James J. Nocon, M.D., J.D.
© 2014
jnocon@me.com
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Addiction Theory:
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An approach to understanding addiction.
A review of addiction neurobiology.
Scope of addi...
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Few Medical Schools Teach Addiction Medicine
“Not enough time in curriculum.”
 Addiction occurs in 1 in 10 patients,...
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What are the critical elements in treating
addiction?
 Attitude (Compassion goes a long way)
 Attitude (Non-judgmenta...
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Special shame reserved for addictive mothers.
Criminalized for using drugs while pregnant
 N.J. Div. of Youth & Fami...
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In a special clinic for “drug abuse in pregnancy”
renamed (with a positive attitude) the “Prenatal
Recovery Clinic:”
 ...
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Pregnancy enhances long-term recovery.
After one year of treatment:
 65.7% of women who entered treatment while

pre...
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Do we all feel good when
someone says something
nice about us?
Does that lead to a positive
attitude?
What does it...
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You can affirm patients, friends, relatives, loved ones,
even strangers and especially your enemies.

Acknowledge their...
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Enhances self worth and self esteem.
Something almost always absent in addicts.
When I affirm someone, I am also af...
Affirm someone every day, especially those
close to you.
 Pay attention to their reaction.
 What effect did the affirmat...
12
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Great question. Like obscenity, hard to define but, “I
know it when I see it.”
Lack of Moral Character – most pre...
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As Voltaire is said to have replied when the
Marquis De Sade invited him to a second
orgy, since he enjoyed the firs...
Entitlement/Despair: I’m
entitled to feel good, or
things are horrible and I
need something to help
me feel good.

Despair...
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“A primary, chronic disease of brain reward, motivation,
memory and related circuitry.”
ASAM describes five charac...
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Researchers have noted that
 Addiction is a chronic relapsing disease.
 Successful treatment is comparable to, or bet...
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What drugs and behaviors have in common, which
results in “the buzz,” is the release of various
neurotransmitters in th...
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Ventral Tegmental Area
(VTA)
 Nucleus Accumbens –
dopamine rich center in
the limbic area
 Prefrontal Cortex – sho...
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Serotonin – sense of well
being.
Endorphins – euphoria.
GABA (gamma amino butyric
acid) – satiety and
somnolence...
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Tolerance: as repeated use of the drug or behavior
depletes the dopamine, more use or more drug, or
both, is req...
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PET/MRI has mapped the location in the brain where
drugs and behaviors have their effects.
The meso-limbic ...
Addiction is a “double whammy.”
1.

2.

Tolerance - The brain needs
more and more of the drug in
order to get the same eff...
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Three critical factors stimulate stem cells to
repair and rebuild neuro-circuitry
 Nutrition and exercise.
 Folic aci...
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Addiction is primarily a disease of the brain, which was
not taught to most of us.
Addiction fits the medical...
Treatment highly cost-effective
Reduction in preterm delivery accounts for huge
benefits for the children and huge savings...
Approximately 89,000 deliveries.
At least 25% use tobacco
Estimates vary from a low of 10% to a high of
20% using alcohol,...
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About 89,000 deliveries in Indiana
51% funded by Medicaid – 45,390
15% substance use - 6,808
90% are undetect...
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Estimated 6,800 Substance users
3400 detected (D) – 3400 undetected (U)
20% Preterm delivery D = 680
35% Pr...
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Alcohol and tobacco,
often used in combination,
cause far more fetal
damage than all other
drugs combined.
Both...
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Marijuana most common. Two surveys in
Indiana are consistent with U.S. data.
 29% tested positive for THC on the first...
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The number one preventable public health issue
in pregnancy. Two major subgroups:
1. Those who are dependent or addicte...
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A 30 y/o woman, back pain from injuries in a
MVA, takes
 10 mg. hydrocodone/325 acetaminophen 4x, daily
 50 mg. amitr...
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Cocaine: all forms
Amphetamines – Increasing
abuse of ADHD prescriptions –
10-20 year olds
M...
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2002-2007: 69/287 patients (24%) tested
positive for opioids
 43 patients in Methadone Maintenance
 4 patients on Bup...
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Gender includes both physical and emotional components that differ
significantly.
 Less alcohol dehydrogenase in wo...
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Opioids – women develop
dependence quicker than
men.


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Ellinwood, et al. Narcotic
addictions in males and females:
...
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Depression common – 45%
 Did the depression contribute to the addiction?
 Or vice-versa?



Substance Abuse - 19%
 ...
Need a Treatment Team
 Create a Recovery Plan with a drug use agreement.
 Follow with non stress tests, biophysical prof...
Effective treatment can occur with a
compassionate provider.
 Pregnant addicts are not necessarily high risk
but they can...
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Pre-conceptual Counseling
Prenatal Care
Labor and Delivery
Analgesia; Anesthesia
Post Partum Care



A more de...
Especially helpful if you care for opioid dependent chronic
pain patients and methadone and buprenorphine patients.
 Will...
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Routine obstetrical care is modified for the substance user.
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Perform all routine screening tests.
Generally...
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Decision for delivery based on obstetrical reasons.
Stress of last few weeks of pregnancy places patient at r...
Epidural anesthesia for labor, delivery and cesarean delivery is the
standard.
 Spinal anesthesia for cesarean delivery.
...
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Recommend at least three postpartum visits:
 Two weeks: stabilize all medications and

maintenance doses.
 Four weeks...
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There are no stupid
questions.

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But I have occasionally
been known to give
stupid answers.

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The goal: a happy
mot...
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The following section is
based on actual cases.
Similarity to anyone you
know is purely
coincidental and a
figm...
Current Evidence
Overdose
Withdrawal
Detoxification
Maintenance
Analgesia/Anesthesia
for Labor and Delivery
 NAS
 Breast...
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2002-2010
Four Groups: 212 Patients
1. Pain patients using only Opioids – 31
2. Pain patients Poly-substance Use – 45...
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Includes opioid/acetaminophen preparations.
N = 31
Preterm Labor: 4 (12.9%)
Positive Meconium (other than...
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Opioids plus cocaine, or THC or benzodiazepines or all
three or more
N = 45
Preterm Delivery: 8 (17.7%)
P...
Opioid (31)
Preterm Delivery:
LBW (<2500g):
Mean Birth Weight
Positive Meconium
NAS Treated
Mean Length of Stay
Failed to ...
Chronic pain patients managed with opioids in a
stable program are at low risk for NAS.
 In both groups doses ranged from...
N = 90 (92 babies)
Mean daily dose:
Preterm Delivery:
Mean newborn weight:
LBW (< 2500g):
 Positive meconium:
 Mean LOS
...
Subutex N = 12; Suboxone N = 34; Total N= 46
Mean dose 14 mg/day.; range 4-24 mg./day
 Preterm Delivery:
5 (10.9%)
 Mean...
Bup. (46)
Preterm Delivery
LBW(<2500g)
Mean Birth Weight
NAS
NAS Treated
Mean Length of Stay
Failed to return PP
PP “negat...
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Opioid dependent chronic pain patients in a
stable program can be managed by any OB
provider.
Opioid maintenance...
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A 32 year old presents to the labor suite at 32 weeks. She
complains of flu-like symptoms for three days ass...
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The mother was subsequently questioned about prior drug use and
revealed an “Oxy” (oxycodone) addiction of 90 mg...
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Opioid metabolism increases in
pregnancy.
 Unless opioid use is adjusted, many patients will

go into withdrawal.

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...
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Hydrocodone, oxycodone and methadone metabolism
Increases with each trimester.
Subtle in 2nd trimester and ...
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High rate of preterm labor - 41%
Increased abruption - 13%
Low Birth weight – 27%
Increased incidence HI...
Prevention of withdrawal is paramount.
The risk of adverse events to the baby from
withdrawal is far greater than from the...
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Michele B. is a 22 y/o
who presents to the
ED comatose barely
breathing.
She appears to be
pregnant at term.
F...
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Characterized by
pinpoint pupils,
respiratory depression,
coma, and pulmonary
edema, then death.
Establish airw...
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Treatment will precipitate a severe withdrawal.
Will need to restart and modify an opioid dose
For maintenance, ...
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Sara P. is a 28 y/o who
presents for her first
prenatal visit at 20
weeks gestation by
dates.
US confirms dates...
Patient presents with abdominal pain, cramps and
diarrhea and may complain of contractions.
 Signs and symptoms often con...
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CNS –hyperactivity in adults; tremors & seizures
in newborn
Metabolic – sweating; yawning
Vascular – hot flas...
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Short Acting (heroin;
morphine; vicodin):
 begins 6-24 hours;
 peak 1-3 days;
 lasts 5-7 days

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Methadone:
 Begin...
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She “ran out” of meds:
 Very common
 Most likely using more than prescribed because of

increased metabolism.
 And, ...
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Methadone vs. Buprenorphine maintenance
Buprenorphine: (key requirements)
 Must be motivated to use buprenorphine
 ...
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Careful review of recent drug use.
Always have Naloxone immediately available.
Check acetaminophen levels in pati...
May use during stabilization
with Buprenorphine or
Methadone or other Opioids
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Phenergan 25 mg q 4-6 H for
withdrawal sy...
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Liz C. is a 35 y/o G 4 P3003 at 31 weeks
long term methadone maintenance
currently at 120 mg/day.
 All UDS negative fo...
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Methadone Withdrawal
 Methadone typically lasts 25-26 hours
 Methadone is more rapidly metabolized as the pregnancy p...
Encourage patient to remain on methadone during
pregnancy.
 Expect dose to increase up to 50% during pregnancy in
about 3...
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Patient must be in opioid withdrawal to start
buprenorphine treatment.
Inpatient: some recommend initiating...
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Epidural – labor/delivery/cesarean
Spinal
Can use intra-thecal opiates/caines
Post op pain management
 Use stand...
Christine O. is A 32 y/o G3 P2002 at 16 weeks
on methadone maintenance at 95 mg/day. She
is a chronic pain patient (gunsho...
Must be closely controlled.
Benefits rarely outweigh risks. Studies indicate 56%
relapse within a month.
 Gradual reducti...
She decreased her
dose to 5 mg. per day
 She went into preterm
labor at 33 weeks.
 The baby was
otherwise well but
spent...
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Hillary C. is a 34 y/o G3P2002, 2 prior C-sections, had a
back injury 6 years ago and multiple back surgeries.
She h...
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Patient did well during pregnancy.
Had a repeat C section and went home on day three
Baby was not observed to hav...
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Maintain current opiate regimen – avoid
withdrawal (both legal to do and meets
standard of care)
 Hydrocodone 5/325 or...
 Concomitant use of two or more psychoactive

substances, in quantities and frequencies that cause
individually significa...
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Opioids and
Benzodiazepines.*
Opioids, THC, and
Cocaine.
Opioids plus:
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Methamphetamines
Barbiturates*...
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Maintain or stabilize opioid component.
Prevent withdrawal
Reduce or eliminate benzodiazepines.
Eliminate ill...
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Used in patients for musculoskeletal spasm and pain.
Most often used for anxiety/panic disorder.

