Pregnant Women with Opioid Use Disorder

 

 

 

 

Before I launch into my blog entry for today, I’d like to remind readers that my intent with my blog is to offer general information. My blog isn’t a substitute for real medical advice based on a face-to-face evaluation by a medical professional. In medicine, the devil is in the details, meaning one patient’s case could vary in some small way that would indicate a completely different approach to treatment. I have people write me for specific and personal medical advice, which I cannot provide. You will be disappointed with my answer, which is nearly always to see your own doctor.

Having said that, this blog entry is about my general recommendations to pregnant women with opioid use disorder:

Medication-assisted treatment with methadone or buprenorphine is still the gold standard of treatment for pregnant women with opioid use disorder. Despite some recent studies which indicate medically-supervised withdrawal in the fetus may not be as dangerous as we previously thought, relapse rates for the mother are still high.

There’s no conclusive evidence that medically supervised withdrawal of opioids during pregnancy reduces the incidence of neonatal opioid withdrawal (NOW), also called neonatal abstinence syndrome (NAS). [1]

That’s right…tapering a pregnant patient off methadone or buprenorphine doesn’t reduce the risk of NAS, probably due to high relapse rates.

In keeping with that information, at our opioid treatment program, our pregnant patients are continued on their life-saving medication. If a pregnant patient demands a taper, even after hearing all the current expert recommendations, I’ll honor her wishes, but only after she signs a form saying she’s been informed about possible harmful outcomes.

Due to the enormous stigma pregnant women with opioid use disorder face, I like to see these patients once per month. I can offer them support and remind then they are doing the right thing for themselves and their babies despite what other people tell them. I can also more closely monitor their medical issues and the adequacy of their dose of methadone or buprenorphine.

I try to address certain issues each month when I a see these pregnant women in our treatment program, to make sure they have all the data needed, and to make sure we have good peripartum planning.

In no particular order, here are the items I review at each visit. If I forget one, since I’m seeing the patient repeatedly, I’ll address it at the next visit.

  1. Recommendations for pregnant patients with opioid use disorder have not changed recently. The gold-standard, best treatment choice is medication-assisted treatment with either methadone or buprenorphine.

Many pregnant women are urged by their family, with the best of intentions, to taper off methadone or buprenorphine while pregnant. Sadly, even some obstetricians still recommend taper off medication-assisted treatment, lacking the information from experts in their own field.

Sometimes I can gently educate these physicians…and sometimes it doesn’t help.

Sometimes I ask the patient if they’d like to bring their significant other, or other relative, to one of our visits so that I can explain the importance of staying in treatment. Often, once the relative has more information, they don’t try to discourage my patients from remaining in treatment. I can only do this with patient consent, though.

2. The risk of withdrawal in the newborn isn’t related to the dose of the mother during pregnancy. It’s counterintuitive, but studies done over the past three to four decades don’t show a clear relationship between dose and risk of NAS. Given this fact, there is no reason to keep the mom’s dose lower than she needs. Since we know that the mother will be healthier and have a better outcome with adequate dosing, we need to titrate the mom’s dose to the point withdrawal symptoms are suppressed.

3. We expect a pregnant patient’s dose to need to increase during pregnancy. This is particularly true with methadone. Because of plasma volume expansion and faster methadone metabolism, the pregnant patient’s methadone blood level will drop during pregnancy, mostly during the last three months. Sometimes splitting the mother’s dose (giving half the dose in the morning and half in the evening) works better than increasing the overall dose. We also have some evidence that splitting the dose may reduce the risk of withdrawal in the newborn, so it’s win-win. Splitting the dose isn’t possible if the patient has an unstable home situation, or if she struggles with other drug use. It’s always a matter of balancing risk and benefit.

After delivery, we usually need to decrease the dose slowly, as the pregnant patient’s body gradually goes back to its pre-pregnancy state.

4. I try to help the mom stop smoking during pregnancy, since there’s good evidence to show smoking cessation reduces the risk of withdrawal in the newborn. This isn’t an easy thing, but very important for the baby’s health – and the mom’s.

5. It’s OK to breast feed while on either methadone or buprenorphine. Studies show only tiny amounts of either medication in the breast milk. Experts say the benefits of breast feeding clearly outweigh the risks. And it’s OK if the patient does not want to breast feed. Let’s not be “breast-bullies” and shame women who decide not to breast feed. Let’s support their decision no matter what.

However, if the pregnant patient has used other substances, particularly during the two months prior to delivery, the neonatologist may make a recommendation not to breast feed. Most commonly, the drug in question is marijuana. I tell my patients to heed the advice of the neonatologist.

6. I make sure the patient understands the plan for pain control during hospitalization. I want to continue the patient’s same dose throughout her hospitalization for the delivery of her baby. Patients can still have epidurals which will work well. After delivery, they can be prescribed short-acting opioids like any other pregnant patient, since the daily methadone or buprenorphine won’t be enough to treat acute pain.

I also make sure patients know the names of medications that are contraindicated with methadone and buprenorphine. If they are given one of the mixed agonists/antagonists like pentazocine (Talwin), butorphanol (Stadol), or nalbuphine (Nubain) they will go into immediate withdrawal. This is more problematic for patients on methadone than buprenorphine. Lately I’ve written the name of all three on a piece of paper and given it to the pregnant patient, determined to avoid therapeutic misadventures that have occurred in the past.

Several years ago, a new-ish obstetrician called me, concerned about one of our patients who had elevated blood pressure after delivery. She wondered if there was something in the methadone that caused this, as she had seen it in several other deliveries.

