Sunday, August 5, 2012

Pregnancy and Addiction - Dr. Stacy Seikel

Dr. Stacy Seikel ( presented at the IDAA 2012 Medical Conference in Orlando Florida on the topic of Addiction and Pregnancy.  Her slides were remarkable and her presentation one of the most informative and engaging presentations I've been priviledged to hear.  Given the importance of her message regarding the future generation and the unborn child, universal screening is the very least that can be considered.  The hundreds present were equally impressed given the level of applause. Dr. Seikel's work is not only cutting edge technologically but she had done amazing networking to ensure that women and families can access the treatments that are needed for the betterment of individuals and society.  It was clear that she was motivated by a deep spiritual and ethical moral system of concern for pregnant women suffering from addiction.  She demonstrated the compassion and empathy for these women who are so commonly ashamed and carry such stigma with their addiction when they simply can't say 'no' without the help of doctors and society when pregnant they want to change.  Dr. Seikel is clearly there for her patients.
The following are the rough notes I took during the presentation with just a few highlights taken from many slides in which she simply wanted to point to one aspect of the problem or the solution. I was unable to get all the information but know that her slides and notes are available through the  International Doctors in Alcoholics Anonymous was very fortunate indeed to have someone of Dr. Seikel's training, experience and high level of functioning in the system where it counts, most to come to the conference to present in the Continuing Medical Education in Addiction Medicine portion of the conference. I would strongly recommend her as one of the finest lecturers I've heard on a terribly important topic in our present day.
Pregnancy and Addiction
  • Dr. Stacy Seikel 
IDAA - Orlando - 2012


12 to 24% women use drug and alcohol during pregnancy
1 of every 3-4 women expose fetus to alcohol

Risk Factors
Family history of addiction
Experienced violence in childhood

Clues in medical history
No prenatal care
-fear of discovery of addiction
-secondary to general chaos in her life

Tattoos or self scarring
-seconary to IVDU or skin popping

Burns on hands and clothing

Positive hepatitis

Nicotine abuse

All pregnant women should be screened for drug and alcohol use
A positive test indicates need for a further evaluation

Elements of the history and physical may indicate need for drug screen

Immunoassay Drug Screens (not test)
  • POC UDS = immunoassay
  • semi quantitative immunoassay - not confirmation test
  • lab screen UDS = immunoassay
  • GCMS= Confirmation test
  • LCMSMS = Confirmation test
  • It’s important to know that a second immunoassay isn’t a ‘confirmation test’, must order a ‘confirmation test’ to know.

Florida’s Prescription Drug Monitoring Program 

PMP - shows every controlled substance prescribed and where from - helps get around the denial, 

Patient advisory reports - used by the methadone maintenance program

We know that relapse is harmful to the fetus hence methadone is better.
Taper isn’t as good but will work with those who want a as a plan b.

Treatment Barriers
Fear, shame and guilt about use
-will she lose children if in treatment
-does she have family support
-attitudes of medical providers
Lack of comprehensive clinical care for all the problems of pregnancy and addiction
  • can she get treatment?  Transportation problems?
  • Care is fragment
  • lack of childcare in treatment
  • basic needs must be met for her to engage in treatment
Co morbid diagnois impacting ability to access services
  • multiple problems associated with co morbidity, ex psychiatric symptons

-known teratogen
-no safe level of drinking in pregnancy

New Alcohol Biomarker in cord blood
=3-4 week retrospective of alcohol use

Medical Complications of Drug Abuse in Pregnancy
Same as in regualar patients

Obstetrical complications of opiate abuse
-Polysubstance abuse is the norm
-increase in spontaneous abortion, esp first trimester
-intrauterine growth retardation
-placental insufficiency
-postpartum hemorrhage
-preeclampsia, eclampsia
-premature labor/membrane ruptures
-septic thrombo

Opioid Dependence (DSM IV) Aka Addiction
Opioid Addiction
-chronic progressive, relapsing
-neurobiolgic changes
 -pharmacologica treatments are effective in normalizing neurobiology

There is a big difference between short acting and long acting opiates.
  • animal studies show long acting opiates can cause healing of the mu receptors which can go back to normal state
  • brain makes new endorphins - so when I ‘m tapering off buprenorphines I encourage my patients to ‘go make endorphins’ - walk the dog, eat chocolate, take a bubble bath etc.

90 meetings in 90 days, is said in AA but it’s no coincidence because the first 90 days has so much healing that is going on.  

Medication assisted treament is one option for people to engage in a treatment program to develop psychosocial skills to be able to tolerate a taper when they have some relapse prevention skills

Drug addiction is a brain disease
  • prefrontal cortex mri studies show ‘disruption of brain circuits involved in reward and punishment’
  • prefrontal cortex is the executive function

Morphine has a jack hammer on and off mu effect
  • altered gene expression - you no longer are the person you were before you used drugs
  • limbic system in overdrive
  • prefrontal cortex not working
  • “You have to use to survive”
-this is why a pregnant woman will use and she is so ashamed, because there’s nothing worse in her eyes and in the eyes of others than a woman who uses drugs
Because relapse is high in this population we have found maintaining women on methadone 

Various Discipline see the Maternal Fetal Dyad differently
-addiction specialists
-corrections officers

“Those in recovery who have themselves experienced loss of control will hopefully have some compassion for these women who get very little compassion from anyone else”
In Florida Orange County have developed an interdisciplinary program involving methadone treatment, hospital, high risk obstetric unit, outpatients and jail

Methadone and Pregnancy
-Methadone is only agonist therapy recognised for use in pregnancy,  Supported by 30 years of research

Federal Laws Governing Addiction Treatment

-requires special federal license
-rules and rules and rules

Opiod agonist maintenance in pregnancy
  • maintenance with methadone during pregnancy produces the same benefits as treatment in non pregnant 
  • The studies  (Jones H, 2008) are really poor by evidence based medicine for taper because of the high risk of relapse.  But if patient individually demands this despite the evidence against it, taper in second trimester - make sure though that there is no significant abstinence syndrome (Luty,J, Nilodeau V, Bearn J 2004) 

Pregnancy patients receive all the same results methadone treatment programs for non pregnant

Clinical Study last year showed buprenorphine may have less abstinence but can have complications for c section 

 Methadone Induction
-start low - go slow
5 days until steady state obtained
  • peaks 2-3 hour after dosing
  • Consider dosing in office and observing patient for 3 hours

Opiate intolerant (or someone you’re not sure) Day 1 10-15 mg max
Opiate tolerant day 1 25 to 40 mg max
Increase every 5 days

The right dose throughout pregnancy is the dose that stops withdrawal

not fda approved, methadone gold standard in pregnancy but can be used and is widely used in Europe
NEJM Dec 2011 study

Suboxone can be changed directly to Subutex

Induction is very tricky because you are supposed to give suboxone when people are in withdrawn but this is contraindicated so while it can be done it’s 

I don’t go from methadone to buprenorphine because of the withdrawal problems

Ongoing illicit or polysubstance use
Perioperative pain management for patients on buprenorphine
anesthetists need to know last dose, 
-continue dose tid or qid (don’t stop because we must avoid withdrawal for fetus in pregnancy
-use non narcotic pain medications
-Fentanyl with it’s high affinity may over ride antagonist effect

With methadone in pregnancy dose once a day and realize post op may need 10 to 20% more narcotic because of pain

Discharge Pain Meds should be a fixed amount - tend to give ‘excess’ medications especially the post op patients who give too much - teen agers are dying from pills in medicine cabinet

Breast Feeding on Methadone
  • it’s okay to breast feed - came from American Academy of Pediatrics

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