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Alprazolam and C...
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Babies of mothers treated with therapeutic
doses of hydrocodone rarely have NAS
Morphine & Heroin – acute, sev...
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CNS signs:
 Irritability, excessive crying; voracious appetite
 Seizures in newborns (but not in adults)

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...
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Combination therapy
 Oral clonidine; phenobarbital (symptomatic)
 Dilute morphine drops

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Increase morphine dos...
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Data indicates buprenorphine safe and
effective in weaning newborn from
methadone with reduced length of stay
when comp...
Long half life
BUT, transfer to milk is minimal.
Maternal dose of 80 mg. per day (typical) yields
infant dose about 2.8% o...
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Substantially reduced NAS.
Minimal to no effect on breastfeeding.
 Although some “lay” websites indicate breastfeedi...
Hydrocodone, oxycodone and fentanyl.
Usual doses for pain relief appear to have
minimal to no effect on infant.
 However,...
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Documented High
dose in Breast
Milk,
Resulted in a
documented infant
death.
Breast feeding
contraindicated.
Does breastfeeding enhance or detract from
ongoing recovery in the postpartum patient?
 The most common cause of relapse ...
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Pregnant addicts want to get better.
Addiction in pregnancy is treatable.
The average competent provider is ex...
And Now for Something Completely
Different…
Jennifer Nocon, Wolf in Fig Tree, 2010
Screening and Detection
Including Urine Drug Screens
A Brief Intervention Process:

FRAMES
First, An Important Digression:
• Alcohol and tobacco cause more fetal
damage,
• Than all the other drugs combined.
Strong Link Between Alcohol/Nicotine Use
and Use of Illicit Drugs
• Among Women using BOTH Alcohol and
Nicotine in the pre...
Knowing That, If You Were to Ask
Only One Question to
Screen for Substance Use

Do you Smoke?
If yes, get a urine drug
scr...
Screening Strategies
 There is no “holy grail” for screening, that is, there is no
single or simple method that works acr...
Screening and Detection
 A combination of screening tools will lead to an
increased level of detection.
 The more freque...
Ethical Duty To Screen all Pregnant and
Postpartum Women for Substance Use
 The American College of Obstetricians and
Gyn...
Universal Screening Means:
That every obstetrical patient is
asked about substance use.
 At the first prenatal or intake...
Why Universal Screening?
Early Detection Leads to Earlier Intervention
 Smoking cessation by 20 weeks:

 Many of the adv...
Screening Leads to Earlier Intervention:
Meconium Testing in 40 Term Newborns of
“Crack” Cocaine Positive Mothers Treated ...
Universal Screening
Is Highly Cost Effective

 When identified and treated:






Rate of abstinence increases,
Mate...
A Basic Screening Strategy
 Start with Two-Item Screen

 Follow with Four P’s Plus or CRAFFT
 Specificity about 75%
 F...
Initial Screening
Focus on Alcohol and Tobacco
 The Author recommends the following combinations
for their ease of use an...
Start with the Two-Item Screen
1. In the last year have
you ever smoked
cigarettes, drank
alcohol or used any
drugs more t...
Two Item Screen
Validity Test


Two random samples of primary care patients
(434 and 702 participants) aged 18 to 59 had ...
Negative Answers on
Two Item Screen
 If the patient states she does not use ATOD, she
is at low risk for substance use.
...
Four P‟s (Plus) Screening
 Did any of your PARENTS have a problem with alcohol or
drugs?
 Do any of your PEERS have a pr...
Four P‟s Plus Results
 A “yes” answer to any question was considered positive.

 The modified 4 P‟s Plus screen adds a q...
CRAFFT
 C - Have you ever ridden in a CAR driven by someone (including
yourself) who was high or had been using alcohol o...
CRAFFT continued
 The authors indicate two or
more positive answers to
CRAFFT indicate a need for
further evaluation.
Cha...
Negative Answers
Two Item Screen and 4P‟s Plus or CRAFFT
 This is typical of about 85% of your patients and
you have just...
When the Screen is Positive:
 Patient is at risk for substance use

 Does not mean she is using.
 Urine Drug screen ind...
Strategies for Using Urine Drug
Screens (UDS) Effectively
 Can be used to determine prevalence in a
population:
 consent...
OPT OUT Approach
to Urine Drug Screens
 Inform patient about routine prenatal care and frequency
of visits.
 Inform pati...
Opt Out Rationale
 State laws are very liberal about what constitutes child
abuse.
 A patient who opts out of a urine dr...
Urine Testing
 It is important to distinguish
urine testing as a screening
process from urine testing
as a treatment adju...
How Long is a Drug Detectable
in Urine After Use?
Alcohol

24 hrs

Amphetamines

48 hrs

Barbiturates

Short acting

48 hr...
Strategy for Routine Urine Testing for
Substance Use in Pregnancy
 First visit even if late
prenatal care.
 If 1st visit...
What Should the Urine Test
Include?
 Depends on the drug use in the area – why a
meconium prevalence study is necessary
...
Urine Drug Screens Indicated:
 At each prenatal visit for any
patient identified as a
substance user.

 Missing appointm...
Intervention Strategies
That Actually Work and are Easy to Implement

 FRAMES – 3-4 minute intervention
 Developed for a...
136

Feedback Tool
Four Points For Clear Communication:

And Clearing up Agreements and Expectations.

1.
2.
3.
4.

Data –...
Feedback: Clearing Up the Data
How it Works
 Always start with the data, an objective description of the
behavior.
 And ...
138

Connecting Through Feeling
 This is about your feeling:
 Use the following four basic feelings:
 Fear (afraid), Sa...
139

Judgment or Opinion
 This is your judgment or opinion and not necessarily
the truth.
 It‟s important to “own” the j...
Feedback:
Ask For What You Want
 What do I want to have happen?

 Key is to be specific – ask for something the patient
...
141

Feedback Summary:
The Four Point Approach to Feedback
 Clarifies the issues

 The capacity to share
feelings enhanc...
142

Feedback from Friends
 A friend told me to always remember:
 What other people think of me is none of my
business.
...
What‟s At Risk
Is a Powerful Therapeutic Tool
 What’s at risk for you to stop smoking cigarettes?
 The patient may say t...
What‟s At Risk?
The Benefits of the Behavior
 Whatever the answer, the question brings the patient into
an awareness of t...
145

What‟s At Risk?
Clinical Example
 At the first visit of a pregnant patient who tested
positive for cocaine.
 I ask,...
146

Follow Up What‟s at Risk
 Follow up quickly with a doable approach, that is, ask if
they are willing to cut down on ...
Now that you Have the Tools,
Let’s do a Brief Intervention
FRAMES INTERVENTION
 FRAMES was used in a World Health Organiz...
FRAMES:
Elements of a Brief Intervention
 F - Feedback about the adverse effects of drugs or
alcohol
 R - Responsibility...
Clinical Example: Patient Admits to Drug
Use, or Has a Positive UDS
 The patient answered “yes” to the 2nd question in th...
First: Ask about Cocaine Use
 What type of cocaine do you use?
Crack

 How often do you smoke crack?
4-5 times per week
...
FRAMES Intervention for Cocaine
Works for Alcohol, Tobacco and Other Drugs.

 Feedback
 About the adverse effects of Coc...
FRAMES Intervention
Responsibility
 Responsibility





For a change in behavior
Two simple statements:
“Only you can...
FRAMES Intervention

Advise
 Advise to reduce or stop use:
 “Harm reduction” strategy works surprisingly
well.
 Medical...
FRAMES Intervention
Menu of Options:
 Offer a MENU of Choices:
 "If you find that cutting back for the next week is
impo...
FRAMES Intervention
Empathy and Self Empowerment
 Empathy is central to the intervention.
 “I realize this must be real ...
FRAMES:
a Motivational Empowerment Approach
 Less emphasis on diagnostic label: “alcoholic;” “addict.”

 Reduces risk of...
The Motivating Questions
(to ask at every visit)
 “How will your life be better by not using (fill
in with substance)?”
...
Some Conclusions
 Addiction in pregnancy is treatable.

