Dr. Dively present on Addiction and Pregnancy

1. ADDICTION AND
PREGNANCY
KRISTI DIVELY, D.O., FACOOG

2. OBJECTIVES
• Understand treatment of opiate addiction in pregnancy
• Understand treatment of benzodiazepine addiction in pregnancy
• Understand treatment of alcohol addiction in pregnancy
• Understand treatment of nicotine addiction in pregnancy
• Review consequences of substance abuse in pregnancy

3. TRENDS IN SUBSTANCE ABUSE
2013 5.4% of pregnant women were illicit drug users (not including nicotine)
15.9% of pregnant women smoke
8.5% of pregnant women report current alcohol use
0.3% report ‘heavy’ use
•Prevalence in public clinic = private practice
•Caucasian > African American > Hispanic

4. WHY SHOULD WE SCREEN?
SCREENING

5. MATERNAL COMPLICATIONS
• Bacteremia, endocarditis (IV drug use)
• Sexually transmitted infections (HIV, Hepatitis C)
• Increase in spontaneous abortion
• Placental insufficiency/abruption
• Postpartum hemorrhage
• Pre-eclampsia/Eclampsia
• Preterm labor
• Premature rupture of membranes

6. FETAL COMPLICATIONS
• Intrauterine growth restriction
• Congenital defects (teratogenic effects)
• Intellectual disability
• Low birth weight
• Neonatal Abstinence Syndrome

7. WHY SHOULD WE SCREEN?
SCREENING
Substance use disorders are treatable

8. ETHICAL DUTY TO SCREEN PREGNANT WOMEN FOR
SUBSTANCE USE
• 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 Medical Association (AMA) 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

9. WHY SCREEN?
• TREATMENT WORKS – 70-80% of pregnant women can have ‘favorable UDS’
at delivery
• Early intervention can reduce many of the adverse effects of tobacco and
cocaine
• Treatment in pregnancy enhances long term recovery – up to 65% are
abstinent at 1 year
• Brief physician advice has been shown to be as effective as conventional
treatment for substance abuse

10. HOW DO WE SCREEN?
• Every pregnant patient should be asked about substance use
 At the first prenatal visit
 At least once per trimester
ACOG Committee Opinion No. 422, December 2008

11. START WITH THE TWO – ITEM SCREEN
• In the last year have you ever smoked cigarettes, drank alcohol or used any
drugs more than you meant to?
• Have you felt you wanted or needed to cut down on your smoking or drinking
or drug use in the last year

12. Two No Answers
• If patient states she does not use alcohol, tobacco or drugs, she is at low risk
for substance use
• Proceed to 4Ps plus
NEXT STEPS

13. 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 drugs 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.

14. NEGATIVE ANSWERS
TWO ITEM SCREEN AND 4P’S PLUS
• This is typical of 85% of your patients. You have accomplished universal
screening in about 90 seconds
• These women are low risk for addiction and should receive routine prenatal
care for the remainder of the pregnancy
• BUT, ask about alcohol, tobacco and drug use each trimester

15. ANY POSITIVE ANSWER
• ANY yes answer on Two-Item Screen or 4P’s Plus
• Patient at risk for substance use
• Urine Drug Test is indicated
• Brief intervention is indicated
• Assess for psychiatric co-morbidity
• Re-evaluate in 2 weeks, if no change in behavior, refer for treatment

16. TREATMENT BARRIERS
• Fear, shame and guilt about use
 Will she lose other children if in treatment?
 Does she have family support?
 Attitudes of medical providers
• Lack of comprehensive clinical care services for all the problems of pregnancy AND addiction
 Can she get to treatment? Transportation problems?
 Lack of childcare while in treatment
 Basic needs must be met for her to engage in treatment
• Co-morbid diagnosis impacting ability to access services
 Difficulty addressing many issues simultaneously
 Depression, anxiety, personality disorder
 Immaturity/lack of coping skills

17. TREATMENT BARRIERS
• Pregnant women may avoid prenatal care due to drug use
 Shame, guilt, fear of involvement of child protective services
• Lack of prenatal care leads to a myriad of other complications
• Lifestyle associated with addiction also impacts pregnancy
 Poor nutrition, intimate partner violence, prostitution, theft/criminal activities

