Hi. I'm Dr. Kristi Dively. And today we're going to talk about addiction and pregnancy. I am board certified in both Obstetrics and Gynecology and addiction medicine. The objectives for this lecture are to define the treatment protocols for opiate addiction. And Pregnant patients to describe the therapeutic... ...approach for benzodiazepine addiction and pregnancy, to identify the methods used in the treatment of alcohol addiction during pregnancy to outline the strategies for managing nicotine addiction and pregnancy, and to list the potential consequences of substance abuse during pregnancy. As we all know, substance abuse is a very serious... ...issue in the United States in 2013. 5.4 % of pregnant Women were illicit drug users and that's not including nicotine 15.9 percent of pregnant. Women smoke and 8.5 percent of pregnant women report, current alcohol, use with point three percent reporting, heavy... ...use the prevalence in public clinics is equivalent to that in private practice and its highest in. Asians, followed by African Americans, followed by Hispanics. So, the first thing we need to talk about is screening and why we should screen patients for substance use disorders. We need to screen because there's a whole host of maternal complications their risk for bacteremia and endocarditis. If they're abusing drugs, be an intravenous route. They're at risk for sexually transmitted infections such as HIV and hepatitis C. There's an increased risk of spontaneous abortion... ...risk of placental insufficiency or abruption. Postpartum Hemorrhage. Preeclampsia and eclampsia preterm labor and premature rupture of membranes. Fetal, complications include intrauterine, growth, restriction. 'S congenital defects, which are teratogenic effects from the substances mental retardation low, birth weight and neonatal abstinence syndrome. So why should we screen? We should screen because substance use disorders are totally treatable. We have an ethical duty to screen pregnant women for substance use ACOG committee opinion 422 addresses, the ethical rationale for Universal screening for at-risk drinking and illicit drug use the American Medical Association, also endorses Universal screening, Why do we screen? We screen Because treatment works 70-80% percent of pregnant women with a substance use... ...disorder can have a favorable you dies at delivery. If they are in treatment early intervention can... ...reduce many of the adverse effects of tobacco and cocaine and treatment in pregnancy. Enhances long-term recovery up to 65 percent of these patients or abstinent one year later. Brief physician advice has been shown to be as... ...effective as conventional treatment for substance abuse. So how do we do it? Every pregnant patient should be asked about substance... ...use at the first prenatal visit and at least, once per trimester, The easiest way to do this is to start with the two items screen. So you ask the patient in the last year. Have you ever smoked cigarettes, drink alcohol, or use any drugs more than you meant to? And then the second one is, have you felt you... ...wanted or needed to cut down on your smoking or drinking or drug use in the last year? If you get two no answers the patient's State she doesn't use Alcohol, Tobacco, or drugs, there at low risk for substance use and you proceed to the second screen, which is the 4-Piece plus, the 4-Piece plus is, did any of your parents have a problem with alcohol, or drugs, do any of your peers have a problem with alcohol, or drugs? Does your partner have a problem with alcohol or drugs? Have you had a problem with alcohol or drugs in the past and Have you smoked any cigarettes used? Any alcohol or any drug in this pregnancy? If all of those answers are - this is going to be typical of 85% of your patients and you've just accomplished Universal screening in about 90 seconds, these women are at low risk for addiction and should receive routine prenatal, care for the remainder of the pregnancy but you want to ask again about Alcohol Tobacco and drug use each trimester. If you get any yes, answer to either of the screens. The patient is at risk for substance. A urine drug. Test is indicated a brief interventions. Indicated, you want to assess for psychiatric, comorbidities such as depression anxiety, bipolar disorder, and re-evaluate the patient in two weeks. If there's been no change in their behavior, in regards to substance use, you want to refer them to treat, Let's talk a little bit about urine drug screens because this can get a little tricky. Many providers. Use a urine drug screen as a routine prenatal, visit prenatal test at the first visit and this is highly recommended. So even if they answered no to all of those screening questions, you may still want to consider doing a urine drug screen, it can be used to determine the prevalence in the population. Consent is not required and it's both ethical and legal. So a urine drug screen is an immunoassay and this is antibody-based. So this is the one you're going to be doing in