 We have a duty to screen and treat.
 Screening takes less that...
The End, at least for now.
 Thank you for patiently persevering through
this lengthy presentation.
 This PowerPoint and ...
Addiction In Pregnancy Ver.2
Addiction In Pregnancy Ver.2
Addiction In Pregnancy Ver.2
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Addiction in Pregnancy: Addiction Theory; Screening and Detection; Clinical Management; Brief Intervention

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Addiction In Pregnancy Ver.2

  1. 1. James J. Nocon, M.D., J.D. © 2014 jnocon@me.com
  2. 2.  Addiction Theory:      An approach to understanding addiction. A review of addiction neurobiology. Scope of addiction in pregnancy Unique issues for women and pregnancy. Clinical Management – Case Scenarios  General principles.  Focus on prescription drug abuse: Opioids.  Screening and Brief Interventions:  Simple screening strategies.  Effective brief intervention techniques.
  3. 3.   Few Medical Schools Teach Addiction Medicine “Not enough time in curriculum.”  Addiction occurs in 1 in 10 patients, and  Directly affects at least 25% of the population.   Minimal faculty with any training. “Students resist learning,” (did med school deans actually say this was a reason for not teaching addiction medicine?).   Miller NS,Sheppard LM, Colenda CC, and Magen J. Why physicians are unprepared to treat patients who have alcohol and drug-related disorders. Acad. Med. 2001;7:410–418. What are the critical elements in treating addiction?
  4. 4.  What are the critical elements in treating addiction?  Attitude (Compassion goes a long way)  Attitude (Non-judgmental)  Attitude (Roll with the Resistance)  Poor Attitudes lead to Shame Based treatment:  52% of physicians agreed that drug use in pregnancy constituted child abuse.  60% of OB nurses hold punitive attitude to laboring addicts even when patient is in recovery
  5. 5.   Special shame reserved for addictive mothers. Criminalized for using drugs while pregnant  N.J. Div. of Youth & Family Servs. v. Y.N. (2013)  This is a case in which a New Jersey Appellate Division Court ruled that a woman who obtains medicallysupervised methadone treatment during pregnancy may be found to have abused or neglected her child.  In contrast, when patients and providers have a positive attitude, pregnancy enhances recovery. 5
  6. 6.  In a special clinic for “drug abuse in pregnancy” renamed (with a positive attitude) the “Prenatal Recovery Clinic:”  2002 to 2012  80% of opioid dependent patients in stable maintenance program and free of other illicit or illegal drugs.  In contrast, in the same clinic in the years prior:  85% of such patients tested positive for illicit or illegal drugs (especially cocaine and marijuana)* *Brown HL, Britton KA, Mahaffey D, Brizendine E, Hiett AK, Turnquest MA. Methadone maintenance in pregnancy: a reappraisal. Am J Obstet Gynecol 1998;179:459-63.
  7. 7.   Pregnancy enhances long-term recovery. After one year of treatment:  65.7% of women who entered treatment while pregnant used no drugs, while  Only 27.7% of non-pregnant women remained drug free. (p<0.0005)   Peles E, Adelson M. Gender Differences and Pregnant Women in a Methadone Maintenance Treatment (MMT) Clinic. J Addictive Diseases 2006; 25: 39-45. A similar result in the Prenatal Recovery Clinic:  65% of women were drug free at 6 months postpartum.
  8. 8.    Do we all feel good when someone says something nice about us? Does that lead to a positive attitude? What does it take to make you say,  “That made my day.” There’s a simple way to do this.  It’s all about Affirmations. 
  9. 9.  You can affirm patients, friends, relatives, loved ones, even strangers and especially your enemies. Acknowledge their Appearance: (“Your tie is so colorful”),  Affirm their Character: (“I trust your compassionate outlook”),  Affirm the Effect they have on you: (“I am safe with you”),  Acknowledge their Skills: (You did a great job presenting the lecture)  9
  10. 10.    Enhances self worth and self esteem. Something almost always absent in addicts. When I affirm someone, I am also affirming myself.  An Affirmation is almost always about something about myself that I see in the other person.  Affirmations to use with patients:   “I am proud of you for coming for care.” “I am proud of you for staying clean.”
  11. 11. Affirm someone every day, especially those close to you.  Pay attention to their reaction.  What effect did the affirmation have?  What effect did it have on you?  Take a risk, affirm the first person you see every day.  Your life, as you know it, will never be the same.  11
  12. 12. 12
  13. 13.     Great question. Like obscenity, hard to define but, “I know it when I see it.” Lack of Moral Character – most prevalent theory. Disease Model of Addiction – Neuro-science Positive Reinforcement theory:  Leads to the initial repetition of drug taking that becomes habitual and eventually compulsive.  Because it feels so good.  Negative Reinforcement theory:  By the time the brain is hijacked by the addictive drugs or behavior, the addict no longer uses the drug or behavior ONLY for the “buzz.”  They use the drug, or act out, just to feel “normal.”  Otherwise, they get “sick.”  Wise RA and Koob GF. The Development and Maintenance of Drug Addiction. . Neuropsychopharmacology 39:254-262, 2014
  14. 14.   As Voltaire is said to have replied when the Marquis De Sade invited him to a second orgy, since he enjoyed the first one so much: “No Thanks,  Once, a philosophy.  Twice, a perversion.”  He might have added:  “Three times, an addiction.”
  15. 15. Entitlement/Despair: I’m entitled to feel good, or things are horrible and I need something to help me feel good. Despair: the effect wears off Preparation: obsessing on how to feel good; what to use or do. Acting out: Using or doing, or both.
  16. 16.    “A primary, chronic disease of brain reward, motivation, memory and related circuitry.” ASAM describes five characteristics (the ABCDE) in its definition:  “Inability to consistently Abstain;  Impairment in Behavioral control;  Craving; or increased “hunger” for drugs or rewarding experiences;  Diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and  A dysfunctional Emotional response” American Society of Addiction Medicine. Public Policy Statement. The Definition of Addiction (Long Version) Approved April 12, 2011. http://www.asam.org/DefinitionofAddiction-LongVersion.html
  17. 17.  Researchers have noted that  Addiction is a chronic relapsing disease.  Successful treatment is comparable to, or better than, compliance with treatment plans for hypertension or diabetes.  And like diabetes and hypertension, addiction is an interaction between:  The substance: alcohol, tobacco and other drugs  The host: genetics, vulnerabilities, co-morbid disorders  The environment: family, culture  McLellen AT, Lewis DC, O‟Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance and outcomes evaluation. JAMA 2000;284:1689-1695.
  18. 18.  What drugs and behaviors have in common, which results in “the buzz,” is the release of various neurotransmitters in the nucleus accumbens in the brain.  Dopamine gives you the “buzz.”  Addiction depletes dopamine and the altered brain cannot manufacture sufficient dopamine to function in a normal manner.  Antidepressants that are dopamine reuptake inhibitors are effective in stabilizing dopamine levels
  19. 19.   Ventral Tegmental Area (VTA)  Nucleus Accumbens – dopamine rich center in the limbic area  Prefrontal Cortex – short term memory  Amygdala – moderates emotional influences on memory – fear response  MFB: medial forebrain bundle These are the primary centers involved in pleasurable sensations. 19
  20. 20.     Serotonin – sense of well being. Endorphins – euphoria. GABA (gamma amino butyric acid) – satiety and somnolence (sleepy after a big meal or sex). Cannabinoids – the human brain has more cannabinoid receptors than any other drug. Also receptors very high in the CNS, ANS, the reproductive and immune systems. 20
  21. 21.     Tolerance: as repeated use of the drug or behavior depletes the dopamine, more use or more drug, or both, is required to get the same effect. Dependence: Removal of the drug or behavior will create withdrawal. Withdrawal: physical and emotional symptoms, often profound. Addiction: There comes a point when the affected person becomes an addict, as if a switch in the brain is flipped, and the person no longer has the ability to make free choices about the continued use of the drug.  Leshner AI. Addiction is a brain disease, and it matters. Science 1997;278:45-47
  22. 22.       PET/MRI has mapped the location in the brain where drugs and behaviors have their effects. The meso-limbic dopamine system is the primary site of dysfunction - the “pleasure center.” Addiction depletes dopamine and the altered brain cannot manufacture sufficient dopamine to function in a normal manner. This process occurs in all addictive drugs and behaviors. Wise RA. Addictive drugs and brain stimulation reward. Ann Rev Neuroscience 1996;19:319-340. McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricuarte GA. Positron emission tomographic evidence of toxic effect of MDMA (“Ecstasy”) on brain serotonin neurons in human beings. Lancet 1998;352:1433-1437.
  23. 23. Addiction is a “double whammy.” 1. 2. Tolerance - The brain needs more and more of the drug in order to get the same effect. And in this process, the brain cells are actually altered. Drugs reduce fear response in Amygdala and Prefrontal cortex – person uses more drug with less fear of consequences. McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricaurte GA. Positron emission tomographic evidence of toxic effect of MDMA ("Ecstasy") on brain serotonin neurons in human beings. Lancet 1998 Oct 31;352(9138):1433-7. 24
  24. 24.  Three critical factors stimulate stem cells to repair and rebuild neuro-circuitry  Nutrition and exercise.  Folic acid important (prevents CNS defects in fetus)  Reading is critical to rebuilding new circuitry It takes 8-12 months for stem cells to make effective repairs.    Relapse in the first 3 months is high. Relapse after 9 months is less than 10%.
  25. 25.       Addiction is primarily a disease of the brain, which was not taught to most of us. Addiction fits the medical model. Successful treatment of addiction is actually better than compliance in hypertension and diabetes management. A positive attitude is required. Patients actually want to get better. What is the scope of the problem and what are the issues for addiction in pregnancy?
