Inspired at AATOD

aaaaaaatod

I just got back from the AATOD (American Association for the Treatment of Opioid Dependence) conference, and I feel inspired, enthusiastic, and relaxed.

Several days before I left for the conference, I talked to a pregnant patient at one of the opioid treatment programs where I work. This patient, dosing on methadone, said her obstetrician insisted she taper down on her dose during pregnancy. When she told me that, my shoulders slumped with fatigue and disappointment. This was a doctor I’ve called on the phone a few times, and met in person once. We’ve talked collegially, and I physically, personally handed her a copy of ACOG/ASAM (American College of Obstetrics and Gynecology, American Society of Addiction Medicine) position paper on the treatment of opioid-addicted pregnant patients.

Needless to say, that document does NOT advise taper of methadone during pregnancy. When I talked to this obstetrician, I’d explained why we usually need to increase the dose during pregnancy. Yet now she’s telling a patient to lower her dose. This is not best practices.

I felt tired, and hopeless about improving physician education in my area. Do these doctors have Teflon brains, and all the information I’ve been trying to provide keeps sliding off their cortexes, into the ozone somewhere?

Yesterday at the AATOD conference, I heard a lecture by one of the main authors of the MOTHER (Maternal Opioid Treatment: Human Experimental Research) trial, Dr. Karol Kaltenbach. I’ve posted blogs about this trial (see Dec 16, 2010, March 23, 2013), which randomized opioid-addicted pregnant women to treatment with either methadone or buprenorphine. The goal was to compare outcomes of the babies born to moms maintained on methadone versus buprenorphine.

Dr. Kaltenbach opened her lecture by making an excellent point: use of legal drugs such as alcohol and tobacco during pregnancy are viewed as public health problems, even though they cause as much or more harm to the fetus as illicit drugs. Yet the general public demonizes moms who use illegal drugs. Pregnant women who use illegal drugs are faced with harsh moral judgments, and punitive responses.

Alcohol, a legal drug, causes harm to 40,000 kids per year, and is the leading preventable cause of developmental disabilities. Consistently, research shows physical and behavioral effects in the children born to moms who drink alcohol. Even though researchers have stated that there’s no safe amount of alcohol during pregnancy, according to the 2011 NSDUH (National Survey of Drug Use and Health), 9% of pregnant women said they were current drinkers, 2.6 said they were binge drinking, and .4% were heavy drinkers.

Pregnant smokers of tobacco are more likely than non-smokers to have a variety of complications, including spontaneous abortions, placenta previa and placental abruption, retardation of fetal growth, low birth weight babies, and preterm labor and birth. After delivery, the risk of SIDS (Sudden Infant Death Syndrome) is six times higher than for babies of non-smoking moms. Their babies are more likely to have ADHD, inattention disorders, ear and respiratory infections.

Yet newspapers now publish sensational articles about “addicted babies” born to mothers with opioid addiction, while ignoring the more common and more harmful effects of alcohol and tobacco. Remember the “crack baby” scare of the 1990’s, which was a media creation with no backing by science?

From the MOTHER study we learned that babies born to moms on buprenorphine have about the same risk of withdrawal, called neonatal abstinence syndrome (NAS), as babies born to moms on methadone. In both groups, fifty percent of the babies had NAS severe enough to need medication to treat opioid withdrawal. The babies were scored on the Finnegan scale, which grades the babies on many signs of withdrawal to indicate when treatment is needed. (By the way, at the AATOD conference I sat near Loretta Finnegan, creator of the Finnegan scale and internationally recognized for her many contributions to the field of alcohol and drug abuse!)

So in both groups, about half of the babies needed medication for withdrawal symptoms. However, the babies with NAS born to the moms on buprenorphine required 89% less medication (morphine solution) and spent 43% less time in the hospital as compared to the babies with NAS born to moms maintained on methadone. The babies born to moms on buprenorphine also spent 58% less time being medicated to treat their NAS.

That’s a significant benefit.

This study was very important for many reasons, but after these results, buprenorphine is slowly becoming the standard of care for pregnant opioid-addicted moms, if it’s available. True, there was a higher drop out of the moms on buprenorphine, but it was not statistically significant, and the moms didn’t leave treatment; they dropped out of the study for whatever reason.

Now for the exciting part: a supplemental study of these children is being completed. This data hasn’t yet been published, but Dr. Kaltenbach says it will show that kids of moms on methadone and buprenorphine were compared and assessed at three months, six months, twelve, twenty-four, and thirty-six months. A standardized scoring system for infant development called the Bayley Scale was used to study these children, and the groups were compared to scores for normal children.

Dr. Kaltenbach says there are no differences between the babies born to methadone versus buprenorphine, and better yet – both groups showed scores in the normal ranges on this scale. The scale measured things like language and motor skills, cognitive abilities, and conceptual and social skills.

The kids are alright!

This data is going to be a huge comfort to worried moms, dosing on methadone or buprenorphine.