your office. Either with a urine drug testing cup or you might have a little dip panel that you put into the urine. The problem with this is it because it's antibody-based. You can have false positives and synthetic. Opioids are often missed. If you have a positive, then you would want to consider sending it for... ...confirmation testing and that would be gas... ...chromatography you know at a lab and that'll show you the specific drug that's being used rather than just a generic benzodiazepine result. It's really important to know what company you're... ...using as far as what lab you're using for gas chromatography. And also what screening tools you're using in your office for urine drug test as far as if it's a cup or a dip, use the confirmation testing and realize recognize that false positives and false negatives do occur on point-of-care testing. It's also important to know when you're ordering a urine, drug screen panel from a lab, what substances your testing, for if you're not testing for the right substances, you aren't going to get the results. So another monitoring tool, besides the Point of Care Drug Test is the pdmp or prescription drug monitoring program. You should certainly be querying it. For all of your pregnant patients to see if they're... ...getting substances prescribed from another... ...provider and especially depending on where you're located, many of them will show you neighboring states or even not neighboring states. So make sure you're checking it appropriately. All right, so on-site, urine drug screens or point-of-care UDS'. are inexpensive there about five dollars for an eleven panel, you get immediate results, you can still send to the lab for a gas chromatography or confirmation if needed, and then it's billable. And then the pdmp, also, you can use it to monitor control prescriptions from other providers, So the point of care test the benefit of it is you get rapid results within minutes of collection. It can reveal the presence of prescribed medication... ...classes and then also a few illicit substances but you got to remember that these are for preliminary treatment decisions or presumed positive. You should be calling these presumed positive or presumed - they're not confirmed positive or negative. the limitation to this is there's a wide variance and cut-offs. Reliability, accuracy, cross, reactivity and reproducibility when using these... ...cups varying on where you're getting for them from. As we mentioned, they're susceptible to false positives and negatives limited substances are detected. So if you're not testing for what's prevalent in your area, you're not going to get the right answer and generally, the manufacturers are recommending lab testing to confirm the results. All right? So when you do a point-of-care UDS and you're looking at opiates. The only thing that opiate strip is testing for is naturally occurring opiates - morphine, codeine, heroin, hydromorphone... ...or which breaks down to morphine and hydrocodone which breaks down to Cody. All other synthetic and semi synthetic opiates need a separate immunoassays. So typically there's a specific oxy strip, a specific methadone strip, a specific, buprenorphine strip, specific propoxyphene strip, a specific test for Tramadol. And again point of care is our screening tools with false positives and false negatives. The biggest thing is to again, well, like I said, know what drug you're testing for. There's very little actual heroin in the United States. These days, it's almost all fentanyl, but there are no CLIA waived point-of-care urine drug screens that test for fentanyl. So, if you're suspicious for opioid abuse, consider sending it for confirmatory testing, regardless of what your cup is showing you. And if you're sending for confirmation, make sure that you're ordering a panel which contains fentanyl. So in office test consider checking for fentanyl. If the ways if there's a way you can consider... ...checking for compliance with prescribed medications, for example, if they're on buprenorphine test for the presence of buprenorphine, not all screens are checking for buprenorphine, so make sure your cup is appropriate. Look at the expanded Panel test to make sure you're... ...testing for what you want to and send it out for confirmatory testing. So what happens when a patient says "no no no I've never used drugs" and the drug test comes back positive or presumed positive. First thing is to stay calm and consider your reaction. Get the facts so you can do the confirmatory testing and you can consult with the toxicologists and then develop a an approach based on safety. So there's multiple ways you can address with... ...the with the patient the urine drug screen came out unexpected, it was positive. It've, for this. Do you know if there's anything you may have used or taken that may give you this positive result? How should I understand this? What you're taking is not theirs? Can you explain it to me? Something else got in there? Patients frequently won't think about