18. MEDICATIONS IN PREGNANCY
• Bentyl
• Catapres
• Claritin
• Colace
• Flexeril
• Guaifenesin
• Imodium
• Maalox
• Melatonin
• Milk of Magnesia
• Mucinex
• Prental Vitamins
• Pepto-Bismol
• Phenergan
• Senna
• Trazdone
• Tums
• Tylenol

19. COMMONLY USED MEDICATIONS (SAFE)
• Seroquel
• Elavil
• Amoxicillin
• Macrodantin
• Zofran
• Reglan
• Zithromax
• Some SSRIs – Lexapro, Celexa, Prozac, Zoloft
• SNRIs – Cymbalta, Effexor
• Wellbutrin
• Buspar
• Vistaril is OK after 12 weeks

20. MEDICATIONS TO AVOID
• Most antibiotics ending in –mycin (except
azithromycin)
• Neurontin
• Ibuprofen
• Abilify
• Sinequan
• Elavil (3rd trimester)
• Diflucan

21. OPIATE SUBSTANCE USE DISORDER
• Risks to Mother
 Postpartum hemorrhage
 Pre-eclampsia/Eclampisa
 Septic thrombophlebitis
• Risks to Fetus
 Spontaneous abortion
 Amnionitis
 Intrauterine Growth Restriction
 Placental insufficiency
 Preterm labor/delivery
 Premature rupture of membranes

22. OPIATE SUBSTANCE USE DISORDER
• Narcan should ONLY be used as a last resort in pregnant patients
 Spontaneous abortion
 Preterm labor
 Intrauterine fetal demise

23. TREATMENT OF OPIOID USE DISORDER
• ACOG Committee Opinion 524 – standard of care is methadone maintenance
• Buprenorphine is an effective option
• Withdrawal from opiates while pregnant is NOT recommended
 Risk of preterm labor, fetal distress, intrauterine fetal demise
 Significant risk of relapse (41%-96%)
• Medication alone is not enough – also needs therapy and psychiatric care
Medication Assisted Treatment

24. PREGNANCY OUTCOMES
• Methadone Maintenance Therapy (MMT) is regarded as an established treatment
with birth outcomes comparable to a general obstetrical population (Kreek MJ, 2000)
 Fewer Preterm Births
 Less Intrauterine Growth Restriction
 Fewer Low Birth Weight Babies
• Less Maternal Drug Use
 Greater reduction in drug use with higher dose of methadone
• Improved Prenatal Care Compliance (Burns L, 2004; Goler NC, 2008)
• There appears “to be no differential effect of either treatment (methadone or
buprenorphine) – it was exposure to stable treatment that was important” (Gibson,
2008)
• MMT in pregnancy is supported by over 50 years of research

25. INTERDISCIPLINARY CARE
• Crucial in treatment of addiction in pregnancy
• Comprehensive MMT with adequate prenatal care can reduce the incidence
of obstetrical and fetal complications, intrauterine growth restriction, and
neonatal morbidity and mortality (Finnegan, 1991)

26. MEDICATION OPTIONS
Medication Primary Use Formulation Treatment Setting Administration
Methadone • Agonist:
Suppresses
cravings and
withdrawals
• Detoxification
• Maintenance
• Liquid
• Tablet/Diskette
• Powder
SAMHSA Certified
Opioid Treatment
Program (OTP)
• Daily at OTP
• Some individuals may qualify for take-home
prescriptions lasting up to 30 days
Buprenorphine (Subutex) • Partial Agonist:
Suppresses
cravings and
withdrawals
partial
stimulation of
brain receptors
• Detoxification
• Maintenance
• Tablet
• Film (Suboxone)
• Physician or
psychiatrist
granted a DEA
waiver
• Some SAMSHA
Certified OTP’s
• Daily
• Individuals can be prescribed a supply to be
taken outside of the treatment setting

27. METHADONE OR BUPRENORPHINE?
• Patients on maintenance therapy who become pregnant should be
maintained on current agent
• Buprenorphine should be initiated when:
 Patient cannot tolerate methadone
 Methadone program is not accessible
 Patient is adamant about avoiding methadone
 Patient is capable of informed consent

