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 www.idaa.org. 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
Prevalence
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
Screening
All pregnant women should be screened for drug and alcohol use
-T-Ace
-TWEAK
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.
E-Forcse
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
Alcohol
-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
-amnionitis
-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
-obstetricians
-therapists
-addiction specialists
-psychaitrists
-pediatricians
-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
Buprenorphine
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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