. Initial dose 4-8 mg per day increased to between 16-32mg over several days Maintenance dose-12-24mg per day 8

9 Buprenorphine The need to adjust dosing of buprenorphine during pregnancy is less than methadone Consider split dosing Complains of discomfort Craving in the afternoon and evening Limitations Adherence to daily sublingual pill or strip 50% drop out by 3-6 months Buprenorphine/Naltrexone Buprenorphine/naltrexone 4:1 Limited absorption of Naltrexone sublingually Almost complete first pass metabolism Limited availability May be safer due to ceiling effect in dose increases Unlikely death from OD Naltrexone Opioid use must be stopped at least 7 days prior to starting naltrexone Assess pregnancy status Blocks pain relief from opiate medications Does not reduce effectiveness of local and general anesthesia Non-narcotic pain relievers can be utilized Neonatal Abstinence Syndrome Finnegan Neonatal Abstinence Scoring System Time to re-evaluate Non-pharmacologic vs pharmacologic treatment Grossman, Osborn, & Berkwitt (2017) 9

10 Guidelines from the Academy of Breastfeeding Medicine Encourage breastfeeding for women treated with methadone who are enrolled in methadone programs Some of the benefits include: Improved maternal infant bonding Favorable effects on NAS Implications for Breastfeeding Breastfeeding encouraged Increases bonding Decreases symptoms associated with neonatal opioid withdrawal syndrome As infants weaned off breastmilk, weaned off medication naturally Keough& Fantasia (2017) NAS New on the market Teach mothers about what they can do to help their babies Reducing nicotine consumption or stopping smoking before birth can reduce NAS Nicotine W/D compounds methadone WD Nicotine W/D --same symptoms as opioid WD Neonates of heavy smokers had peak NAS scores that were 57% higher, took 33% longer to peak and had 54% longer duration Choo, R., Huestin, M., Schroeder, J., Shin, A., & Jones, H. (2004). Neonatal abstinence syndrome in methadone-exposed infants is altered by level of prenatal tobacco exposure. Drug and Alcohol Dependence 75, Long acting Buprenorphine Injectable Invivior(one month) implant Sublocade Naltrexone implant (not in USA yet) (2-3 months duration) 10

11 Vulnerabilities Psychological and emotional distress has been identified as a risk factor Women more likely to have co-existing disorders: anxiety, depression, PTSD, eating disorders and agoraphobia with and with out panic May use to cope with negative emotions. Barriers to Treatment Only 20% of adults with OUD get treatment Cost and access reported as primary barrier Insurance coverage Most states cover all three medications through Medicaid state pharmacy program Some have lifetime limitations May require prior authorization, step therapy, or fail preferred medication first policy Saloner B & Karthikeyan S. (2015) Predictors of long term abstinence Stayed on either methadone or buprenorphine Worse outcomes: Severity (IV/Cocaine use) Younger age Psychiatric symptoms Restrictions on Prescribing Any provider with controlled substance privileges can prescribe buprenorphine acute withdrawal in an inpatient setting To prescribe for maintenance Need waiver from SAMHSA as per special requirements noted in CARA Bill signed into law at the end of July 2016 NP/PA Training 24 hours requirements for NPs available free at AANP & APNA websites 11

12 Quality measures for Buprenorphine treatment Quality of Life indicators Issues in delay of treatment Prior authorization- disrupts the continuity of care Hub and spoke model Most common drop out reason I felt cured, I wanted to do it on my own Treating for OUD The benefit of MAT for the safety of the mother and health of the neonate Mothers in care Improved nutrition Decreased drug use Teach the patient and family members about overdose treatment Prescribe for patient and family members Naloxone 4mg nasal spray Discuss nasally inhaled Naloxone Signs and symptoms of overdose Breathing slow nonresponsive to touch or voice Pupillary constriction Nail beds cyanotic SAFETY Ongoing exposure to opioids increases risk of opioid use disorder CDC guidelines for managing chronic pain with opioids Prescription monitoring program Changes in amount and duration of acute doses of prescription pain meds Using non-opioids to treat pain Instructing people about safe storage and disposal Locked med boxes Destroying old prescriptions Not sharing with others 12

13 Additional resources Substance Abuse and Mental Health Services Administration Web page for free information on Substance use disorder and treatment Substance Abuse & Mental Health Services Administration (SAMHSA) National Institute on Drug Abuse Clinical Opiate Withdrawal Scale REFERENCES American Society of Addictions Medicine (2015) National Practice Guidelines for the use of Medications in the treatment of Addiction involving opioid use. Chevy Chase, MD American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women & American Society of Addiction Medicine. (2016). Opioid abuse, dependence, and addiction in pregnancy, committee opinion 524. Retrieved from: Publications/Committee-Opinions/Committee-on-Health-Care-for- Underserved-Women/Opioid-Abuse-Dependence-and-Addiction-in- Pregnancy American Society of Addiction Medicine. (2011). Public Policy Statement: Definition of Addiction. Chevy Chase, MD: American Society of Addiction Medicine. Retrieved from: statements/1definition_of_addiction_short_4-11.pdf?sfvrsn=0 References Grossman, M.R., Osborn, R.R. & Berkwitt, A.K. (2017). Neonatal abstinence syndrome: Time for reappraisal. Hospital Pediatrics, 7(2), doi: /hpeds Keough, L. & Fantasia, H.C. (2017). Pharmacologic treatment of opioid addiction during pregnancy. Nursing for Women s Health, 21(1), doi: /j.nwh Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics,134(2), e.547.doi: /peds Kramlich, D., Kronk, R., Marcellus, L, Colbert, A., & Jakub, K. (2018) Rural postpartum women with substance use disorder. Qualitative Health Research. 28(9), Martin, P.R. & Finlayson A.J. (2015) Opioid use disorder during pregnancy in Tennessee: Expediency vs Science. American Journal of Drug and Alcohol Abuse, 41(5), Rudd, R., Seth, P. David, F., & Scholl, L. (2016). Increases in drug and opioid-involved overdose deaths: United States, Morbidity & Mortality Weekly Report, 65, Saloner, B. & Karthikeyan, S. (2015). Changes in substance abuse treatment use among individuals with opioid use disorders in the United States: Journal of the American Medical Association, 314(14), Retrieved from: Saloner, B., Stoller, K., & Alexander, G.C. (July 17, 2018) Moving addiction care to the mainstream- Improving the quality of Buprenorphine treatment. New England Journal of Medicine Doi: /nejmp