Posts Tagged ‘Pregnant women using drugs’

Updates

Empty board

 

Prisoner death from drug withdrawal:

In my blog entry on October 20, 2015, I discussed the horrible death from drug withdrawal suffered by David Stojcevski in the Macomb County, Michigan, jail. I’ve been scouring the internet looking for updates on the lawsuit the family has filed against the county, but haven’t found anything. However, I’m pleased to find many news stories about this awful incident, which helps to keep the issue of medical treatment of prisoners in the news. This is something we must change. Incarcerated people should not be allowed to die from drug withdrawal!

http://www.newsjs.com/ca/cops-arresting-man-in-murder-probe-leave-him-locked-on-bus-with-passengers/diV1CbLR9C6B0bMHAlNf4Wk68k_mM&authuser=0/

Bad legislation:

On April 12, 2015, I blogged about NC bill S297, which is legislature intended to make drug use by a pregnant woman a criminal act. Regrettably, this sorry and misguided piece of legislation was passed on its first reading in the NC senate. It’s now been referred to the Committee on Rules and Operations of the Senate. If you live in NC, when you vote, remember that Republican Brent Jackson presented this bill, which I believe will keep pregnant women from seeking medical care during pregnancy if they have the disease of addiction. This bill is not good for society, pregnant women, and especially not good for fetuses.

Probuphine:

I’ve written a few blog entries (September 2, 2011; March 30, 2013; May 21, 2013; and November 7, 2015), about Probuphine, implantable small rods that deliver buprenorphine into a patient’s bloodstream over six months.

In January of 2016, an advisory committee to the FDA voted to recommend Probuphine for approval by the FDA for the treatment of opioid addiction. The FDA is expected to hold its vote at the end of this month. You will recall that despite a similar recommendation last year, the FDA did not approve this implant, stating more study was needed, especially on patients who were stable at lower dose of buprenorphine.

This time, Titan Pharmaceuticals is seeking approval in patients who are stable on 8mg of the sublingual buprenorphine or less per day.

Of the minority of people on the advisory panel who voted no to the recommendation, concerns were expressed about identifying appropriate patients for this medication, and risks of both implantation and removal of the rods.

I’m still not clear if there will be changes to the rules for implantation and removal of the Probuphine rods. For a buprenorphine prescriber to be able to offer Probuphine, she would have to take a training class for the procedures for implantation and removal. This requires time away from work, to meet an uncertain demand for this product. Not all doctors who prescribe buprenorphine will want do this procedure anyway.

If I want to do this procedure in my office, how to I get the implants? Do I have to buy them, and wait for the patient to pay me back? Do I write a prescription and have the patient pick them up at the pharmacy? Will insurance cover the medication and the procedure? If yes, how long would I have to wait for payment from these companies? I’ve been able to stay in business at my private office by keeping overhead pared to a minimum, so if Probuphine requires an investment by me, I may decide it’s not worth my time and effort.

Hepatitis C treatment

As described in my July 3, 2015 blog entry, the CDC recently reported a surge in the numbers of U.S. citizens who have contracted Hepatitis C. Now another drug has entered the market to treat Hep C, but remains extremely expensive. Earlier this year, Merck pharmaceutical company launched a new Hep C drug called Zepatier. It’s an oral drug that costs an estimated $54,000 for a twelve week course, compared to $80,000 for a similar course of Harvoni. However, early reports say Zepatier cure rates may not be as high as Harvoni’s, so we await more information.

Many health insurance systems can’t afford to pay this much money for treatment of their insured, and so many people infected with Hep C have found their insurer refuses to pay for this new treatment that cures Hep C in most patients. Without insurance, few people could shoulder that expense themselves.

So we have another treatment option, and a little bit less expensive. Let’s hope this trend continues.

ALKS 5461

In my blog post from January 17.2015, I reported a new drug on the horizon that was hoped to be a novel treatment for resistant depression. This medication, known as ALKS 5461, contains buprenorphine (just like Suboxone, Subutex) and samidorphan, a new opioid receptor blocker. The medication was theorized to treat depression by the buprenorphine’s antagonistic action on the kappa receptors, and the samidorphan would serve to block the effect of buprenorphine on opioid receptors, so that the patient would not develop an opioid dependency.

Unfortunately, ALKS 5461 failed to show benefit in two phase III clinical trials, leading Alkermes stock to fall when this data was announced in January of 2016. Despite these results, Alkermes is reported to be continuing research into this potential new medication for depression.