  26. 26. Treatment highly cost-effective Reduction in preterm delivery accounts for huge benefits for the children and huge savings for the taxpayer.  Sad to say: when physicians were required to drug test and report drug use, Black women were 10 times more likely to be reported to authorities by M.D. than White women.    Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med 1990;322:1202-6.
  27. 27. Approximately 89,000 deliveries. At least 25% use tobacco Estimates vary from a low of 10% to a high of 20% using alcohol, illegal or illicit drugs in pregnancy.  For purposes of this presentation, the estimate is 15% (consistent with other US data)     13,350 patients of which 90% go undetected, or  12,015 untreated patients and newborns
  28. 28.       About 89,000 deliveries in Indiana 51% funded by Medicaid – 45,390 15% substance use - 6,808 90% are undetected – 6,127 35% Preterm delivery – 2,144 Mean nursery cost per preterm $75,000  Total cost just for the nursery stay:  $160,800,000.00
  29. 29.        Estimated 6,800 Substance users 3400 detected (D) – 3400 undetected (U) 20% Preterm delivery D = 680 35% Preterm delivery U = 1190 Total is 1870 preterm deliveries Difference from 90% U is 2144 - 1870 = 274 At $75,000 per “Premie” nursery cost, detection of 50% saves Medicaid at least:  $20,550,000.00 – that‟s 20 Million dollars just for the nursery LOS.
  30. 30.     Alcohol and tobacco, often used in combination, cause far more fetal damage than all other drugs combined. Both Legal to use. Women are not “criminalized” for smoking cigarettes during pregnancy Yet far less harmful drugs, also legal, can lead to a felony conviction in 25% of the U.S.
  31. 31.  Marijuana most common. Two surveys in Indiana are consistent with U.S. data.  29% tested positive for THC on the first prenatal visit in a major Southwestern Indiana Hospital (2006)  40% positive for THC in a similar Indianapolis survey (2005)  In both surveys, all patients were detected by a urine drug screen at the first prenatal visit.
  32. 32.  The number one preventable public health issue in pregnancy. Two major subgroups: 1. Those who are dependent or addicted to any one of the following Rx: ▪ Opioids: hydrocodone, oxycodone, methadone ▪ Benzodiazepines: Xanax, Klonopin, Valium ▪ Amphetamines: (ADHD Rx abuse) ▪ Antidepressants: (overprescribed for women) 2. Those dependent or addicted to any combination of the above. ▪ Poly-substance use and abuse.
  33. 33.  A 30 y/o woman, back pain from injuries in a MVA, takes  10 mg. hydrocodone/325 acetaminophen 4x, daily  50 mg. amitriptylene at bedtime, daily.  Stable relationship; 2 kids doing well.  Good full-time job, enjoys life.   What percent of women dependent on medications vs. what percent are addicted? Does it matter?
  34. 34.               Cocaine: all forms Amphetamines – Increasing abuse of ADHD prescriptions – 10-20 year olds Methamphetamine Ecstacy Rohypnol GHB Ketamine PCP Salvia LSD and other hallucinogens Anabolic steroids Inhalants Nicotine, and Alcohol.
  35. 35.  2002-2007: 69/287 patients (24%) tested positive for opioids  43 patients in Methadone Maintenance  4 patients on Buprenorphine Maintenance  2008-2010: 75% tested positive for opioids  47 patients in Methadone Maintenance  42 patients on Buprenorphine Maintenance  More pregnant patients in maintenance with good outcomes, notwithstanding NAS.
  36. 36.   Gender includes both physical and emotional components that differ significantly.  Less alcohol dehydrogenase in women’s stomachs  More rapid uptake of alcohol into bloodstream: get drunk faster.  Get high faster with cocaine. The most significant emotional factor is the extraordinary high incidence of physical and sexual abuse of women with addictions.  If sexually abused as a child:  6 times more likely to become drug addict  4 times more likely to become an alcoholic ▪ Kendler KS, et al. Arch Gen Psychiatry. 2000;57:953-959.  PTSD (grossly under diagnosed): may be as high as 70-80% of addicted women.
  37. 37.  Opioids – women develop dependence quicker than men.   Ellinwood, et al. Narcotic addictions in males and females: a comparison. Int. J Addict 1966;1:33-45 Nicotine – women more likely to use smoking for weight control and reduce stress  Gritz, et al. Smoking cessation and gender: the influence of physiological, psychological and behavioral factors. J Am Med Women‟s Assoc 1996;51:35-42.
  38. 38.  Depression common – 45%  Did the depression contribute to the addiction?  Or vice-versa?  Substance Abuse - 19%  Many chronic pain patients have been treated with a benzodiazepine and easily become dependent: especially Xanax; Klonopin    Anxiety disorders – 16% (Xanax very common) PTSD (grossly under diagnosed) may be as high as 80% Bipolar – often unrecognized; be aware of aripiprazole – may cause significant HTN and Diabetes.
  39. 39. Need a Treatment Team  Create a Recovery Plan with a drug use agreement.  Follow with non stress tests, biophysical profiles and ultrasounds for growth restriction.  Encourage breast-feeding, especially in methadone patients  Instruct methadone and buprenorphine patients to take their maintenance dose on day of delivery or arrange for patient to receive maintenance dose at appropriate time after admission.  For acute postoperative pain, methadone and buprenorphine patients will gain relief with doses of opiates 70 to 100% over usual doses. 
  40. 40. Effective treatment can occur with a compassionate provider.  Pregnant addicts are not necessarily high risk but they can be “high maintenance.”  Thus, a team spreads the workload.  A basic team may include:      Provider (MD, OB Clinical Nurse, OB PA) Addiction Counselor (access to Psych services) Social worker Dietician: very important person.
  41. 41.      Pre-conceptual Counseling Prenatal Care Labor and Delivery Analgesia; Anesthesia Post Partum Care  A more detailed description of obstetrical guidelines in a “how to” format can be found:  Toolkit: Treating Opioid Dependence in Pregnancy  http://www.indianaperinatal.org
  42. 42. Especially helpful if you care for opioid dependent chronic pain patients and methadone and buprenorphine patients.  Will allow for a modification of opioid maintenance prior to pregnancy.  Evaluate existing medical problems, especially diabetes and hypertension.  Allows for a discussion of risks for the mother and fetus of substance use.  Especially helpful for the older mother to discuss genetic risks.  Allows for optimal diet and exercise counseling.  Allows for consultation with mental health providers for management of coexisting psychiatric co-morbidity.  
  43. 43.  Routine obstetrical care is modified for the substance user.      Perform all routine screening tests. Generally, prenatal visits occur every two weeks until 36 weeks, then weekly. Create a recovery plan with a drug use agreement. (drug contract) Urine drug screen at every prenatal visit – enhances recovery. Care coordination for psychiatric co-morbidity.  Encourage other forms of support: therapy, AA, etc.  Arrange to see social service consultant frequently.  Dietician review at each visit.  Growth restriction is common, especially in methadone maintenance patients.  Follow with non stress tests, biophysical profiles and ultrasounds for growth restriction.  Encourage breast-feeding, especially in methadone patients  Create a delivery plan.
  44. 44.       Decision for delivery based on obstetrical reasons. Stress of last few weeks of pregnancy places patient at risk for relapse. Induction of labor based on obstetrical reasons. Early induction for IUGR in methadone patients. Have detailed reports of drug use and maintenance medications available for nursing staff and anesthesiologists. Instruct methadone and buprenorphine patients to take their maintenance dose on day of delivery or arrange for patient to receive maintenance dose at appropriate time after admission.
  45. 45. Epidural anesthesia for labor, delivery and cesarean delivery is the standard.  Spinal anesthesia for cesarean delivery.  Intrathecal opioids very effective for acute pain relief.  For acute postoperative pain, methadone and buprenorphine patients will gain relief with doses of opiates 70 to 100% over usual doses.   The largest group of patients best tolerates morphine.  Hydromorphone (Dilaudid) also well tolerated  Typically, postpartum analgesia is to:  Start Ibuprofen 800 mg. every 8 hours  Alternating with oxycodone 10 mg, every six hours.  This regimen is effective for about 90% of patients.  In is imperative to inform the patient to continue her maintenance dose on the day of admission and to restart maintenance as soon as oral intake is tolerated.
  46. 46.  Recommend at least three postpartum visits:  Two weeks: stabilize all medications and maintenance doses.  Four weeks: Routine testing: Pap, STD, etc.  Six weeks: Social service consultation with focus on continued therapy, support and maintenance.    Urine drug screen at each visit. Breast feeding support at each visit. Family planning discussion at each visit.
  47. 47.  There are no stupid questions.  But I have occasionally been known to give stupid answers.  The goal: a happy mother and healthy baby.
  48. 48.     The following section is based on actual cases. Similarity to anyone you know is purely coincidental and a figment of your imagination. Names have been changed to protect the guilty. In this realm, there are no innocents.
  49. 49. Current Evidence Overdose Withdrawal Detoxification Maintenance Analgesia/Anesthesia for Labor and Delivery  NAS  Breastfeeding.      
  50. 50.   2002-2010 Four Groups: 212 Patients 1. Pain patients using only Opioids – 31 2. Pain patients Poly-substance Use – 45 3. Methadone Maintenance - 90 4. Buprenorphine Maintenance – 46 ▪ Subutex – 12 ▪ Suboxone - 34
  51. 51.         Includes opioid/acetaminophen preparations. N = 31 Preterm Labor: 4 (12.9%) Positive Meconium (other than opiates): none Mean newborn weight: 3085.9 grams LOS (newborn): 3.3 days; range 2-21 days NAS treated: 1 Intrapartum complications: 7  No overdoses.  Nicotine use (> 0.5ppd): 21 (67.7%)
  52. 52.         Opioids plus cocaine, or THC or benzodiazepines or all three or more N = 45 Preterm Delivery: 8 (17.7%) Positive Meconium (other than opiates): 12 (26.6%) Mean newborn weight: 2879 grams LOS (newborn): 7.8 days; range 2-89 days NAS treated: 5 Intrapartum complications: 7  One antenatal overdose – mother and fetus survived  One fatal postpartum overdose – “street methadone”  Nicotine Use (> 0.5ppd): 30 (66.6%)