telling... ...you prescribe medications because they're prescribed. So it's okay because they came from a doctor, but if they don't tell you, they're taking ativan, don't tell you they're taking oxy then you can't address it. So the biggest thing is to remain calm and not. Not be accusatory. And these are just all of the different things... ...that can give you a positive. Or these are false positives. Sorry, these are all of the different things that might give you a false positive result on a urine drug screen. So some of the most common ones is that Sertraline... ...can give you a positive benzo test. bupropion can give you a positive in feta mean test, metformin can give you a positive amphetamine mean test. Pseudoephedrine - So if they're taking cold medication. They could have a positive amphetamine test. Salicylates, could give you a false, positive cocaine. NSAIDs, can give you a false positive cannabis. and dextromethorphan can give you a false positive opioid. So, keep in mind, the things that can give you false positives, Now let's talk about getting them into treatment. So a pregnant patient is abusing a substance and you're recommending treatment, you're going to get resistance to this and why are you going to get resistance? Well the biggest reason is fear, shame and guilt about the use, is she going to lose her other kids if she goes into treatment, does she have family support? And unfortunately, the attitudes of medical providers towards people who suffered from the disease of addiction. one bad experience with a can really throw them for a loop and they don't want to trust us. There's also the issue of lack of comprehensive... ...clinical care services for all of the problems of pregnancy and addiction. So can she even get to treatment? Does she have a way to get transport? Who's going to take care of her kids while she's in treatment? Her basic needs must be met in order for her to be able to engage in the treatment and then most of these patients also have comorbid diagnosis and that impacts their ability to access services. It's very difficult to address their many issues simultaneously. Many of these patients also have depression anxiety personality disorder, many of these patients that have been using substances for many years, their brain arrests at the age, they started using drugs frequently as a teenager. So then they have immaturity and lack of coping skills. All right, so we're going to move into the specific substance uses. Opioids is definitely the biggest part of this lecture, but we are going to touch on the other substances as well. So in a mom, who's abusing opiates the risks to, the mom include postpartum, Hemorrhage, preeclampsia and eclampsia and septic thrombophlebitis. The risks to the fetus include spontaneous, abortion, amnion itís, intrauterine growth restriction, placental insufficiency, preterm labor, and delivery. And Immature rupture of membranes. Narcan should only be used as a last resort in a pregnant patient because you have a risk of spontaneous abortion, preterm labor and intrauterine fetal demise. But obviously, if Mom's not breathing, you need to give him Narcan. Treatment of opioid use disorder, so ACOG committee opinion 524 says, that the standard of care is methadone maintenance, buprenorphine is an effective option withdrawal from opiates while pregnant Is Not recommended. Now, there's a little bit of a theoretical risk of preterm Labor, fetal distress intrauterine fetal demise... But these patients, when they're pregnant, they... ...are going through withdrawal every single day, you know, when they're using, they're going through withdrawal before they get their next drug. The bigger thing is there risk of relapse 41% to 96% of these patients relapse. If they don't go on medication assisted treatment medication alone is not enough. They need to also be in therapy. They also need psychiatric care. If indicated medication is not the answer, it's just a tool to help with their recovery process. So methadone maintenance therapy is regarded as an established treatment with birth outcomes, comparable to a general obstetric population. So there was fewer preterm births, less IUGR, and fewer low birth weight babies. There was less maternal drug, use the higher, the dose of methadone, the greater the reduction of drug use. They had improved compliance with prenatal care. And there appeared to be no, differential effect of either treatment with exposure to stable treatment So it doesn't matter if they're on methadone or buprenorphine, the point is, they're on something and they're in treatment, going to psychiatric care going to drug and alcohol treatment. Methadone maintenance therapy is supported by over 50 years of research. So this is the gold standard but buprenorphine is a completely acceptable alternative in the correct patient. Population. interdisciplinary care is crucial in the treatment of addiction period, but even more so See? Comprehensive. methadone maintenance therapy with adequate prenatal. Care can reduce the