Methamphetamine Abuse During Pregnancy

Methamphetamine Abuse During Pregnancy Robert Davis, MD / r.w.davismd@gmail.com ❶ Statistics ❷ Pregnancy Concerns ❸ Postpartum Concerns ❹ Basic Science ❺ Best Practice Guidelines ❻ Withdrawal ❼ Recovery ❽ Key Clinical Points ❾ References 1

Amphetamine-Related Hospitalizations in the United States 2

Amphetamine-Related Hospitalizations by US Census Region 3

Pregnancy Concerns Growth Restriction Low Birth Weight Placental Hemorrhage Managing Intoxication Prenatal Care Mental Health and Medical Comorbidity 4

Postpartum Concerns Withdrawal Syndrome NAS Breastfeeding Recovery Social Work Involvement Mental Health and Medical Comorbidity 5

Stimulant Stimulants Drug Class Sedatives/Anxiolytics/Hypnotics Opioids Inhalants Cannabis Hallucinogens Tobacco Other Alcohol Caffeine Meth Bath Salts Stimulants Ecstasy RX Amphetamines Cocaine 6

Dopamine Epinephrine Norepinephrine Serotonin 7

1 2 3 4 Onset of Action Peak Plasma Concentration Plasma Half-life Duration of Action Seconds to Minutes 30 to 180 Minutes 12 to 34 Hours 24 Hours or More 8

Short-Term Effects Loss of appetite Increased heart rate, blood pressure, body temperature Dilation of pupils Disturbed sleep patterns Nausea Bizarre, erratic, sometimes violent behavior Hallucinations, hyperexcitability, irritability Panic and psychosis Convulsions, seizures and death from high doses Long-Term Effects Permanent damage to blood vessels of heart and brain, high blood pressure leading to heart attacks, strokes and death Liver, kidney and lung damage Destruction of tissues in nose if sniffed Respiratory problems if smoked Infectious diseases and abscesses if injected Malnutrition, weight loss, severe tooth decay Disorientation, apathy, confused exhaustion Strong psychological dependence Psychosis, depression, neural cell damage and destruction 9

Best Practice Guidelines Agitation Hypertension Seizures Hyperthermia Tachycardia Cardiac Arrest 10

Agitation Acutely intoxicated patients may become extremely agitated Treat severely intoxicated patients immediately with intravenous or intramuscular benzodiazepines Benzodiazepines Physical Restraints Physical restraints should be avoided if possible 11

Methamphetamine poisoning can produce a hyperadrenergic state associated with an increase in both alpha- and beta-adrenergic tone * Hypertension α and ß* Sedation is the mainstay of therapy Avoid medication with beta-blocking activity * Benzodiazepines Hydralazine Nifedipine Labetalol * Institute Magnesium Sulfate therapy if eclampsia is suspected Seizures Avoid pre-term or operative delivery by way of accurate diagnosis and treatment Seizures caused by acute methamphetamine intoxication are usually brief and self-limited, and do not require medical therapy Prolonged seizures are treated initially with benzodiazepines Diazepam Midazolam Magnesium Sulfate Phenytoin 12

Antipyretics have no role in the management of hyperthermia due to methamphetamine intoxication Hyperthermia Control of hyperthermia (temperature 41.1 C/ 106 F) involves eliminating excessive muscle activity and aggressive cooling Increased body temperature in this setting arises from muscular activity, not an alteration in the hypothalamic temperature set point Sedation Aggressive Cooling Antipyretics Should additional rate control be needed, treat with a calcium channel blocker such as diltiazem Tachycardia Although tachycardia is common among patients intoxicated with methamphetamine, heart rates are usually in a range that is well tolerated in the short-term Benzodiazepine therapy often reduces CNS catecholamine release sufficiently to produce an adequate reduction in heart rate Benzodiazepine Beta-blockers 13

Cardiac Arrest No predisposing factors rigorously predict collapse, but the clinician should anticipate clinical deterioration and cardiac arrest in any wildly agitated patient, particularly those requiring physical restraints Some patients with severe methamphetamine intoxication will sustain sudden cardiovascular collapse 14

Withdrawal Syndrome Dysphoria Anhedonia Fatigue Increased Sleep Insomnia Agitation Anxiety Depression Drug Craving Increased Appetite 15

Recovery Individual Counseling Family Therapy Group Psychotherapy Crystal Meth Anonymous Contingency Management 16

Key Clinical Points 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Methamphetamine has become the most common illicit substance of abuse requiring medical treatment during pregnancy Methamphetamine ingestion results in significant CNS penetration and leads to indirect sympathetic activation through the release of epinephrine, norepinephrine, dopamine, and serotonin 1 2 3 4 5 6 7 8 9 10 11 12 13 14 17

Significant cardiovascular effects are vasoconstriction, tachycardia, and labile blood pressure Patients are typically hypertensive, although catecholamine depletion over time can result in hypotension Arrhythmias and myocardial ischemia can occur Hemorrhagic stroke has been reported 1 2 3 4 5 6 7 8 9 10 11 12 13 14 In the setting of acute methamphetamine intoxication, the ensuing seizures, severe hypertension, and hyperthermia can be fatal Treatment goals include provision of a calm environment, with or without a benzodiazepine, and airway protection Active cooling, antihypertensives, and anticonvulsants should be used as needed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 18

Methamphetamine-induced seizures can masquerade as eclampsia Methamphetamine withdrawal causes fatigue, depression, hunger, and intense cravings Breastfeeding is not recommended for women with ongoing methamphetamine use Social work consult should be ordered for all patients False positive urine toxicology for methamphetamine may be caused by ephedrine administered during labor 1 2 3 4 5 6 7 8 9 10 11 12 13 14 19

Thank You! 20

References & Guidelines* Chestnut's Obstetric Anesthesia Principles and Practice, 5 th Edition, 2014, Chapter 54, Section X, pp. 1195-1218, The Parturient with Systemic Disease, Substance Abuse by Lisa R. Leffert, MD Textbook of Substance Abuse Treatment 5 th Edition, 2015, American Psychiatric Publishing Principles of Addiction Medicine 5 th Edition, 2014, ASAM UpToDate, Methamphetamine: Acute Intoxication (April 6, 2017) PC424 SLHS Clinical Drug Testing in the Obstetrical and Infant Population Appropriate Use of Drug Testing in Clinical Addiction Medicine, ASAM 2017 Management of the Patient in Labor Who Has Abused Substances, Geary and Turnquest, Clinical Obstetrics and Gynecology, Vol. 56, No.1, 166-172 (2013) Amphetamine Ingestion Presenting as Eclampsia, Elliot and Rees, Canadian Journal of Anaesthesia, 1990/337: 1/pp 13-3 Seizures Presenting in Pregnancy: Eclampsia or Something Else? Kapoor and Jackson, (2013) Journal of Obstetrics and Gynecology, 33:6, 630-630 Postpartum Convulsions and Acute Hemodynamic Instability in the Parturient with Recent Amphetamine Intake, K. M. Kuczkowski; Arch Gynecology Obstetrics (2009) 280; 1059-1061 Maternal-Fetal Medicine, 8 th Edition, 2019, Creasy and Resnik Methamphetamine Abuse in Women of Reproductive Age, ACOG Committee Opinium, 2017, Number 479 Evaluation of Amphetamine-Related Hospitalizations and Associated Clinical Outcomes and Costs in the United States, JAMA Network Open. 2018;1(6):e183758. doi:10.1001/jamanetworkopen.2018.3758 October 19, 2018 * Best Practice Guidelines (Short and Long Versions) found in NOTES section of this slide 21