  53. 53. Opioid (31) Preterm Delivery: LBW (<2500g): Mean Birth Weight Positive Meconium NAS Treated Mean Length of Stay Failed to return PP PP “negative” Opioid + (45) p 4 (12.9%) 3 3085 g 0 1 3.3 3 23 (74.2%) 8 (17.7%) 8 2879g 12 (26.6%) 5 7.8 13 25 (55.5%) NS NS NS 0.001 NS 0.01 0.01 NS Incidence of NAS treated in all opioid dependent patients in Prenatal Recovery Clinic: 6/76 or 7.8%
  54. 54. Chronic pain patients managed with opioids in a stable program are at low risk for NAS.  In both groups doses ranged from:   Hydrocodone: 40-80 mg./day  Oxycodone: 40-80 mg./day Even the polysubstance patients had reasonably good outcomes.  There is NO indication to shift these patients to methadone.  Doing so deviates from expected standards of care. 
  55. 55. N = 90 (92 babies) Mean daily dose: Preterm Delivery: Mean newborn weight: LBW (< 2500g):  Positive meconium:  Mean LOS  NAS treated:  Intrapartum Comp:  Nicotine:      90 mg.; range: 15-200 mg./day 28 (30%) 2718g 31/92 (33.7%) 9 (10.8%) 30.3 days 80 (86.9%) 15 51/90 (56.6%)
  56. 56. Subutex N = 12; Suboxone N = 34; Total N= 46 Mean dose 14 mg/day.; range 4-24 mg./day  Preterm Delivery: 5 (10.9%)  Mean newborn weight: 3079.5 g  LBW (< 2500g): 5 (10.8%)  Positive meconium: 3 (6.9%)  Mean LOS (days): 6.78; range 2-49*  NAS: 8  NAS treated: 6  Intrapartum Complications 8  Nicotine Use: 29 (63%)   * 3 newborns with benzodiazepine withdrawal.
  57. 57. Bup. (46) Preterm Delivery LBW(<2500g) Mean Birth Weight NAS NAS Treated Mean Length of Stay Failed to return PP PP “negative” Meth (90) p 5 (10.9 %) 4 3079 g 8 6 (13%) 6.78 days 13 (28.8%) 29 (65.1%) 27 (30%) 26 2718g 89 80 (89%) 30.3 days 28 (31.1%) 59 (65.5%) 0.001 0.01 0.005 0.001 0.001 0.001 NS NS See also, Kakko J, Heilig M, Sarman I. Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal growth and neonatal outcomes in two consecutive case series. Drug Alcohol Depend 2008 Jul 1;96(1-2):69-78.
  58. 58.     Opioid dependent chronic pain patients in a stable program can be managed by any OB provider. Opioid maintenance is far easier than managing diabetes in pregnancy. Even so-called “chronic pain” patients using other drugs are relatively low risk for NAS. Buprenorphine (Suboxone) is superior to methadone in all respects.
  59. 59.       A 32 year old presents to the labor suite at 32 weeks. She complains of flu-like symptoms for three days associated with chills, hot flashes and diarrhea. She is yawning frequently and appears exhausted. A urine drug screen is negative. The monitor tracing reveals mild short contractions every 2 minutes, a fetal heart rate of 160, and she is 4 cm. dilated and 50% effaced. Attempts to stop the contractions failed and she delivered a 1700gram pre-term male with Apgar scores of 7 and 9. The baby appeared well for about 6 hours and then developed a persistent irritable cry, tachypnea, restlessness and tremors. An astute nurse ordered a drug screen which revealed opioids, specifically oxycodone. The newborn was treated for NAS while spending 62 days in the NICU.
  60. 60.     The mother was subsequently questioned about prior drug use and revealed an “Oxy” (oxycodone) addiction of 90 mg per day. She ran out of drugs 3-4 days prior to admission. Note: Oxycodone and hydrocodone are more rapidly metabolized in pregnancy and a patient in withdrawal may test negative 3-4 days after last drug use. In retrospect, she presented in acute opioid withdrawal, which has a high incidence of: Abruption – 12%  Pre term Labor – 41%    She was started on buprenorphine/naloxone with a good response and agreed to addiction treatment. Six months later, she remained opioid free on buprenorphine/naloxone maintenance and attends an addiction treatment program.
  61. 61.  Opioid metabolism increases in pregnancy.  Unless opioid use is adjusted, many patients will go into withdrawal.  Withdrawal is more hazardous to mother and fetus:  Than NAS,  Than all other obstetrical conditions.
  62. 62.        Hydrocodone, oxycodone and methadone metabolism Increases with each trimester. Subtle in 2nd trimester and overt clinical withdrawal in 3rd. Up to 50% of patients affected. Doses may increase by 50% to prevent withdrawal. Methadone patient may be in chronic withdrawal by third trimester. Higher dose methadone actually has better outcome. McCarthy, J. J., M. H. Leamon, et al. (2005). "High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes." Am J Obstet Gynecol 193(3 Pt 1): 606-610.
  63. 63.         High rate of preterm labor - 41% Increased abruption - 13% Low Birth weight – 27% Increased incidence HIV; Hep B; Hep C Current recommendation is to avoid withdrawal during pregnancy This includes “detoxification” during pregnancy. The risk of adverse events to the baby from withdrawal is far greater than from the treatment of neonatal abstinence. Lam SK, To WK, Duthie SJ, Ma HK. Narcotic addiction in pregnancy with adverse maternal and perinatal outcome. Aust N Z J Obstet Gynaecol 1992 Aug;32(3):216-21.
  64. 64. Prevention of withdrawal is paramount. The risk of adverse events to the baby from withdrawal is far greater than from the treatment of neonatal abstinence.  Treatment may include increasing the opioid dose.     Efforts to wean off or “detox” opiates in pregnancy carry an increased risk of harm to the fetus. This represents a shift in the standard of care from “lowest possible dose” to “appropriate” doses to prevent withdrawal.
  65. 65.      Michele B. is a 22 y/o who presents to the ED comatose barely breathing. She appears to be pregnant at term. Fetal heart rate is 180 BPM. There is some froth to her breath. Diagnosis?
  66. 66.     Characterized by pinpoint pupils, respiratory depression, coma, and pulmonary edema, then death. Establish airway. Inject Naloxone – repeat if long acting opiate present, e.g., methadone. Naloxone will not harm fetus.
  67. 67.     Treatment will precipitate a severe withdrawal. Will need to restart and modify an opioid dose For maintenance, use methadone or buprenorphine Methadone:  Start at 20 mg BID and increase 5-10 mg per day until stable.  (Some suggest starting at 10 mg. BID)  Buprenorphine/naloxone:  start at 2 – 4 mg;  increase by 2-4 mg every 6 hours until withdrawal is abated.
  68. 68.     Sara P. is a 28 y/o who presents for her first prenatal visit at 20 weeks gestation by dates. US confirms dates. She is using 180 mg of “oxy” per day and her last dose was 2 days ago. She is yawning constantly, appears sleepy and complains of hot flashes.
  69. 69. Patient presents with abdominal pain, cramps and diarrhea and may complain of contractions.  Signs and symptoms often confused with “the flu.”  Also has yawning, lacrimation, restlessness; may have tachycardia.  UDS may be negative for opiates! (many metabolites cleared in urine during early withdrawal.  A typical history reveals Rx for hydrocodone/acet. 5/500 for injuries in auto accident years ago   Admits taking more than prescription allows – commonly up to 15 - 20 pills a day  UDS positive for opiates; often find THC, Benzodiazepines, cocaine.
  70. 70.       CNS –hyperactivity in adults; tremors & seizures in newborn Metabolic – sweating; yawning Vascular – hot flashes and chills Respiratory – increased rate; respiratory alkalosis GI – cramps, nausea, vomiting, diarrhea Drug specific effects – methadone has a prolonged withdrawal: 10 – 20 days.
  71. 71.  Short Acting (heroin; morphine; vicodin):  begins 6-24 hours;  peak 1-3 days;  lasts 5-7 days  Methadone:  Begins 1-3 days;  peaks 3-6 days;  Lasts 2 weeks or more
  72. 72.  She “ran out” of meds:  Very common  Most likely using more than prescribed because of increased metabolism.  And, pregnancy will increase pain, especially in lower back as belly gets bigger.  May need “early refill” and closer monitoring.  Or, did someone “steal” her meds.  Is there an “agreement” in place.
  73. 73.   Methadone vs. Buprenorphine maintenance Buprenorphine: (key requirements)  Must be motivated to use buprenorphine  No more than one prior buprenorphine use  No poly-substance use, especially benzodiazepines  Psychiatric co-morbidity – other meds? Interactions?  Needs to attend counseling, at least once per month  UDS every prenatal visit.   Methadone by default. Detoxification is NOT a good strategy.
  74. 74.     Careful review of recent drug use. Always have Naloxone immediately available. Check acetaminophen levels in patients using opiate/acetaminophen compounds. Stabilizing withdrawal:     Oxycodone: may use oxycodone 10-20 mg q 4-6h for up to 72 hours to stabilize patient in withdrawal and then switch to buprenorphine. Buprenorphine: 2-4 mg. every 4-6 hours: most stable between 816 mg. Methadone: 10-20 mg BID, increasing dose by 5-10 mg daily. Buprenorphine most rapid and least risky for pregnant patient.
  75. 75. May use during stabilization with Buprenorphine or Methadone or other Opioids  Phenergan 25 mg q 4-6 H for withdrawal symptoms – best for nausea, vomiting and GI symptoms  Phenobarbital, 30 mg TID for neurological withdrawal symptoms.  Clonidine 0.1 mg TID – vascular withdrawal symptoms; hot flashes and chills.
  76. 76.  Liz C. is a 35 y/o G 4 P3003 at 31 weeks long term methadone maintenance currently at 120 mg/day.  All UDS negative for any other substances  Depressed but stopped taking her Sertraline due to “suicidal” thoughts one week ago.  Complains of electric shock like feelings in her brain.  Also waking up about 3-4 AM with nausea, cramps, muscle aches and sweating.
  77. 77.  Methadone Withdrawal  Methadone typically lasts 25-26 hours  Methadone is more rapidly metabolized as the pregnancy progresses  Characteristic of this process is that the patient wakes up in withdrawal  Typically needs to increase dose of methadone 5-10 mg and assess: eventually may need 50% increase  Sertraline Withdrawal  “Brain Zaps” (not documented but often reported)  Otherwise symptoms similar to methadone withdrawal  May need to start an anti-depressant with a longer half life such as fluoxetine or citalopram.  Patients on multiple drugs may have complicated withdrawals.
  78. 78. Encourage patient to remain on methadone during pregnancy.  Expect dose to increase up to 50% during pregnancy in about 35% of patients.  Doses typically range from 50-150 mg. per day.  Higher doses not associated with severity of NAS but improve maternal compliance with prenatal care.*  Patient should be encouraged to breast feed.  Note: Methadone was never FDA “approved” for treatment for opiate dependence in pregnancy.   *McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet Gynecol 2005;193:606-10.