28. DOSING IN PREGNANCY
• Dosages of methadone or buprenorphine may need to increase over the
course of pregnancy
 Metabolic changes
 Increased fluid volume

29. WHAT IS THE RIGHT DOSE IN PREGNANCY?
THE DOSE THAT STOPS WITHDRAWAL!
• Increased blood volume
• Larger tissue reservoir
• Methadone loss to amniotic fluid
• Altered maternal metabolism
• Metabolic activity of placenta
• Metabolic activity of fetus
• Patient may require progressive
increases throughout pregnancy
• Split dosing is an option to maintain
adequate blood levels with fewer
increases
• Counseling is essential to address
cravings, stress, anxiety

30. METHADONE INDUCTION
• Opioid intolerant patient – Day 1 10-15 mg maximum
• Opioid tolerance unknown – Day 1 15 mg maximum
• Opioid tolerant – Day 1 25-40 mg maximum

31. METHADONE INDUCTION
• Start low, go slow
• 5 days until steady state obtained
• Peak 2-3 hours after dosing
• See patients frequently to monitor for oversedation
• Consider dosing in the office and observing the patient for 3 hours

32. METHADONE INDUCTION
• Some patients over report their opioid use due to fear of not getting enough
methadone to prevent withdrawal
• Pregnant women often have decreased tolerance because they have been
trying to stop using on their own

33. METHADONE DOSING/INDUCTION IN THE HOSPITAL
• If methadone maintenance patient is admitted to the hospital, best to
continue dosing the way they were dosed at clinic (daily vs. split)
• If you divide the dose, they may have mild withdrawal symptoms for a few
days until they reach steady state
• When transitioning from daily dosing to split dosing, you need to give 25-50%
more the first day of split dosing

34. SPLIT DOSE INDUCTION
• Consider split dose in patients who are feeling OK throughout the day but
experiencing withdrawal symptoms by bedtime and worse by morning
• Day 1 – 100% of current dose, observed
 50 % of dose to take in 12 hours
• Day 2 and beyond – 50% of dose Q12 hours
• Poor results seen from starting with half the usual dose on day 1

35. BUPRENORPHINE TREATMENT
• Not FDA approved for use in pregnancy
 Widely used in Europe
• Recommend buprenorphine monotherapy only (Subutex)
• Improved pregnancy outcomes seen with methadone appear to be duplicated
with buprenorphine
• MOTHER Study – less severe NAS, shorter hospital stays for newborns of
mothers on buprenorphine

36. BUPRENORPHINE DOSING
• Goal is to find the lowest dose at which patient is not using other opiates, not
experiencing any withdrawal symptoms, minimal or no side effects, and no
uncontrollable cravings for drugs of abuse
• Patients must have discontinued the use of opiates and be in the early stages
of withdrawal before initiating buprenorphine
• Start with 4 mg buprenorphine, repeat dose in 2-4 hours if indicated. Repeat
as needed until patient is comfortable and not exhibiting symptoms of
withdrawal (maximum dose 32 mg daily)
• Dosing may be split twice daily or three times daily as needed to minimize
withdrawal symptoms
Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid
Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No. (SMA) 04-3939. Rockville, MD:
Substance Abuse and Mental Health Services Administration, 2004.

37. BREASTFEEDING AND MEDICATION ASSISTED
TREATMENT
• ACOG Committee Opinion 524 and 658
• Breastfeeding may reduce Neonatal Abstinence Syndrome symptoms
• Breastfeeding promotes mother-child bonding
• Minimal levels of methadone and buprenorphine are passed into breastmilk
• Contraindicated in women with HIV and current users of illicit substances

38. WHAT HAPPENS WHEN PATIENT HAS ACUTE
PAIN?
LABOR AND DELIVERY, SURGERY

39. ACUTE PAIN MANAGEMENT FOR PATIENTS ON
METHADONE
• Ensure maintenance therapy is continued
• Maintenance WILL NOT treat acute pain
• Stadol will cause acute and severe immediate withdrawal of the methadone
maintained mother and fetus – Stat Cesarean section!