incidence of obstetrical and fetal complications, intrauterine, growth restriction, and prenatal morbidity and mortality. So there's three options out there. But we're only going to talk about two of them. Because naltrexone is not indicated for treatment and pregnancy. So methadone is an Agonist and it suppresses the cravings and withdrawal symptoms. You can use this for detoxification, you can also use it for maintenance, it comes as a liquid, a tablet, / diskette or a powder, you can only get them at a samsa. Certified opioid treatment program and the way the patient's get it is that they have to go there every day to get. There goes some individuals after a while can qualify for take home prescriptions, which could be take home for a Sunday or take home for two or three days or, you know, if they're stable, they might even be able to get take home prescriptions for a month, for 30 days. Buprenorphine is a partial Agonist. So it suppresses, the cravings and withdrawals. But it's only partially stimulating, the brain receptors, you can also use this for detoxification or maintenance. This comes in a tablet form, a film form, which is suboxone. So it's buprenorphine plus naloxone and there's also a long-acting injection, which is supplicated. The newest DEA regulations, allow anyone to prescribe. Dosing is daily with the tablet or Film Form, every 28 days with the injection and individuals can be prescribed to supply to be taken outside of the treatment center. So they can take this medication home. This is one of the best things about this medication. Is if you have somebody that's rural or doesn't live near an OTP or doesn't have a way to get to an OTP, they can get this medicine, they can give it to themselves at home. So how do you start somebody on buprenorphine? We're mostly going to talk about buprenorphine at this point because unless you work in an OTP, you aren't going to be able to prescribed Methadone for induction. So, but you could use a COWS, a clinical opiate withdrawal... ...scale to induce either buprenorphine or methadone. Be very careful, not to put them into precipitated withdrawal, buprenorphine. You can start 12 to 18 hours after heroin. And methadone. You can start 24 to 48 hours after heroin. But remember, this is heroin or actual opiates such as oxycodone or Percocet. If they've got fentanyl, you have to wait longer and even that methadone 24 to 48 hours, that's what the literature says, but real world, it's more like 45 days. And with fentanyl, it's more like two or three days before you want to start it, but you can go over all of these questions with the patient I have had patients. It's induced at home that I just give them the scale and say you know, most of this stuff they can do on their own assess themselves. and then get a total score and you want to make sure they're in like moderate opioid withdrawal. Before they start taking their buprenorphine. Which one do you use? Well, if they're already on maintenance therapy and they become pregnant, they should stay on the current agent. You shouldn't be switching them from buprenorphine to methadone or methadone to buprenorphine when they're pregnant. The criteria for buprenorphine is that the patient cannot tolerate methadone. Methadone program is not accessible. Patient is adamant about avoiding methadone and the patient is capable of informed consent. So if they meet one of those criteria typically for me it's the patient is out of about avoiding methadone, then they would be a candidate for buprenorphine. So let's talk about the pharmacology of these. So all the opiates all the receptor cells in your body. Have three opiate receptors on it, Kappa, Delta and Mu... ...methadone binds to all three. So it's a full agonist. So it binds to The receptors, it stimulates, the... ...receptors gives them relief from cravings and relief from withdrawal symptoms because it is a full agonist you develop a tolerance and then you need more and more and more and more to get the same effect. Buprenorphine is a partial agonist it only binds to the Mu receptor. So because it's a partial agonist, it stimulates the cells enough to give relief from cravings and withdrawal. But not enough to develop a tolerance. Now, they can develop a physical dependence, but they don't develop a tolerance. It has a ceiling effect. So even if they take more than prescribed, they don't feel any different. So there's no incentive to abuse it. And then naltrexone, which I want to talk about although right now it's not really being used in pregnancy is an agonist. So naltrexone blocks the receptor and if they use, they don't get the response, their body expects, they don't feel high and usually that they can be like what's the point of doing this? I don't feel this way. Why am I bothering to use drugs? So, how do you dose this? So the dosages of methadone or buprenorphine may need to increase over the course of the pregnancy due to metabolic changes and increased fluid volume. So I know I just told you that once they're stable they