And I got inspired at the AATOD conference. I heard one speaker tell the audience “you do it until they get it. You tell them over and over and over again. Whatever it takes.” And I thought to myself, this is correct. I can’t give up on the obstetricians in my area. Maybe they don’t agree with me, but I am not out on a limb with what I’m saying. It’s backed up with fifty years of studies and science. I am listening and reading information from the experts in the field. I need to be persistent, and keep repeating the data, mailing the data…skywriting the data…whatever.

It’s refreshing to be around people who understand opioid addiction and its treatment. It’s encouraging to hear how workers in the opioid addiction field are finding new ways to help our patients and advocate for them.

I’m going to call this OB – again –and re-inform her – nicely – about what’s found in that position paper, co-authored by doctors from her own specialty. I’m also going to suggest she direct some of her concern towards her patients who use the legal drugs of alcohol and tobacco, since they cause significant harm to infants.

And yes, I know most of the patients enrolled in OTPs also smoke, and I am going to help them with that, too…if they want it.

1. http://www.asam.org/docs/publicy-policy-statements/1-opioids-in-pregnancy—joint-acog-4-12.pdf?sfvrsn=2

2. “Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure,” by Hendree Jones, Karol Kaltenbach, et. al., New England Journal of Medicine, December 9, 2010, 363;24: pages 2320-2331.

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10 responses to this post.

  1. I feel much the same… AATOD is always a refreshing time. It’s very much needed every 18 months. I regret I didn’t get to see you while we were there.

    I blessed to be able to tour Dr. Kaltenbach’s OTP for mothers while I was there where several of the MOTHER study participants are patients. I look to Dr. Kaltenbach and Sharon Dembinski as the leading experts on these issues, and it’s wonderful we have practitioners prioritizing studies and research in this area.

    Now if we can get our judges, child welfare workers & others to understand and accept the science we’ll be doing well for our patients. There are two areas – one in NC and one in GA – where I have been partnering with Mark Parrino & AATOD to try to bring change through diplomacy with judges who have yet to realize the scientific realities of these situations.

    I am already looking forward to Atlanta in April 2015!

    Reply

    • Hi Zac,
      Yes, I wanted to meet you. You know the program director at Stepping Stone, I think. We are involved with some advocacy issues and he mentioned talking with you. And you know our regional director of CRC, who was going to introduce me to you but it never happened…all so busy.
      I really enjoyed AATOD.

      Reply

      • Yes, I think the world of David and am glad I have been able to partner with him over the past few months along with Mark Parrino and Kenny House. We had a wonderful meeting with Jerry Rhodes, the two Regional VP’s & several regional managers from CRC at the conference about collaboration and partnership between NAMA-R and CRC going forward. I must say all the advocates (3 of us) in that meeting walked away encouraged and optimistic about the future. I truly feel Jerry Rhodes was a deserving recipient of the Marie Award this year.

        I had an amazing interaction with Dr. Kreek that I documented on tnmethadone.org if you haven’t had a chance to see it yet as well.

        I am planning on visiting some of the Western NC OTPs in the coming months, so we’ll make sure to coordinate so we can meet at that time.

        Thank you, on behalf of the patients in the southeastern z United States I represent, for being a warrior for evidence-based treatment and recovery.

        Zac Talbott
        NAMA-R

  2. Posted by Robin Robinette on November 14, 2013 at 5:56 pm

    Bravo Dr. Burson! We’ll said. I wanted to meet you @ AATOD, but missed you somehow. I’m going to distribute the Finnegan Scale to Pediatricians & hospitals in my area. I don’t really think they are treating NAS we’ll here.

    Reply

  3. Hard for clinician to keep up with humongous amount of scientific information. I almost feel sympathy for them. We do have the responsibility to provide them with the best information available to use and back it up with journal article. Back at the time of the TIP#1 State Methadone Treatment Guidelines (vastly ignored by the grand majority of
    http://ctcertboard.org/files/TIP1.pdf‎ .
    all mmt. Methadone was researched more than any other treatment protocol, including the dominant ’12Step facilitation’ which at the time much was written about. But had nearly zero studies (most facilities stating, (my paraphrasing) “all we need to know about effectiveness is a God and a spiritual program”. Now all the proponent are running around trying to prove their effectiveness ”scientifically”. All their studies are based on confirmation. Not one study have not dare to refute their finding. Having all
    of the characteristic of a pseudoscience. http://en.wikipedia.org/wiki/Pseudoscience‎

    According to the 12 step tradition ”recovery” can only be gain with abstinence from all drugs (including medication). It wasn’t long ago that facilities as well as sponsors will required their patients to get off their anti-psychotic and antidepressant medication. Most facilities wouldn’t even give you an aspiring for a head ache. In fact one of the motivating factors for the existence of American Society of Addiction Medicine was about these poorly conceived disillusion.

    You haven’t the faintest idea of how poorly we have been treated by a profession we should trust. You are getting a hint though.