40. POST-OPERATIVE PAIN IN METHADONE PATIENTS
• Give the confirmed maintenance dose of methadone
• Give appropriate analgesic for the surgery, may need to increase dose 15% or
more due to high tolerance

41. ACUTE PAIN MANAGEMENT FOR PATIENTS ON
BUPRENORPHINE
• Buprenorphine – highly avid binding
to receptor
• May block or reverse mu opioid
analgesia
• Best practices continue to evolve
• Options
• Non-opioid therapies
• Continue maintenance dose of
buprenorphine and add avidly
binding opioid such as
hydromorphone or fentanyl
• Continue buprenorphine in divided
6-8 hour doses and titrate
Gourlay and Heit, 2008; Kornfeld & Manfredi, 2009

42. EMERGENCY SURGERY/CESAREAN SECTION
• If patient on buprenorphine, there may be some opiate receptor blockade
due to high affinity for mu receptor (not from naloxone)
• Regional anesthesia helpful (if possible)
• Fentanyl and hydromorphone can override buprenorphine
• Will need higher dose

43. RELAPSE PREVENTION PLAN
PATIENTS REQUIRING POST OPERATIVE PAIN CONTROL WITH OPIATES
• Patient does not touch paper prescription
• Caregiver handles and fills the prescription and administers medication as
ordered to the patient
• The patient does not touch pills or bottle
• Patient does not count the pills
• After 24 hours of not requiring opiate pain medications, caregiver disposes of
left over medication
• OB and addiction physician work together

44. POSTPARTUM DOSING OF METHADONE OR
BUPRENORPHINE
• May need to decrease dose due to fluid shifts in postpartum period
• See patient immediately upon discharge from the hospital before giving ‘take
home’ doses of medication or prescription
• Buprenorphine dose may need to be decreased if it was increased during the
third trimester

45. SEDATIVE/HYPNOTIC SUBSTANCE USE DISORDER
• Risks to Mother
 Seizures from abrupt withdrawal
 Respiratory depression in overdose
• Risks to Fetus
 Congenital defects
 Neonatal Abstinence Syndrome
 Fetal death/spontaneous abortion
if abrupt withdrawal

46. TREATMENT OF SEDATIVE/HYPNOTIC USE DISORDER
• Slow taper, ideally in the second trimester
• Taper 5-10% /day
• Use the same benzodiazepine they have been abusing for the taper if possible
• Barbituates should be avoided due to risk of congenital defects
• Always in conjunction with interdisciplinary care!

47. ALCOHOL USE DISORDER
• Risks to Mother
 Injury while intoxicated
 Delirium Tremens in withdrawal
 Nutritional deficiencies
 Deficient milk ejection
 Precipitous labor
 Ataxia
 Respiratory depression
• Risks to Fetus
 Fetal Alcohol Spectrum Disorder

48. FETAL ALCOHOL SPECTRUM DISORDER
• Direct Effect of alcohol on developing fetus
• Alcohol affects the fetal brain throughout entire pregnancy
• Binge drinking (5 or more drinks on one occasion) is especially detrimental to
the fetus
• Leading known cause of preventable intellectual disability
 Two times more common than Down Syndrome
• Alcohol related birth defect (ARBD) and alcohol related neurodevelopmental
disorder (ARND)

49. EFFECTS OF ALCOHOL ON FETUS
• Spontaneous abortion
• Intellectual disability
• Low birth weight
• Cardiac abnormalities
• Skeletal abnormalities
• Ocular problems
• Hemangiomas

50. FETAL ALCOHOL SYNDROME
• Pre and post natal growth
restriction
• CNS deficits
• Facial feature anomalies
 Short palpebral fissures
 Elongated midface
 Thin upper lip
 Flattened maxilla

51. FETAL ALCOHOL SPECTRUM DISORDER (FASD)
• Children are frequently misdiagnosed as having a psychiatric disorder
• Children with FASD:
 May not complete tasks
 Cannot recall information
 May not take in the information
 May hit others
 Can misinterpret intentions
 May take unnecessary risks
 Do not perceive danger

52. TREATMENT OF ALCOHOL USE DISORDER
• Taper using short acting benzodiazepines
• Barbituates should be avoided due to risk of congenital defects
• Always in conjunction with interdisciplinary care!