don't need to go on higher doses. But pregnancy is the exception. How would you induce them on methadone if they're... ...opioid intolerant on day one you would start him on ten to 15mg maximum if you... ...don't know their tolerance 15 mg maximum on day one, if they're opioid tolerant you can start with 25 and 40 mg a day. 25 and 40 mg a day You can induce somebody on methadone in the hospital even if you're not a methadone provider even if you're not an OTP, there's a whole lot of regulations that go along with that and making sure they're set up. With aftercare. I'm not going to go into all of that, but certainly, if you're interested in learning more about it, it's easy to find. The biggest rule is to start low and go slow with methadone. It takes five days until they reach their steady state. It'll Peak 2 to 3 hours after dosing. You need to be seeing these patients frequently to monitor for over sedation. And if you're in an OTP, consider dosing them in the office and observing them for three hours for the first few doses. Some patients that come into an opioid treatment program or come into a, even an office will over report, their opioid use because they're fearful that they won't get... ...enough medication and then they'll be in withdrawal. Pregnant women also often have a decreased tolerance because they have been trying to stop using due to their pregnancy. So you want to start low and go slow and this is the rule for buprenorphine as well. So if you're dosing and methadone maintenance patient, while in the hospital, it's best to continue dosing once a day or however they were being dosed at their Clinic. If they were being those daily or if they were having split dosing, if you divide the dose, they may have mild withdrawal for a few days until they reach their steady state. But when transitioning from daily dosing to be BID or TID, you might need to give 25 to 50% more methadone the first day of split dosing to override that withdrawal symptoms. If you're going to split those induction on day one you give a hundred percent of their current... ...dose and then 50% of the dose to take in 12 hours, day, 2 and Beyond, then you would do 50% of the dose every 12 hours on a scheduled basis. Buprenorphine treatment is not FDA approved for use in pregnancy, but it is widely used in Europe. They recommend buprenorphine monotherapy, only, which is subutex, but this is changing. There is more support for using the buy, the product that has both buprenorphine and naloxone in it. The improved pregnancy outcome seen with methadone... ...appear to be duplicated with buprenorphine and the mother study showed there was less severe. Neonatal abstinence syndrome shorter hospital... ...stays for newborns of moms on buprenorphine. We're going to go into the pain one in just a second, but I just want to talk about the difference between... ...buprenorphine alone and buprenorphine and naloxone... ...buprenorphine has to be taken sublingually. It has to be absolved absorbed under the tongue. If they swallow it, it doesn't work if they take it appropriately, then a lock, some gets absorbed, but there's not really a lot of bioavailability for it. So it's not like the naloxone is Our opiate use. A lot of patients, have that misperception and honestly a lot of times, I let them have that misperception. but what the naloxone is there... ...for is to prevent them from crushing it up and injecting it. If they crush up and inject the product with buprenorphine and naloxone in theory, the naloxone blocks the buprenorphine, and prevents the patient from getting high from it, patients, tell you, that's not true, but that they can get high from it. And in general, they always want the The buprenorphine only product. So generally the way it should be prescribed is the product that has both in it but in pregnancy is one of the things where they're saying, it's okay for buprenorphine alone. But again the thought is changing because of the diversion that's going on. So what do we do when a patient has acute pain like labor and delivery and surgery. So if it's a patient on methadone, you want to make sure they stay on their method, their maintenance methadone therapy. Maintenance will not treat their acute pain. Stadol, all will cause acute and severe immediate withdrawal of the methadone maintained mother and fetus resulting in a stat C-section. So avoid having all this or avoid that happening, rather postoperatively. And methadone patients, you want to continue to give them their confirmed... ...maintenance dose of methadone and you can give appropriate analgesic for the surgery. You may need to increase the dose 15% or more due to high tolerance. Yeah. On buprenorphine patients, buprenorphine very, highly avidly binds to that mute receptor, and it may block or reverse Mu opioid analgesic and the best practices are continuing to involve, but the options are non opioid therapy. So obviously utilizing NSAIDs or acetaminophen as much as possible. You can continue their maintenance dose of buprenorphine and