    Reply

  4. Posted by KMW on January 10, 2014 at 6:58 am

    Hi Dr. Burson, I stumbled upon your blog yesterday and have been glued to it since. I have enjoyed reading through your informative posts. I have only made it back to May of 2013, so I have a ton more to read, but wanted to thank you for your commitment to educating others in your field on MAT.

    I had an unplanned pregnancy almost 6 years back and had been “treating” my addiction myself with suboxone. When I found out I was pregnant I was a mess. I couldn’t figure out how I was going to taper myself down and not take it. I had people tell me that they had taken while they were pregnant and they never told their doctors. This just didn’t sit well with me. Pregnancy is scary enough thinking about all the “what if’s” without keeping something like that from my Doctor.
    I started asking around to find names of doctors who had good reputations. I had heard from some people that some doctors refused to continue suboxone maintenance while pregnant, or that I would have to switch to methadone. Nothing against methadone, I just didn’t see how that set up would work with having kids and my schedule at that time. Regardless, at this point it had been 4 days since my positive pregnancy test and I was a losing my mind, I knew I needed to find a doctor and get their professional opinion QUICK. One friend spoke very highly of his doctor, and while discussing my situation, I found out this doctor was an OBGYN before he started addiction treatment. That was all I needed to hear!
    I still remember walking into his office the first time, I sat down and could hardly get a sentence out before dissolving into hysterics. The emotional beating I had not only given myself, but others had so graciously given me as well, in the week leading up to that appointment were too much for any person to handle. I had family members tell me they were going to lock me up until I got the “$#*@” out of my system, that no blood of theirs would be born addicted to “#$@*”. How could I do this to my child? All sorts of ignorant abuse without even understanding “what” suboxone is, or even used for. I am an honest person, I don’t hide my past because I believe everything has happened for a reason. It is all a part of who I am and how I got here, so I am used to the stigma attached to buprenorphine. I had already thought that I could never handle seeing my baby going through WD and knowing I was the reason for that suffering, so I was beating myself up. My doctor was God sent, no doubt! He patiently explained my options, went over possible outcomes and problems, made himself available to answer any questions family members had and offered to talk with my obgyn. When I showed up for my second appointment he had a stack of information regarding buprenorphine and pregnancy for me to share with my family. I did end up bringing my fiance in with me so he could talk to with my doctor himself.
    He is still the best! I consider myself so lucky to have found him. Doctors like the two of you make a huge difference in this world! I can’t wait to share your blog with him!
    My baby was born in a Baltimore city hospital, I thought that would at least have some knowledge of pregnancy and patience treated with buprenorphine, it wasn’t much. My obgyn was good in the sense that she told me to follow my drs orders, but beyond that, not much. At one point, after I had gotten my epidural, I was in excruciating pain. I was begging them to please do something, something wasn’t right. I had been through this before and I knew I shouldn’t feel the way I was. One “family” member in the room made a comment along the lines of ‘just go to sleep and stop trying to get pain meds’, she said this in front of the nurse and gave her a “look”. Umm last time I checked epidurals don’t get you high, but whatever, I was in too much pain to worry about whatever ridiculous nonsense she was talking about. Apparently the nurse must have agreed because it took another hour of me complaining before they realized my epidural wasn’t even “in” and I was sitting in a puddle of what should have been numbing me.
    I ended up getting a c-section, and was given 2 5mg oxycodones every four hours. I will say, I got somewhat lucky, I had a nurse who had worked with methadone patients and their babies. She understood that 10mgs wasn’t doing much for me and made sure to be there at 4hrs on the dot. She also spent a great deal of time asking me questions and educating herself with whatever I could tell her regarding buprenorphine. The down side of this was she expected the my sons WD to be comparable to that of the babies she had cared for. She would point out things and say “see that is the WDs”. Personally, I didn’t agree with all that she pointed out, but maybe I didn’t want to see it. My son scored relatively low our entire 3 days, but during her 2 shifts there were huge spikes in his scores. I found this interesting. They gave him a UA (my son) and that came back positive, at this point I can’t even remember what for. I asked and they told me the things it could be and I had never even heard of them before. I also knew I hadn’t done anything. They had given me something when I first went into get labor induced, so I could rest until they gave me the epidural. I remember asking if this could be what it was. They did another UA on him and I never heard anything more. I assumed I was probably right and they had probably just “assumed” I had been doing something I shouldn’t be. The part that made me most upset was that a social worker had to see me. WHY? EXCUSE ME? I have other children, is my name in the system? My name isn’t in any system! So based on my medication, my child may be in danger? They can choose to do a home visit as well, but I guess they didn’t see any need to since it was never done.

    I apologize for rambling, just thought I would share a little. So yes, the stigmas and ignorance are alive and well, but thanks to the efforts of Doctors like yourself, and mine as well, people are learning and that is a huge step in the right direction!

    Reply

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