NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE Treatment Strategies for Women and Families with Substance Abuse: The participant will be able to: Interpret the term “opioid use disorder,” explain the benefits of Methadone Assisted Treatment (MAT) and identify the characteristics of Neonatal Abstinence Syndrome.

1. National Perinatal Association
Conference
Presented by Sarah Maurer, MA,
LPC, CCDP-D, Clinical Director,
Center for Life Solutions
October 17, 2014

2. Disclosure Information
 I have no relevant financial relationships to disclose
 I intend to discuss off-label / investigative uses of the
following commercial product: Buprenorphine /
Naloxone, Tradename Suboxone, manufactured by
Reckitt Benckiser Pharmaceuticals, Inc.

3. What are opioids?
 Medications that relieve pain
 Reduce intensity of pain
signals reaching the brain
 Affect brain areas controlling
emotion
 Opioids are synthetic
(manufactured in a lab)  Examples: hydrocodone
(Vicodin), oxycodone
(OxyContin, Percocet),
morphine (Kadian, Avinza),
codeine, and related drugs.

4. What are opiates?
• Drug derived from opium
• Most common example: Heroin
• Processed from morphine,
a naturally occurring substance extracted from the poppy
plant
 Typically sold as a white or brownish powder (“China
White”) or as a black sticky substance ("black tar”)
• Although purer heroin is becoming more common, most
street heroin is "cut" with other drugs or with substances
such as sugar, starch, powdered milk, or quinine

5. Opioid Use Disorder
 “Includes signs and symptoms that reflect
compulsive, prolonged self-administration of
opioid substances that are used for no legitimate
medical purpose or, if another medical condition is
present that requires opioid treatment, that are
used in doses greatly in excess of the amount
needed for that medical condition” (Diagnostic and
Statistical Manual of Mental Disorders, Fifth
Edition, p. 542).

6. What is tolerance?
 “A need for markedly increased amounts of opioids
to achieve intoxication or desired effect”
 “A markedly diminished effect with continued use
of the same amount of an opioid”
 From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, p.
541

7. What is withdrawal?
 First, there must be cessation or reduction of opioid
use that had previously been heavy and prolonged
(longer than 3 weeks)
 OR administration of an opioid
antagonist (naloxone
or naltraxone) after
a period of opioid use
AND…
 From: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

8. What is withdrawal?
 Three (or more) of the following symptoms developed within minutes
to several days:
 Dysphoric mood (depression)
 Nausea or vomiting
 Muscle aches
 Watery eyes
 Runny nose
 Dilated pupils
 Excessive sweating
 Diarrhea
 Yawning
 Fever
 Insomnia
 Piloerection (goose bumps, goose flesh)

9. Speed & Severity of Withdrawal
 Heroin, pain pills – (short acting) withdrawal
symptoms begin within 6-12 hours after last dose;
peak within 1-3 days (acute withdrawal) and
gradually subside over period of 5-7 days
 Methadone / Suboxone – (long acting) withdrawal
symptoms may take 2-4 days to develop
 Less acute withdrawal symptoms, including anxiety,
dysphoria, anhedonia, and insomnia can last for
weeks to months

10. Medicated Assisted Treatment
 Evidence-based practice that combines
pharmacological interventions with
substance abuse counseling and social
support
 MAT for opioid dependence:
Methadone, Suboxone, Naltrexone and
Vivitrol

11. How does methadone work?
 Methadone binds to the same receptor sites as other
opioids (opioid agonist)
 Orally effective
 Slow onset of action
 Long duration of action
 Slow offset of action

12. Treatment Outcome Data:
Methadone
 8-10 fold reduction in death rate
 Reduction of drug use
 Reduction of criminal activity
 Engagement in socially productive roles- improved
family and social function
 Increased employment
 Improved physical and mental health
 Reduced spread of HIV
 Excellent retention