  79. 79.        Patient must be in opioid withdrawal to start buprenorphine treatment. Inpatient: some recommend initiating treatment with buprenorphine, 2-4 mg sublingual by either tablet of film. Increase dose by 2-4 mg every 6 hours to stop withdrawal symptoms. Convert to buprenorphine/naloxone for outpatient use. Target doses range from 4 to 24 mg per day Most pregnant patients are stable at 8-16 mg per day in divided doses. Withdrawal from buprenorphine is much milder than all other opioids.
  80. 80.     Epidural – labor/delivery/cesarean Spinal Can use intra-thecal opiates/caines Post op pain management  Use standard opiates – morphine, Dilaudid  Use 70-100% more or double the dose for a morphine or Dilaudid pump  Ibuprofen; 800 mg q 8 h as soon as tolerated  Lots of stool softener
  81. 81. Christine O. is A 32 y/o G3 P2002 at 16 weeks on methadone maintenance at 95 mg/day. She is a chronic pain patient (gunshot wound) and stable at this dose.  She chose to self detox by 5 mg a week.  Apparently, the methadone clinic was cooperative.  She was made well aware of the risk of pre-term labor, among other issues. 
  82. 82. Must be closely controlled. Benefits rarely outweigh risks. Studies indicate 56% relapse within a month.  Gradual reduction to minimize withdrawal  Symptomatic treatment: Typical doses:  Phenergan 25 mg q 4-6 H for withdrawal symptoms – best for nausea, vomiting and gastrointestinal symptoms  Phenobarbital, 30 mg TID for neurological withdrawal symptoms.  Clonidine 0.1 mg TID – vascular withdrawal symptoms.  
  83. 83. She decreased her dose to 5 mg. per day  She went into preterm labor at 33 weeks.  The baby was otherwise well but spent about 60 days in the NICU.  A cautionary tale. 
  84. 84.   Hillary C. is a 34 y/o G3P2002, 2 prior C-sections, had a back injury 6 years ago and multiple back surgeries. She has chronic pain, attends physical therapy weekly. She presents at 12 weeks for prenatal care. Pain medication includes:  Percocet 10/325; 2 q 6 h  Fentanyl patch 0.75 mcg every 72 hours (10 per month)   She works full time as a truck dispatcher and wants to continue working. She states she has pain and it is tolerable but is most concerned about not being to get to sleep. „If I can‟t sleep, I always have a bad pain day.”
  85. 85.     Patient did well during pregnancy. Had a repeat C section and went home on day three Baby was not observed to have withdrawal. Adequate sleep is very important for chronic pain patients.  Benadryl, up to 100 mg h.s., will work for many patients.  Tricyclic Anti-depressants appear to work well for sedation and pain moderation  Amytriptyline 50 mg h.s. is typical starting dose; can go to 150 mg.  Fine PG, Miaskowski C, Paice JA. Meeting the challenges in cancer pain. J Support Oncol. 2004;2(suppl4):5-22  Avoid benzodiazepine medications.
  86. 86.  Maintain current opiate regimen – avoid withdrawal (both legal to do and meets standard of care)  Hydrocodone 5/325 or 10/325 (up to 2 tabs q 6h)  Oxycodone 5/325 or 10/325 (up to 2 tabs q 6h)  Low rate of NAS noted with these doses   Requirement of opiate may increase Pain moderators may be helpful  Amytryptilene 50-100 mg h.s.  Gabapentin 300 mg TID  Physical Therapy – maintain mobility.
  87. 87.  Concomitant use of two or more psychoactive substances, in quantities and frequencies that cause individually significant distress or impairment.  In one study, 107/287 or 37.2% of pregnant women presented for prenatal care with polysubstance use. ▪ Nocon JJ. Substance use disorders. In D.R. Mattison (Ed.), Clinical Pharmacology During Pregnancy (pp. 217-256). Boston: Elsevier (2013).  Common conditions with polysubstance use: ▪ ▪ ▪ ▪ Chronic pain conditions Fibromyalgia Bipolar Anxiety disorders
  88. 88.    Opioids and Benzodiazepines.* Opioids, THC, and Cocaine. Opioids plus:       Methamphetamines Barbiturates* Alcohol* Nicotine Too numerous to mention All of the above. *Deadly combinations
  89. 89.       Maintain or stabilize opioid component. Prevent withdrawal Reduce or eliminate benzodiazepines. Eliminate illegal substances – cocaine; THC Smoking Reduction Many require more intensive addiction counseling.
  90. 90.   Used in patients for musculoskeletal spasm and pain. Most often used for anxiety/panic disorder.  Alprazolam and Clonazepam are Category D  Abrupt cessation will cause withdrawal, often severe AND prolonged.  More prudent to prevent withdrawal.  Gradual wean tolerated  NAS:  Neonatal withdrawal will often occur and may be more severe than opioid withdrawal.  Benzodiazepines prolong NAS from opioids  Best to avoid starting benzodiazepine in pregnancy.
  91. 91.      Babies of mothers treated with therapeutic doses of hydrocodone rarely have NAS Morphine & Heroin – acute, severe NAS but rapid – over in 72 hours Methadone – prolonged – 14-28 days with 6-8 weeks not uncommon Buprenorphine – mild and often not requiring treatment Breastfeeding assists NAS recovery
  92. 92.  CNS signs:  Irritability, excessive crying; voracious appetite  Seizures in newborns (but not in adults)      GI signs: vomiting; diarrhea Respiratory signs: tachypnia; hyperpnea ANS signs: sneezing, yawning, tearing Finnegan Scale: (or Lipsitz Scale) Finnegan and Kaltenbach (1992) in Hoekelman (ed) Primary Pediatric Care. St. Louis; CV Mosby 1367-1378.
  93. 93.  Combination therapy  Oral clonidine; phenobarbital (symptomatic)  Dilute morphine drops    Increase morphine dose until signs of withdrawal controlled Maintain controlling dose for 2 days Then wean morphine dose every 1-2 days. AAP Committee on Drugs. Neonatal Drug Withdrawal. Pediatrics 1998; 101: 1079-1088.  Clinical Report: Neonatal Drug Withdrawal. Pediatrics 2012;129:e540– e560. 
  94. 94.  Data indicates buprenorphine safe and effective in weaning newborn from methadone with reduced length of stay when compared to morphine.  Kraft WK, Gibson E, Dysart K, et al. Sublingual Buprenorphine for Treatment of Neonatal Abstinence Syndrome: A Randomized Trial. Pediatrics 2008;122:e601-607
  95. 95. Long half life BUT, transfer to milk is minimal. Maternal dose of 80 mg. per day (typical) yields infant dose about 2.8% of maternal.  Some studies indicate concentrations in breast milk unrelated to maternal methadone dose.  Appears to have mitigating effect on NAS – shorter LOS of breast-fed infants.     Phillip BL, Merewood A, O‟Brien S. Methadone and breastfeeding; new horizons. Pediatrics 2003;111:1429-1430.
  96. 96.   Substantially reduced NAS. Minimal to no effect on breastfeeding.  Although some “lay” websites indicate breastfeeding is contraindicated,  All the evidence supports breastfeeding  If it is used to treat NAS in newborn and the dose from breast milk is substantially lower, then breastfeeding is not a problem.  Kraft WK, et al. Sublingual buprenorphine for treatment of neonatal abstinence syndrome: a randomized trial. Pediatrics; published online August 11, 2008.
  97. 97. Hydrocodone, oxycodone and fentanyl. Usual doses for pain relief appear to have minimal to no effect on infant.  However, many of these patients also use pain moderators which may depress infant:    Benzodiazapines: Xanax; Klonopin  Gabapentin: Neurontin  Amytryptilene: Elavil (generally safe)  Cyclobenzaprine: Flexoril  High rate of tobacco use in these patients.
  98. 98.    Documented High dose in Breast Milk, Resulted in a documented infant death. Breast feeding contraindicated.
  99. 99. Does breastfeeding enhance or detract from ongoing recovery in the postpartum patient?  The most common cause of relapse is stress, and it doesn‟t take much.  If breastfeeding is not going well and the patient is experiencing significant stress, she is ripe for relapse.   Plays into low self esteem - “I‟m a failure”  Baby always crying – “I need some peace and quiet.”  Despair – using drugs to “numb out.”
  100. 100.      Pregnant addicts want to get better. Addiction in pregnancy is treatable. The average competent provider is expected to be able to treat uncomplicated opioid dependence in pregnancy. Treating addicts saves money. Putting them in jail costs 4-5 times more than prenatal care.
  101. 101. And Now for Something Completely Different… Jennifer Nocon, Wolf in Fig Tree, 2010
  102. 102. Screening and Detection Including Urine Drug Screens A Brief Intervention Process: FRAMES
  103. 103. First, An Important Digression: • Alcohol and tobacco cause more fetal damage, • Than all the other drugs combined.
  104. 104. Strong Link Between Alcohol/Nicotine Use and Use of Illicit Drugs • Among Women using BOTH Alcohol and Nicotine in the pregnancy • 20.4% used Marijuana • 9.5% used Cocaine • Women NOT using Alcohol or Nicotine • 0.2% used Marijuana • 0.1% used Cocaine Alcohol and Nicotine use is a “marker” for other drug use.
  105. 105. Knowing That, If You Were to Ask Only One Question to Screen for Substance Use Do you Smoke? If yes, get a urine drug screen. If no, AND she did not use alcohol in this pregnancy, it’s unlikely she is using illicit of illegal drugs.
  106. 106. Screening Strategies  There is no “holy grail” for screening, that is, there is no single or simple method that works across a range of addictions.  CAGE: alcohol in men.  TACE: alcohol in women.  TWEAK: alcohol in the current pregnancy  Two Item Screen: broad screen for current use  Four P’s Plus: broad screen for current pregnancy.  CRAFFT: reveals drug behavior in adolescents
  107. 107. Screening and Detection  A combination of screening tools will lead to an increased level of detection.  The more frequently the screening, the greater the degree of detection.  The evidence supports this premise.  And also indicates that screening is, in itself, a powerful form of intervention.  But first, is there a duty to do any of this?  And if so, why is there so much resistance?
  108. 108. Ethical Duty To Screen all Pregnant and Postpartum Women for Substance Use  The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 422 addresses the ethical rationale for universal screening for at-risk drinking and illicit drug use.  American College of Obstetricians and Gynecologists. At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. ACOG Committee Opinion No. 422, December 2008.  The American Medical Association also endorses universal screening.  Blum LN, Nielson NH, Riggs, JA. Alcoholism and alcohol abuse among women: report of the Counsel on Scientific Affairs. American Medical Association. J Womens Health 1998;7:861-871 111