I was mystified. No, I said, I didn’t know of any data saying that methadone raised blood pressure. Worried, I combed the literature but didn’t find anything.

Then I got a copy of the patient’s hospital record. Shortly before the patient had elevated blood pressure, she got a dose of Nubain.

Mystery solved. The Nubain put the patient into immediate withdrawal, resulting in very high blood pressure and other miseries. I hadn’t considered this possibility before, because I had talked to this OB in the past about the need to avoid the mixed agonists/antagonists. She must have forgotten this.

So now, I give all pregnant patients a piece of paper on which I write the three medications, and tell the patients to tell their providers that they are allergic to all three medications. I hope this will prevent further episodes of precipitated withdrawal in patients.

7. I make sure our pregnant women know their babies will need to stay in the hospital for monitoring for six or seven days. I want them to be prepared for this, since it’s upsetting not to be able to bring the baby home immediately.

The baby must stay to be evaluated for withdrawal. Because of the very long-acting nature of both methadone and buprenorphine, the infant won’t have withdrawal as soon as it is born. Withdrawal, if it occurs, can be delayed up to six days. I tell the moms-to-be that the prolonged admission is for the baby’s safety.

Lately, more hospitals are encouraging “rooming-in” which means the infant and mother have a room assigned to them where the mom can keep the room dark and quiet, and either breast feed or cuddle with skin-to-skin contact that soothes the baby.

This newer way uses non-medical means to reduce the infant’s withdrawal symptoms. Sometimes it isn’t possible, obviously, if the baby has other major medical issues, and may have to be admitted to the intensive care unit. But when possible, rooming in is a wonderful option.

8. All drug use is of special concern during pregnancy. Ironically, we have more data about the harm caused by alcohol during pregnancy, yet it’s legal, and part of many social activities. If the mom struggles with use of alcohol or other drugs, we try to refer her to inpatient treatment programs, for more intensive treatment of her substance use disorders.

Our first choice is the state facility in Greenville, NC, called Walter B. Jones Alcohol and Drug Use Treatment Center. They do a terrific job, and admit pregnant women as a priority. They can provide prenatal care as well as maintaining the patient on methadone or buprenorphine. And they can address whatever other drug use has been a problem, providing a much higher level of support. Soon, that standard of care may be offered at other North Carolina ADATC programs, as they become certified as opioid treatment programs too

.Pregnant women on medication-assisted treatment can’t be admitted to many inpatient residential programs, because these programs won’t “allow” patients to dose daily with methadone or buprenorphine. This severely limits our choices for pregnant patients. I hope this will change soon, since those programs aren’t observing the standard of care for pregnant women.

Let me say a little about stigma and bias. We’ve seen too many sensationalistic stories in the media about “drug-addicted babies.” As a point of fact, babies aren’t born with addiction. They may be drug-dependent, but they aren’t addicted, since the definition of addiction requires mental obsession with the drug, and craving. Newborns obviously can’t formulate that mental preoccupation for substances.

Pregnant moms face a great deal of stigma for having substance use disorders. These disorders are defined by loss of control over the substance, yet if one of these women become pregnant, they are suddenly reviled for their lack of control. They are sometimes judged severely, and told they must not care about their babies or they would quit using drugs.

Substance use disorders are so much more complicated than that.

In fact, harsh confrontation of a pregnant woman predicts treatment failure, with worse outcomes in both mom and baby.

Best results are seen when the woman is treated with compassion, and motivated by hope.

All mothers want to have healthy babies, and moms who use drugs are no different. They want to be good moms, and they want to do the right thing for their babies. Sometimes pregnancy can be a positive thing, since it can be a strong motivator for patients to ask for help. Let’s support them in any way that helps.

  1. Jones et al, 2017 “Medically Assisted Withdrawal (Detoxification: Considering the Mother –Infant Dyad,” Journal of Addiction Medicine, Vol. 11, No. 2, March/April 2017)

 

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3 responses to this post.

  1. Posted by Jude DiMeglio Trang on September 9, 2018 at 6:28 pm

    Thank you Jana for your insightful and pertinent blogs. Our 25-yr-old son died of a heroin overdose after drinking alcohol. We have a blog too: OpiateNation.com. I cited your Aug 2017 blog on overdoses in combo with alcohol and benzos – our son’s story. I am finishing a memoir for families, friends, addicts with the hope of removing shame and shedding light and hope.

    Reply

  2. Posted by Elizabeth on September 10, 2018 at 3:19 am

    Really informative and heartening post. If I can humbly add one thing — maybe start talking to your patients about the long term likelihood of being able to care for their child. I’m fostering a boy born under the circumstances you describe above. After he was discharged from the hospital he went with his mother into a long term residential rehab. Ultimately she couldn’t manage sobriety and a toddler so he came into care. Thankfully his mother had bonded with him and their relationship is still very intact and loving despite her inability to parent him full time. I fully credit this little miracle to the amazing pre-natal care, counseling, and long term treatment she received. I don’t know how this story will end but I will say – having fostered children ripped right from their mothers at birth -that no good comes from shaming and punishing an addicted mother.

    Reply

  3. Posted by Alan Wartenberg MD on September 10, 2018 at 8:21 pm

    I would add that buprenorphine (in the form of the injectable buprenex) is also widely used in pregnancy, and that it can also cause a severe opioid withdrawal in women who are on methadone (and potentially produce precipitated withdrawal in the neonate as well). In fact, it was the widespread use of buprenex, used largely because of little or no respiratory depression in the moms, that led physicians in Europe to explore its use in treatment of opioid dependency.

    Reply

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