13. Methadone Treatment
Typical intake day
 Admission Process:
 Counseling- ASI (Addiction Severity Index)
 Counseling Assignment & Treatment Plan
 Medical History & Physical
 Drug Screen & Blood Work
 TB Testing
 Initial Dose Established By Physician
 Referrals

14. Daily Medication
• Drink, rinse, speak to nurse
prior to stepping away from
window
• Lock Boxes
• Return take-home bottles
with labels intact (reduce
diversion)
 CLS is open 6am to 5:30pm
M-F; 7 to 11am on Sat. Closed
Sunday (take home medication
is provided for Sundays)

15. Drug Testing:
Random, every 6 to 8
weeks, can be more often
if warranted
• Oral Fluid Test
• Urine Screen

16. Counseling
 All clients are required to attend
regular counseling.
 CLS provides individual
counseling, family conferencing,
and group education.
 We have 12 LPCs, LCSWs,
Certified Drug & Alcohol
Counselors, & counselors-in-
training on staff
 Amount of counseling required
depends on treatment level

17. Take Home Medication
 Must meet criteria
 It’s a privilege, NOT a right
 Patient must be up-to-date with counseling in
order to earn take home medications

18. Medically Supervised Withdrawal
 Should be attempted when it is desired by a stable
patient who has a record of abstinence
 Should be done within the framework of a support
network, counseling, medical care and stable home
environment
 Withdrawal process might take months to years
 Some will never get off methadone due to medical or
psychological issues
 Average length of methadone treatment is one to
three years

19. Buprenorphine
 Buprenorphine: Subutex
 Buprenorphine/Naloxone: Suboxone
 Both approved for the treatment of opiate
dependence. Both contain the active ingredient
buprenorphine hydrochloride
 Partial agonist- produces a
ceiling effect at higher doses
 Binds strongly to the opioid
receptor and is long-lasting &
blocks the effects of other opioids

20. Why did the FDA approve two
medications?
 Subutex contains only buprenorphine
 The second medication, Suboxone, contains
naloxone
 Subutex is given during the first few days of
treatment
 Suboxone is the formulation used in the majority
of patients

21. How is Suboxone different from
Methadone?
 Subutex and Suboxone are
the first narcotic drugs
available under the Drug
Abuse Treatment Act (DATA)
of 2000 for the treatment of
opiate dependence that can
be prescribed in a doctor’s
office
 This change will provide
more patients the
opportunity to access
treatment
 Methadone can only be
dispensed in a limited
number of clinics that
specialize in addiction
treatment.
 There are not enough
addiction treatment centers
to help all patients seeking
treatment

22. How is Suboxone different from
Methadone?
 Less tightly controlled than methadone
 Lower abuse potential
 Less dangerous in an overdose
 Less is known about the long-term effects of Suboxone
 Newer treatment
 Less research compared to methadone
 Suboxone is currently not FDA approved to treat
pregnant patients
 Less research, but could be very promising!

23. Naltrexone
 Naltrexone is used to help opiate addicts who have
stopped taking opiates to stay drug-free
 Naltrexone is not a narcotic. It works by blocking the
effects of opiates, especially the "high'' feeling that
makes you want to use them
 It will not produce any narcotic-
like effects or cause mental or
physical dependence

24. How is Naltrexone different from
Methadone & Suboxone?
 Naltrexone will cause withdrawal symptoms in
people who are physically dependent on opiates
 Naltrexone treatment is started after you are no
longer dependent on opiates
 Length of time this takes depends on which opiates
were taken, the amount used, and how long the
individual has been using
 Very low retention rate
 NOT approved for pregnant women / Contraindicated

25. Vivitrol
 Vivitrol is Naltrexone in a monthly injection
 First approved to treat alcohol dependence.
 Recently been approved to prevent relapse to opioid
dependence after opioid detox
 You must stop taking opioids before starting
VIVITROL.
 NOT approved for pregnant women / Contraindicated

26. Neo-natal Abstinence Syndrome
(NAS)
 Infants exposed to opioids have higher incidence of
NAS
 Characterized by hyperactivity of CNS & ANS that is
reflected in changes in GI tract & respiratory system
 Withdrawal symptoms begin from minutes to hours
after birth to 2 weeks later (most appear within 72
hours)