  109. 109. Universal Screening Means: That every obstetrical patient is asked about substance use.  At the first prenatal or intake visit, and  At least once per trimester thereafter. Clear distinction between verbal screening and drug screening ACOG Committee Opinion No. 422, December 2008. 112
  110. 110. Why Universal Screening? Early Detection Leads to Earlier Intervention  Smoking cessation by 20 weeks:  Many of the adverse effects of nicotine, cigarette smoke and additives avoided, specifically: 20% of all low birth weight babies 8% of preterm babies 5% of all perinatal deaths Did we mention that tobacco causes more fetal damage than all the other drugs combined?  Cocaine cessation by 24 weeks Reduces prevalence of low birth weight and preterm labor 113
  111. 111. Screening Leads to Earlier Intervention: Meconium Testing in 40 Term Newborns of “Crack” Cocaine Positive Mothers Treated 2002-2007  All 40 tested positive for cocaine at first prenatal visit.  All used “crack cocaine.”  27 (67.5%) negative at birth: mean newborn wt/gm: 3253.55; s.d. 473.99  13 positive. mean newborn wt/gm: 2775.85: s.d. 466.68 p<0.01 (Author’s data base, Indiana University)  It takes 10-14 weeks for the meconium to “clear” after cessation of cocaine use - mechanism is unclear.  Thus, for a term newborn to be negative, the mother had to be drug free well before the third trimester.  Early intervention clearly reduces the low birth weight effects of cocaine use in pregnancy. 114
  112. 112. Universal Screening Is Highly Cost Effective  When identified and treated:      Rate of abstinence increases, Maternal and fetal complications decrease. Less Preterm labor Less Growth restriction Less abruption  Reducing preterm labor and low birth weight account for the largest savings.  Hubbard RL, French MT. New perspectives on the benefit-cost and cost-effectiveness of drug abuse treatment. NIDA Res Monogram 1991;113:94-113. 115
  113. 113. A Basic Screening Strategy  Start with Two-Item Screen  Follow with Four P’s Plus or CRAFFT  Specificity about 75%  Follow any “yes” answers with more specific evaluation.  Follow any “yes” answers with UDS at that visit.
  114. 114. Initial Screening Focus on Alcohol and Tobacco  The Author recommends the following combinations for their ease of use and high reliability.  Two Item Screen and Modified Four P’s Plus  Two Item Screen and CRAFFT  The screening questions should be asked at the initial history and physical and repeated at each trimester.  Starting with questions about legal substances, alcohol and tobacco, will be less threatening and patients are more likely to acknowledge use of legal rather than illegal substances. 117
  115. 115. Start with the Two-Item Screen 1. In the last year have you ever smoked cigarettes, drank alcohol or used any drugs more than you meant to? 2. Have you felt you wanted or needed to cut down on your smoking or drinking or drug use in the last year? 118
  116. 116. Two Item Screen Validity Test  Two random samples of primary care patients (434 and 702 participants) aged 18 to 59 had the following results:  “No” to each question: 7.3% chance of a current substance use disorder  1 yes answer: 36.5% chance  2 positive responses had a 72.4% chance  likelihood ratios were 0.27, 1.93, and 8.77 respectively  Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two item conjoint screen for alcohol and other drug problems. J Am Board Fam Prac 2001;14:95-106. 119
  117. 117. Negative Answers on Two Item Screen  If the patient states she does not use ATOD, she is at low risk for substance use.  Proceed to 4 P‟s Plus or CRAFFT  Negative answers on either 4P‟s or CRAFFT  Low risk of addiction – send for routine prenatal care.  Urine screen only if all patients get initial urine screen.  Any “yes”answer – order urine drug screen  Drug screen positive – active using – intervention.  Drug screen negative – needs more evaluation; repeat questions and UDS at each prenatal visit. 120
  118. 118. Four P‟s (Plus) Screening  Did any of your PARENTS have a problem with alcohol or drugs?  Do any of your PEERS have a problem with alcohol or drugs?  Does your PARTNER have a problem with alcohol or drugs?  Have you had a PROBLEM with alcohol or dugs in the past?  (Plus) Have you smoked any cigarettes, used any alcohol or any drug in this PREGNANCY?  Morse B, Gehshan S, Hutchins E. Screening for substance abuse during pregnancy: improving care, improving health. Washington, DC: National Center for Education in Maternal and Child Health; 1977. 121
  119. 119. Four P‟s Plus Results  A “yes” answer to any question was considered positive.  The modified 4 P‟s Plus screen adds a question about the current pregnancy and a positive answer identifies 34% of drug and alcohol users.  With a positive answer about “partner,” 65% were found to need drug treatment.  Chasnoff IJ, Hung WC. The 4 P’s Plus. Chicago, IL: NTI Publishing; 1999. 122
  120. 120. CRAFFT  C - Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs?  R - Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in?  A - Do you ever use alcohol or drugs while you are by yourself or ALONE?  F - Do you ever FORGET things you did while using alcohol or drugs?  F - Do your FAMILY or friends ever tell you that you should cut down on your drinking or drug use?  T - Have you ever gotten in TROUBLE while you were using alcohol or drugs?
  121. 121. CRAFFT continued  The authors indicate two or more positive answers to CRAFFT indicate a need for further evaluation. Chang G, Orav EJ, Jones JA, et al. Self-reported alcohol and drug use in pregnant young women: a pilot study of associated factors and identification. J Addict Med 2011; 5:221.  Consider that any positive answer indicates the necessity for a urine drug screen and further assessment.
  122. 122. Negative Answers Two Item Screen and 4P‟s Plus or CRAFFT  This is typical of about 85% of your patients and you have just successfully accomplished universal screening in about 90 seconds.  These women will be at a very low risk for addiction and should receive routine prenatal care for the remainder of the pregnancy.  But, repeat screen in each trimester. 125
  123. 123. When the Screen is Positive:  Patient is at risk for substance use  Does not mean she is using.  Urine Drug screen indicated.  Brief Intervention is indicated.  Assess psychiatric co-morbidity, especially PTSD.  Re-evaluate in two weeks.  If no change in behavior, refer to specific treatment program.
  124. 124. Strategies for Using Urine Drug Screens (UDS) Effectively  Can be used to determine prevalence in a population:  consent not required  both legal and ethical.  Necessary to monitor opioid dependent patients.  Many providers use UDS as a routine prenatal test at the first visit; this is highly recommended:  Use “opt out” approach for informed consent. 127
  125. 125. OPT OUT Approach to Urine Drug Screens  Inform patient about routine prenatal care and frequency of visits.  Inform patient that a number of routine screening tests are done in pregnancy, which include blood tests, diabetes tests, genetic tests, tests for sexual infections, ultrasound, and urine tests for protein, sugar, infection and drugs.  Inform patient that she may “opt out” of any test.  If patient opts out of urine drug screen, inform her that pediatricians may order drug screens after baby is born. 128
  126. 126. Opt Out Rationale  State laws are very liberal about what constitutes child abuse.  A patient who opts out of a urine drug screen creates a reasonable basis to suspect drug use.  Thus, pediatricians may legally order urine and meconium tests on the newborn without parental consent.  Patient must be informed of this if she opts out.  When informed and treated in a respectful manner, our experience has been that patients rarely drop out of care.  Not one of the author‟s 500 substance use patients opted out. 129
  127. 127. Urine Testing  It is important to distinguish urine testing as a screening process from urine testing as a treatment adjunct.  Urine testing only captures recent use.  In contrast, it is well established that urine testing in the substance user at every visit enhances recovery and abstinence. 130
  128. 128. How Long is a Drug Detectable in Urine After Use? Alcohol 24 hrs Amphetamines 48 hrs Barbiturates Short acting 48 hrs Long acting 7 days Benzodiazepines 72 hrs Cocaine 72 hrs Marijuana 30-40 days Morphine/Heroin 72 hrs Methadone 96 hrs Codeine Nicotine 72 hrs. Chronic use Opiates Single use Up to 10 days 3-5 days from last use 131
  129. 129. Strategy for Routine Urine Testing for Substance Use in Pregnancy  First visit even if late prenatal care.  If 1st visit before 16 weeks, repeat urine screen at least once at 20-24 weeks  Rationale: many of the adverse effects of nicotine and cocaine can be markedly diminished if intervention occurs in first half or pregnancy 132
  130. 130. What Should the Urine Test Include?  Depends on the drug use in the area – why a meconium prevalence study is necessary  Indianapolis: THC, cocaine, opiates, benzodiazepines most common; methamphetamine rarely found.  Southwestern Indiana: methamphetamine more common than cocaine  Northwest Indiana: “street methadone,” ecstasy
  131. 131. Urine Drug Screens Indicated:  At each prenatal visit for any patient identified as a substance user.  Missing appointments.  Any prior history of drug use.  Late Prenatal Care.  Admits to using alcohol and tobacco in current pregnancy.  Preterm Labor – may be opioid withdrawal.  Persistent requests for opioids or benzodiazepines.  Abruption, also may be opioid withdrawal.  Monitoring methadone or buprenorphine .  Monitoring the opioid dependent chronic pain patient.  Dental carries  Growth restriction.  Unexplained fetal demise.
  132. 132. Intervention Strategies That Actually Work and are Easy to Implement  FRAMES – 3-4 minute intervention  Developed for alcohol reduction.  Also a good template for any drug intervention.  Two Intervention Tools to Make It Work:  Feedback  What‟s at Risk? 135
  133. 133. 136 Feedback Tool Four Points For Clear Communication: And Clearing up Agreements and Expectations. 1. 2. 3. 4. Data – Objective Agreement Feeling – Connection Judgment – Subjective Opinion Wants – What you want the patient to do.
