OPIOIDS: and beyond

Davida M. Schiff, MD, MSc February 16, 2021

www.mghcme.org Disclosures

Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

www.mghcme.org Historical Context

Eugene Grasset, La Morphinomane [The Morphine Addict], 1897

Slide from Mishka Terplan www.mghcme.org Historical Context (cont.)

Laudanum bottle. Source: University of Buffalo, Addiction Research Unit

Slide from Mishka Terplan www.mghcme.org Historical Context: Racism & war on drugs

www.mghcme.org Pregnant/Parenting women with SUD vilified by society

No other disease in medicine where politics/policy/stigma have such significant impact on care

https://www.nytimes.com/interactive/2018/12/28/opinion/abortion-law-poverty.html www.mghcme.org Pregnancy: Intersection of Addiction + Reproductive Life Course

Pregnancy

Slide/concept from Mishka Terplan www.mghcme.org Pregnancy Addiction

• Excitement • Sadness • Motivation • Fear • Joy • Shame

Slide Courtesy of Jessica Gray www.mghcme.org Treatment of OUD in Pregnancy

• Medication treatment with methadone or + behavioral therapy is the standard of care

• Trial (2010) • RCT of Buprenorphine v. Methadone • Bup w/ shortened length of stay for • Methadone group significantly higher retention than buprenorphine (31 v. 17%)

www.mghcme.org agonist treatment in Pregnancy

Benefits Risks • Reduces illicit opioid use and risky behaviors • Neonatal Withdrawal • Helps remove women from unhealthy environment • Low birthweight • Limited data on neurodevelopmental • Improves maternal nutrition, outcomes • Prevents fluctuation in maternal drug level

• Reduces overdose risk, complications of IVDU

• Improves participation in prenatal care Adapted from and other drug • Enhances ability to prepare for birth treatment guidelines for pregnant, substance using women, 1995 • Women are more likely to retain custody of children Saia, KA et al. Caring for Pregnant Women with in the USA: • Children are more closely monitored when women Expanding and Improving Treatment. Curr are part of a treatment program Obstet Gynecol Rep (2016) 5:257–263 • Reduces the frequency of obstetrical complications

www.mghcme.org Case Based Example

• Kelly is a 34 y/o G1P0 black woman with polysubstance use including and opioid use disorder, dependence presenting to initiate care at 34wks, she had been actively using throughout her pregnancy. • She has a history of DCF involvement herself as a child, her both struggled with active during her childhood • She presents for care to your clinic and desires a healthy pregnancy but remains ambivalent about starting methadone or buprenorphine.

www.mghcme.org Pregnant Women with OUD Face Unique Treatment Barriers

Mental health: Higher rates of depression, anxiety and PTSD Childcare responsibilities Fear of child welfare involvement

Successful treatment for Women • Integrates mental health treatment • Reduces barriers for childcare and transportation • Provides a safe and empowering environment • Addresses needs of pregnant and women

National Survey of Treatment Services (NSSATS), Terplan, AJPH, 2015

www.mghcme.org Why do pregnant women avoid treatment?

• Desire to minimize exposures to fetus, avoid the risk of neonatal withdrawal • Shame/stigma of drug use during pregnancy • Avoid child protective services reporting • Fear of punitive response • Historical/community views on medication treatment

www.mghcme.org www.mghcme.org Barriers exist to accessing buprenorphine when pregnant

(Patrick, JAMA Network Open, 2020)

www.mghcme.org Pregnancy & medication dosing adjustments: rapid metabolism

For maternal stability dose adjustments needed during pregnancy and postpartum

✓ Dose increases are due to changes in metabolism and not marker of disease severity

✓ Offer women split dose in pregnancy to maintain Payte 2002 therapeutic level

Bogen 2013; Tracy 2005; Jarvis 1999 Shiu Can J Hosp Pharm 2012; McCarthy J Addict Med. 2015, 2018 www.mghcme.org Buprenorphine v. Bup-Nal in Pregnancy

Buprenorphine Buprenorphine-Naloxone Monoproduct (Subutex) (Suboxone) • Advantages • Advantages – MOTHER Trial looked at – No changes during buprenorphine mono pregnancy or postpartum product v. methadone period, when transition • back to combined Disadvantages product can be – Potential for diversion, challenging for women injection misuse, due to concerns about victimization/coercion of equal effectiveness pregnant people to sell • Lack of evidence of harm given higher street value with combined product https://med.dartmouth-hitchcock.org/documents/Use-of-Buprenorphine-Naloxone-in-Pregnancy.pdf www.mghcme.org What about detoxification?