53. NICOTINE USE DISORDER
• Risks to Mother
 Lung disease
 Multiple types of cancer
 Coronary artery disease
 Stroke
• Risks to Fetus
 Spontaneous abortion
 Placental abruption
 Placenta previa
 Low birth weight
 Congenital Defects
 Preterm delivery
 Uterine bleeding
 SIDS

54. NICOTINE USE DISORDER
• Effects are lifelong in children
 ADHD
 Asthma and respiratory disorders
 Middle ear infections
 Increased risk for diabetes
 Increased risk for obesity

55. TREATMENT OF NICOTINE USE DISORDER
• Gradual cessation is best
• If pregnant woman is unable to stop with behavioral interventions, nicotine
replacement products can be used
• Limited studies on use of buproprion

56. STIMULANT USE DISORDER
• Cocaine
• Methamphetamine

57. STIMULANT USE DISORDER
• Effects on Mother
 Seizures
 Hypertension/hypertensive crisis
 Cardiac events and maternal death
 Stroke
• Effects on Fetus
 Placental abruption
 Premature labor
 Spontaneous abortion
 Premature rupture of membranes
 Congenital defects (meth)
 Attention impairments in child
 Low birth weight
 SIDS

58. TREATMENT OF STIMULANT USE DISORDER
• No detoxification protocol
• Can use short term benzodiazepines and antidepressants for symptom
treatment
• Consider monitoring fetus if patient beyond 24 weeks gestation
• Interdisciplinary care

59. CANNABINOID USE DISORDER
• Risks to Mother
 Panic attacks
 Short-term memory impairment,
amnesia
• Risks to Fetus
 Intrauterine growth restriction
 Abnormal startle reflexes in
newborns
 Reduced memory and verbal skills
at age 4 but does not appear to
decrease intelligence

60. CANNABINOID USE DISORDER
• May affect fetal brain development and child behavior
• Treatment the same as non-pregnant patient
• Supportive care and interdisciplinary care

61. NEONATAL ABSTINENCE SYNDROME
• Neonate suffering withdrawal symptoms
• Primarily seen in opioid use, but also seen with benzodiazepines, alcohol,
barbituates, antidepressants (SSRIs) and nicotine
• Onset of symptoms depends on substance
• Myriad of symptoms

62. NEONATAL ABSTINENCE SYNDROME
• CNS Effects
 Irritability
 Hypertonia (increased muscle tone)
 Hyperreflexia
 Seizures (1-3%)
• GI Effects
 Diarrhea
 Vomiting
 Abnormal sucking/poor feeding
 Poor weight gain

63. NEONATAL ABSTINENCE SYNDROME
• Respiratory Effects
 Tachypnea
 Respiratory Alkalosis
• Autonomic Effects
 Sneezing
 Lacrimation
 Yawning
 Sweating
 Hyperpyrexia
 High pitched cry

64. NEONATAL ABSTINENCE SYNDROME
• Delayed effects may be seen for 4-6 months
 SIDS

65. TREATMENT OF NEONATAL ABSTINENCE SYNDROME
• Primarily symptomatic
• Decrease environmental stimuli
• Soothing behaviors
• When supportive measures fail, medications can be used

66. CHILDREN AND YOUTH SERVICES
• Lancaster County PA Children and Youth Services have stated that they cannot
open a case on a child that has not been born yet
• Therefore, mandatory reporting of drug use in pregnant patient is not
necessary
• If you fear another child in the home is at risk due to maternal drug use, then
consideration should be given to reporting use
• Mothers in treatment will be looked upon more favorably than mothers
continuing to abuse substances

67. CHILDREN AND YOUTH SERVICES
• 13 states have legislation to terminate parental rights due to maternal drug
use
 Florida, Illinois, Indiana, Ohio, Maryland, Minnesota, Nevada, Rhode Island, South
Carolina, South Dakota, Texas, Virginia and Wisconsin
• 8 states require reporting of drug testing
 Arizona, Illinois, Iowa, Massachusetts, Michigan, Minnesota, Utah and Virginia

68. REFERENCES
• Center for Substance Abuse Treatment. Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction. Treatment Improvement Protocol (TIP) Series 40. DHHS Publication No.
(SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.
• https://www.oasas.ny.gov/AdMed/documents/treatmentpreg.pdf

69. CONTACT INFORMATION
• Kristi Dively, D.O.
• Retreat at Lancaster County
• 717-859-8000 x1127
• Email: kristid@retreatmail.com