  134. 134. Feedback: Clearing Up the Data How it Works  Always start with the data, an objective description of the behavior.  And be very specific and non-judgmental.  When the listener and speaker agree about the data, the resistance to feedback is decreased.  Example: “The data is…Your urine drug screen was positive for THC” (you may have to show her lab results) the 137
  135. 135. 138 Connecting Through Feeling  This is about your feeling:  Use the following four basic feelings:  Fear (afraid), Sad (grief), Mad (angry) and Glad (happy)  By expressing how you feel, the patient connects at a deeper level.  Most of the time the feelings for the provider will be fear or sadness.  Example: “I am afraid that you may lose custody of your baby”
  136. 136. 139 Judgment or Opinion  This is your judgment or opinion and not necessarily the truth.  It‟s important to “own” the judgment:  this separates it from the data and feeling, and  makes it sound less like a condemnation  “My opinion is that you can readily commit to quitting...” (be specific about what she will do)  Works for cigarette smoking
  137. 137. Feedback: Ask For What You Want  What do I want to have happen?  Key is to be specific – ask for something the patient can do with success.  Sets up a “win-win” for the patient  Be Specific  “I want you to go to two NA meetings this week.”  Then, get specific about where and when.  You may ask, “How will I know you went to the meetings” 140
  138. 138. 141 Feedback Summary: The Four Point Approach to Feedback  Clarifies the issues  The capacity to share feelings enhances empathy in the relationship.  Empowers the listener to act.  The listener is more likely to act than resist.  Empowers accountability and responsibility.
  139. 139. 142 Feedback from Friends  A friend told me to always remember:  What other people think of me is none of my business.  Another said, Perhaps a wee-bit more of the scatological humor in this presentation  And, it helps to keep in mind:  When things become so serious and so sacred that we can't laugh about them, it means that we have elevated the profane to the realm of the sacred and misplaced the sacred in the process.
  140. 140. What‟s At Risk Is a Powerful Therapeutic Tool  What’s at risk for you to stop smoking cigarettes?  The patient may say there is no risk, obviously because she knows quitting is beneficial. Well, there must be, otherwise you would stop smoking.  Then we “flip” the question, so to speak and ask, how does it serve you to smoke or, what’s the payoff you have been collecting all this time for keeping this pattern in your life?  The Payoff is at risk if she quits smoking  Helps to identify the choices made and the price they pay to get whatever it is they want.  They become aware of the cost of the pattern on their life.  “What‟s at risk for you to stop smoking cigarettes? 143
  141. 141. What‟s At Risk? The Benefits of the Behavior  Whatever the answer, the question brings the patient into an awareness of the problem and that the payoff, “feeling good, relaxing”, etc., is the issue at risk, that is, she will have to give that up if she stops smoking.  Note that many women continue to smoke because they have learned to use smoking to curb their appetite and control their weight – that may be a very big payoff!  And there may be much at risk (resistance) to quitting.  Knowing this will allow for a more comprehensive approach to the problem. 144
  142. 142. 145 What‟s At Risk? Clinical Example  At the first visit of a pregnant patient who tested positive for cocaine.  I ask, “name one way your life may be better by not using cocaine (or smoking crack – I attempt to be specific about dealing with how they use the drug).  “I’ll be a better mother, or I’ll have more money for the baby” are typical answers.  So, what’s at risk for you to stop smoking crack and be a better mother.  The Risk is she will have to give up the very things she fears the most.  Often, it’s the friends with whom she smokes crack  And, of course the drug reduces her fears.
  143. 143. 146 Follow Up What‟s at Risk  Follow up quickly with a doable approach, that is, ask if they are willing to cut down on their use of the drug during in the next week?  Again, ask what‟s at risk to do so – and when they identify the payoff, ask if they will give some of that up for one week.  Most will agree to do so.  Then get specific about what they will do to stop and how will you know?  Usually, they say they will have some extra cash. Keep on asking the question, “how will you life be better if you weren‟t using drugs?”  In the author‟s clinical experience, 80% of patients will substantially decrease or stop their substance use.
  144. 144. Now that you Have the Tools, Let’s do a Brief Intervention FRAMES INTERVENTION  FRAMES was used in a World Health Organization study to assess brief interventions. The study evaluated heavy male drinkers from 12 countries with obvious cultural differences in alcohol use.  A brief intervention resulted in a decrease in alcohol use of 27%, compared to 7% among controls, still present 9 months after the intervention.  FRAMES also works well with other drug use.   World Health Organization Brief Intervention Study Group. A cross national trial of brief interventions with heavy drinkers. Am J Public Health 1996;86:948-955. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993 Mar;88(3):315-35.
  145. 145. FRAMES: Elements of a Brief Intervention  F - Feedback about the adverse effects of drugs or alcohol  R - Responsibility for a change in behavior:  A - Advise to reduce or stop use:  M - Menu of options: treatment; medications  E - Empathy is central to the intervention.  S - Self-empowerment: You can change.  Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems; a review. Addiction 1993;88:315-335 148
  146. 146. Clinical Example: Patient Admits to Drug Use, or Has a Positive UDS  The patient answered “yes” to the 2nd question in the two Item screen at her first prenatal visit:  Have you felt you wanted or needed to cut down on your drinking, smoking or drug use in the past year?  She also answered “yes” to question 4 of the 4 P‟s Plus:  Have you had a problem with alcohol or drugs in the past?  AS a result a UDS was ordered with “opt out” consent and the result was positive for cocaine.  This is a good example of the value of point of service UDS.  At the follow-up visit, it is important to show the patient a copy of the positive drug test, in this case, cocaine. Such “proof” can break through even the most hard-core denial. 149
  147. 147. First: Ask about Cocaine Use  What type of cocaine do you use? Crack  How often do you smoke crack? 4-5 times per week  How much does that cost you? 40 dollars a hit  Does it get you high? Don‟t wait for an answer - show her the test result.  Start FRAMES intervention 150
  148. 148. FRAMES Intervention for Cocaine Works for Alcohol, Tobacco and Other Drugs.  Feedback  About the adverse effects of Cocaine  Specific feedback for specific drug  Use Feedback Tool Formula: Data-FeelingOpinion-Want  The data is your urine screen was positive for cocaine  I’m afraid that if you are positive at delivery, CPS will investigate and may remove the baby from your care.  My opinion is that you can stop using  I want you to stop using now 151
  149. 149. FRAMES Intervention Responsibility  Responsibility     For a change in behavior Two simple statements: “Only you can decide that you want to stop using.” “Are you willing to stop using now?” You may add, “I’m proud of you for choosing to stop.” 152
  150. 150. FRAMES Intervention Advise  Advise to reduce or stop use:  “Harm reduction” strategy works surprisingly well.  Medically, it’s a slow wean from the drug.  "For the next week, will you cut down your use of cocaine by 2 times per week. Can you make that stretch?  Set up a “win-win” for the patient, that is, challenge her to do something she can do.  “Since cocaine costs you 40 dollars a “hit,” that means you will have 80 dollars more.”  “I want you to buy something for yourself with the money.”  “What will you buy?” (always reward success). 153
  151. 151. FRAMES Intervention Menu of Options:  Offer a MENU of Choices:  "If you find that cutting back for the next week is impossible, then we should consider other options.“  Or, “You may need additional support for your choice to stop using.”  For example:  Referral to counseling services/social services  Adjunct medications;  Support Groups: AA, NA, Smoking cessation groups 154
  152. 152. FRAMES Intervention Empathy and Self Empowerment  Empathy is central to the intervention.  “I realize this must be real hard to do.”  “I am proud of you for considering a change.”  “I am proud of you for being honest with me.”  Self-empowerment:  I am proud of you for agreeing to cut back.  You will find that you can succeed.  “I am glad that you continue to come for prenatal care.” 155
  153. 153. FRAMES: a Motivational Empowerment Approach  Less emphasis on diagnostic label: “alcoholic;” “addict.”  Reduces risk of “shaming”  Motivation empowers patient to make choices and take action – we call this “accountability.”  Emphasizes personal accountability to change.  Remember to order a UDS for each prenatal visit:  Document the date of the negative test  Tell her you are proud of her for getting clean  This is very powerful reinforcement
  154. 154. The Motivating Questions (to ask at every visit)  “How will your life be better by not using (fill in with substance)?”  I‟ll be a better mother – of course you will.  I‟ll have more money – how much more?  I‟ll have a safer house – what do you need to be safe?  When she is clean ask, “How is your life better now that you are not using (substance)?”  Record specific answers  Say, “I‟m proud of you.”
  155. 155. Some Conclusions  Addiction in pregnancy is treatable.  We have a duty to screen and treat.  Screening takes less that 5 minutes.  Identifying the patient is more than half the battle.  Stay positive.  Affirm someone else later today.  Affirm someone every day.
  156. 156. The End, at least for now.  Thank you for patiently persevering through this lengthy presentation.  This PowerPoint and others will be sent on request: jnocon@me.com      Addiction Medicine in Pregnancy Addiction and Breastfeeding Effects on the Fetus Motivational Tools for Brief Interventions. Toolkit Opioid Dependence in Pregnancy

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