add an avidly binding, opioids, such as Hydromorphone or fentanyl, or you could continue buprenorphine And split them into more frequent dosing. So those them every 6 to 8 hours and titrate for pain management. In pain patients, they tend to do better with smaller doses more frequently to manage their pain. If you have to have an emergency surgery or C-section and the patient is on buprenorphine, there may be some opiate receptor blockage due to the high affinity for the MU receptor. Not from the naloxone. regional anesthesia is very good if at all possible... ...Fentanyl and hydromorphone can override buprenorphine if you need something else for pain, but they're... ...typically going to need a higher dose than the average patient. What do you do? If If you have a patient who has a history of opioid addiction, but you have to give them opioid pain medication. There's several things that you can discuss with the patient and usually, when I have this discussion with the patient, I make sure their partner comes with them or whoever's going to be managing the medication, because the... ...patient should not be managing their own medication. So whoever is their caregiver for this instance. You know, if it's a baby typically, it's going to be the husband. The patient does not touch the paper prescription. If there even is One most of the time we're re-prescribing the caregiver handles and fills the prescriptions and administers the medication as ordered to the patient. The patient doesn't touch the pills. They don't touch the bottle, they don't count the pills. Once the patient has not required opiates for 24 hours. The caregiver that disposes of the leftover medication, and if you have a patient who is on methadone or buprenorphine, please coordinate with them, we love to talk to people about our patients and we are happy to talk to you about recommendations for pain management. So reach out to us. Postpartum for Methadone or buprenorphine you may need to decrease their dose due to fluid shifts in the postpartum period. If you're the one orphaning provider, you want to see them immediately upon discharge from the... ...hospital before giving any take-home doses of medication or prescription. and buprenorphine dose may need to be decreased if it was increased during the third trimester. Now if it's a buprenorphine provider, you don't... ...necessarily need to see them immediately, but I generally at least have a phone. In conversation with these patients, I say, please call the office when you have the baby. So we can tell you what to do with your meds after delivery. When dosing for buprenorphine for any patient, the goal is to find the lowest dose at which the... ...patient is not using other substance not using other opiates. Not experiencing any withdrawal, symptoms, they're having minimal or no side effects and no uncontrollable cravings for their drug of abuse, the patients must have discontinued. The use of opiates and be in the early stages of withdrawal before starting buprenorphine and you can start with 4 mg of buprenorphine and repeat the dose into 24. Hours. If indicated, then repeat as needed, until the patient is comfortable and not exhibiting symptoms of withdrawal. The maximum daily dose is 32 milligrams in reality. Very few patients, need more than 16 milligrams, dosing maybe split twice daily or three times... ...daily as needed to minimize withdrawal symptoms. In pregnant. Patients, it's much more common that they're going to need split dosing and non-pregnant patients. Typically once daily dosing is sufficient. What happens if they're breastfeeding? Well, ACOG says, breastfeeding May reduce new now neonatal abstinence syndrome symptoms. Breastfeeding promotes mother-child bonding minimal... ...levels of methadone and buprenorphine are passed into breast milk. The only time it would be contraindicated is in women with HIV and women who are currently using other illicit substances. All right, so those are the opiates. Now we're going to talk about sedative-hypnotics... ...risks to the mom or the risk of a seizure from abrupt withdrawal. Risk to the fetus include congenital, defects, neonatal abstinence syndrome, fetal death or spontaneous abortion if they have abrupt withdrawal, So the treatment of this is going to be a slow taper, which you're going to do ideally in the second. Trimester, this is what you're going to do in a patient, who's been on Xanax twice a day for the last 10 years, which isn't appropriate to begin with but that's a whole other discussion to have, but your patient who's managed on a stable dose. Those people, you can wait until the second trimester if you have somebody that's taking any and all benzos, they can get their hands on and as much possible... ...doses as they can get their hands on. You should not be waiting until second trimester, you want to taper them five to ten percent decrease daily. If possible use the same benzo, they've been abusing so that you're not exposing the fetus to a new medication. and barbiturates should be