27. Methadone provides the following
advantages:
 Reduces illegal opioid use as well as use of other drugs
 Helps to remove the opioid-dependent woman from
the drug-seeking environment & eliminates the
necessary illegal behavior
 Prevents fluctuations of the maternal drug level that
may occur throughout the day

28. Methadone provides the following
advantages (con’t):
 Improves maternal nutrition, increasing the weight of
the newborn
 Improves the woman's ability to participate in prenatal
care and other rehabilitation efforts
 Enhances the woman's ability to prepare for the birth
of the infant and begin homemaking
 Reduces obstetrical complications

29. Priority Population
 Pregnant women are considered to be a “priority
population” - This means they are assessed & admitted to
an appropriate level of care within 48 hours of contact
 Receive state-funded treatment if no insurance, but will
typically be covered under Medicaid
 CLS currently has 43 pregnant women in treatment (total
population = 514).

30. Factors that influence NAS
1. Types of substances used by mothers
2. Timing & dosage of methadone before labor
3. Characteristics of labor
4. Type & amount of anesthesia or analgesic during
labor
5. Infant maturity & nutrition

31. Factors that influence NAS (con’t)
6. Metabolic rate of infant’s liver
7. Presence of intrinsic disease in infants
 With appropriate pharmacotherapy, NAS can be
treated satisfactorily without any severe neonatal
effects
 There is no compelling evidence that lowering
maternal methadone dosage avoids NAS, in fact
lowering a mother’s methadone dose may be more
harmful

32. Outpatient Treatment
St. Louis Area
• SAMHSA Treatment Locator:
http://findtreatment.samhsa.gov/
• Bridgeway– St. Charles, University City, S. Vandeventer
(Suboxone), Town & Country
• Preferred–St. Charles, Miami St., S. Broadway
• Provident –West County, Chippewa
• St. Louis Valley Hope- (Suboxone) Olive Blvd.
• New Beginnings CSTAR- N. Kingshighway
• Queen of Peace Center- N. Newstead
• Places for People- Chouteau
• Salvation Army- Washington Ave.
• BASIC- Locust St.
• Alternative Behavioral Care- St. Peters (Suboxone)
• Gateway- Olive St.

33. Self-Help Groups
 Narcotics Anonymous
 Alcoholics Anonymous
 Al-Anon Family Groups
 Celebrate Recovery
 Smart Recovery

34. Community Resources
 SAMHSA Treatment Locator:
http://findtreatment.samhsa.gov/
 Department of Behavioral Health Division of Alcohol
and Drug Abuse: http://dmh.mo.gov/ada/
 Self-Help Communities:
 Narcotics Anonymous: http://www.na.org/
 Alcoholics Anonymous: http://www.aa.org/
 Al-Anon Family Groups: http://www.al-anon.org/
 Celebrate Recovery: http://www.celebraterecovery.com/
 Smart Recovery: http://www.smartrecovery.org/

35. Questions?
 Contact Information:
 Sarah Maurer, LPC, CCDP-D
 Clinical Director
 314-292-6359
 sarah@centerforlifesolutions.org
 Center for Life Solutions, Inc.
 637 Dunn Rd., Ste. 180,
Hazelwood, MO, 63042
 Office: (314)731-0100,
Fax: (314)731-0111

36. References:
 American Psychiatric Association: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric
Association, 2013.
 Center for Substance Abuse Treatment. Medication-Assisted Treatment
for Opioid Addiction in Opioid Treatment Programs, Treatment
Improvement Protocol (TIP) Series 43, DHHS Publication No. (SMA)
08-4214. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2005, reprinted 2006 and 2008.
 DrugFacts: Prescription Drugs: Abuse and Addiction. (October 2011).
Retrieved November 6, 2013, from
http://www.drugabuse.gov/publications/research-
reports/prescription-drugs/what-prescription-drug-abuse