Pregnant Women Using Drugs

Pregnant addicts are the most stigmatized group in U.S. society. Even other drug addicts regard pregnant addicts with scorn. But the nature of addiction is the loss of control – pregnant addicts usually do want to stop using drugs, but have lost the power to do so without help. And even if they do seek help, pregnant women face special barriers to proper care. The stigmatization alone is enough to keep many women from getting help. They face overwhelming shame and blame from society and from their own families. Pregnant women don’t tell their obstetricians about their addiction, for fear they will be treated harshly by the professionals on whom they must depend to deliver medical care. I’ve already blogged about the atrocious misinformation some obstetricians accept as true about opioids addiction and treatment during pregnancy.  Female addicts, scared and ashamed to ask for help, try to hide their addiction as well as they can, and hope for the best.

If a pregnant addict does seek help, many treatment programs won’t accept her into treatment, because she is too high risk. Addiction treatment programs sometimes don’t want the liability of a pregnant addict.

At one of the opioid treatment programs where I used to work, a woman came for admission in her fifth month of pregnancy. I tried to be gentle as I asked her why she’d waiting so long to get help. She laughed without humor and told me she’d been turned away from three other treatment facilities. The first was an inpatient residential treatment program that turned her away because she was addicted to opioids. They told her if they took her into their treatment program, she would have to undergo withdrawal, because they did not “believe” in methadone or buprenorphine (Subutex). And if she went into withdrawal, she could miscarry.

They directed her to an inpatient detoxification program that also declined to admit her because they didn’t want her to miscarry while in their facility. They (correctly) referred her to an opioid treatment program. The first opioid treatment program offered only methadone, and since she preferred buprenorphine, they referred her to the clinic where I worked. This patient had (correctly) heard new studies showed less severe withdrawal in babies born to moms on buprenorphine (Subutex) compared to moms on methadone.  That clinic then referred her to our clinic, since we do use buprenorphine. All of this took a few weeks, delaying her entry to treatment. The treatment programs made the right decisions, but addiction treatment is so patchwork that it took time for her to ping-pong from place to place until she found the treatment she needed.

Pregnant women fear they will lose custody of their children if they admit to being addicted and ask for help. Sadly, in some counties in my state, their fear is well-grounded. Some women are told they will lose their children because they have enrolled in medication-assisted treatment with methadone or buprenorphine, even though it’s the treatment of choice for opioid-addicted pregnant women. In most cases, treatment center staff can act as advocates, and talk to social service workers who may not be well-informed about addiction treatment. Punishing a mom for getting help doesn’t help anyone. Word spreads in addict social networks, making other women less likely to get help for addiction.

Often, the pregnant addict’s husband or partner is also addicted. He may try to keep her away from drug addiction treatment, fearing loss of control over her, or he may feel like he’ll be asked to stop using drugs too. Even if she’s able to go to treatment, having a drug-using partner makes it more difficult to stop using herself.

Women, pregnant or not, tend to have childcare issues. If they want to get help, who will watch the children while they attend treatment?

Despite the difficulties faced by pregnant addicts, most want desperately to deliver a healthy baby. We know from several studies that harsh confrontation predicts addiction treatment failure in pregnant women. That is, if treatment facility personnel, obstetricians, nurses or any other member of the treatment team tries to blame and scare a pregnant addict into stopping drug use, it backfires. Pregnant women tend leave treatment when they are treated harshly, and have worse outcomes than women who stay in treatment.

I’ve written blogs about the negative attitudes some medical professionals have toward pregnant opioid addicts who come for treatment with buprenorphine (Subutex) or methadone. Thankfully, that’s not a universal attitude. Recently an obstetrician referred her patient to us, calling ahead to speed things along. I called her back after I saw the patient, and we had a cordial conversation which I appreciate all the more in view of negativity I’ve experienced in the past.

I thought again about the topic of opioid-addicted pregnant addicts because of an article in my most recent issue of Journal of Addiction Medicine. This article described the outcome of a study of opioid-addicted pregnant patients in rural Vermont. Since methadone and buprenorphine (Subutex) are the treatments of choice for these patients, the study looked to see if better access to these treatments improved outcomes. The results showed, not surprisingly, improved access to medication-assisted treatment for opioid addiction in pregnant addicts improved the health outcomes for both mothers and babies. Earlier research showed the same result, but this was a rural group, underrepresented in past studies.

Meyer, M, et. al, “Development of a Substance Abuse Program for Opioid-Dependent Nonurban Pregnant Women Improves Outcome,” Journal of Addiction Medicine, Vol. 6 (2) pp.124-130.