“Pregnant patients should be advised that withdrawal during pregnancy increases the risk of relapse without fetal or maternal benefit” Obstetrics and Gynecology May 2018

“Pharmacotherapy is preferable to medically assisted withdrawal because withdrawal is associated with high relapse rates which lead to worse outcomes” ACOG Committee Opinion, 2017

www.mghcme.org Emerging treatments for OUD in pregnancy • Naltrexone IM – Insufficient data to support naltrexone initiation during pregnancy • Some safety data out of Australia in pregnancy • Currently being studied in pregnancy in US – For those who become pregnant on naltrexone, may continue after careful discussion of risks of discontinuation (relapse) and limitations of data in pregnancy • Anesthesia consult for pain management

• Buprenorphine-XR – NIDA CTN-0080 evaluating the impact of treating pregnant women with BUP-XR, compared to BUP-SL

Hulse Aust N Z J Obstet Gynaecol 2002 ; Hulse Aust N Z J Obstet Gynaecol 2003; Jones Am J Addict 2012 ; Towers Am J Obstet Gyn 2019 www.mghcme.org Shared Decision Making to Aid Medication Choices

• Motivational Interviewing Skills: – Rolling with Resistance – Developing Discrepancy

Guille, Psych Res Clin Pract 2019; 1:27–31 www.mghcme.org Trauma is Nearly Universal

• 55 to 99% of women with substance use problems report history of physical and sexual abuse

• Women with a history of childhood sexual abuse – 60% more likely to have alcohol problems – 70% more likely to have used illegal drugs

Najavits et al., 1997; Dube et al., 2005 www.mghcme.org What does it mean to provide “trauma-informed” care?

• Goal – Restore a sense of autonomy and control

• Pearls – Be compassionate and empathic – Give as much control and choice as possible – Validate any concerns as understandable and normal – Build upon strengths and promote resilience – During emotional times, ask, "how can I support you right now?"

Sheway http://sheway.vcn.bc.ca/ www.mghcme.org Preparing for delivery

• Antenatal consults ✓ Anesthesia ✓ Delivery Pain Management ✓ Discuss if patient wishes to avoid additional opioid exposure ✓ ✓ NAS/NOWS education ✓ Plan of Safe Care, Federal and State reporting requirements for substance exposed newborns. • Patient education ✓ Agonist medication • Peripartum dose adjustments – continue same dose during labor • Review risks/monitoring for postpartum sedation ✓ Trauma-sensitive birthing experience

www.mghcme.org Moving from shame-based to empowerment-based language

Assumption Helpful Response “She just wants attention” “She is crying out for our help” “Those moms have poor coping methods” ”They have survival skills that got them to where they are now” “Don’t ask them about it or they will get “Talking about trauma gives people upset” permission to heal” “They should be over it already” “Recovery is a process, it takes time” “They’ll never get over it” “People can recover" “They are weak” “They are stronger for having experienced trauma” “This person is sick” “This person is a survivor of trauma”

www.mghcme.org What’s “New” in Care of Opioid- Exposed Infants

• more often on medications for opioid use disorder (rather than illicit opioid use) • More emphasis on family-centered and non- pharm care for infants with NAS / neonatal syndrome (NOWS) – Skin-to-skin care – Rooming-in – – Others (acupressure, ) • Eat-sleep-console approach to assessment • Methadone or morphine for pharm therapy • As needed dosing www.mghcme.org Factors impacting neonatal withdrawal in substance-exposed newborns

• Medication dose does not correlate with withdrawal severity • Buprenorphine may cause less severe withdrawal than methadone

• Genes a significant role in the severity of withdrawal • Tobacco, , selective serotonin reuptake inhibitors (SSRIs), gabapentin, and other substances increase the severity of neonatal withdrawal

More severe symptoms likely a combination of genetic predisposition, multiple exposures, and hospital NAS protocols

Cleary 2010; Jones 2012; Wachman 2013; Wachman 2018; Brogly 2014 www.mghcme.org Breastfeeding and NAS / NOWS

• Mothers who are stable on methadone, buprenorphine, or buprenorphine/naloxone should be encouraged to breastfeed. • Naltrexone likely ok for breastfeeding, limited data. • Contraindications to breastfeeding: – Ongoing non-prescribed substance use, HIV – Hep C or Hep B with /cracked nipples – Active use • Breastfeeding recommended regardless of maternal methadone or buprenorphine dose.

Reference: Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018. www.mghcme.org Summary

• Pregnancy is a time of high stigma and high motivation • Methadone and buprenorphine in pregnancy are standard of care • NAS/NOWS is expected and treatable outcome of in utero opioid exposure • Clinicians play an important role in providing non-stigmatizing, non-judgmental evidence-based treatment to help women with OUD and their families

www.mghcme.org Thank you

[email protected]

Thank you to Dr. Jessica Gray for developing this initial slideset www.mghcme.org Resources

https://journeyrecoveryproject.com

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