avoided as a detox medication, due to the risk of congenital defects. And again, always always, always interdisciplinary care. Alcohol. Use disorder the risks to the mom include injury, while intoxicated liver damage delirium, tremens and withdrawal nutritional deficiencies because they're not eating or only drinking, deficient milk ejection, and sometimes precipitous labor risks to the fetus include fetal, alcohol spectrum disorder, So fetal alcohol spectrum disorder is a direct effect of alcohol. On the developing fetus alcohol affects the fetal brain throughout the entire pregnancy and binge... ...drinking which is five or more drinks on one... ...occasion is especially detrimental to the fetus. Alcohol is the leading known cause of preventable intellectual disability. It's twice as common as Down syndrome and they can have either alcohol-related birth defects alcohol-related neurodevelopmental disorders or both. Effects of alcohol in the fetus. It can cause intellectual disability, spontaneous abortion, low birth weight, they can have cardiac abnormalities skeletal abnormalities ocular problems hemangiomas. They can have pre and postnatal growth restriction, they can have CNS deficits. They can also have facial feature anomalies so they get a short palpebral fissures or an elongated... ...mid-face or a thin upper lip with an indistinct filled. Indistinct philtrum, they could have a flattened maxilla, micrognathia. minor ear abnormalities. They might have epicanthal folds or a low nasal bridge. So sometimes you can see the physical changes kids that have fetal alcohol Spectrum Disorder are frequently misdiagnosed as having a psychic... ...disorder because children with this may not... ...complete tasks because they either can't recall the information or they may not take in the information. They may hit. Others because they may end misinterpret intentions. They may take unnecessary risks because they can't perceive the danger. These kids are frequently diagnosed with things like. Oppositional Defiant Disorder or intermittent explosive disorder or borderline personality disorder. If you aren't asking the right questions about the history then you don't know what to look for. The treatment of alcohol use disorder is to taper them using a short-acting Acting benzodiazepine. So like Lorazepam, barbiturate should be avoided due to the risk of congenital defects. And again, always in conjunction with interdisciplinary care. You can use a CIWA, a clinical institute withdrawal... ...assessment scale for to determine how severe their withdrawal is. And it can provide a symptom, triggered regimen or a fixed regimen. There's multiple different ways that you can detox a patient so much of it depends. If are they in patient or the outpatient? Are they managing themselves? But you can either do it based on, you know, you can treat them based on when they're see was greater than 7, you give a dose of medicine or Or you can just do a scheduled taper, you know, four times a day, then three times a day. Then, two times a day, every hospital is going to have their own policy. Everybody will do it. Their own way, even for me with individual patients, I do things differently. Depending on what they've been using, how much they've been using, how long they've been using. Nicotine use disorder. So, risks to the mom include lung disease, there's multiple types of cancer associated with it, coronary artery disease and stroke risk, to the fetus include spontaneous, abortion placental abruption, placenta, previa, low birth weight. There may be some congenital defects associated with nicotine use, preterm delivery, uterine bleeding and SIDS. the effects are lifelong and children. So moms who smoked during pregnancy, Their children have higher rates of ADHD, they have higher rates of asthma and respiratory... ...disorders and there's some studies that even say these kids may be at increased risk for diabetes and obesity. Treatment of nicotine use disorder. It is recommended that they actually gradually quit. This is not a time to cold turkey at. So I usually tell them to cut down one or two cigarettes every day, if they're unable to stop with just behavioral interventions nicotine replacement, products can be used but intermittent formulas such as gum and lozenges, or preferred over continuous formulas like the patch. And there's limited studies on the use of bupropion and pregnancy. Stimulants things like cocaine and methamphetamine... ...risks to the mom include seizures hypertension or hypertensive crisis effects on the fetus include placental abruption. Premature labor spontaneous abortion, premature rupture of membranes. Methamphetamines can cause congenital defects. There can be attention impairments in the child risk of low birth weight and also increased risk of SIDS. Treatment with stimulant use disorder, there's no detox for it. You can use short-term benzodiazepines and antidepressants for symptom treatment. You may want to consider monitoring the fetus. Inpatient, if they're beyond 24 weeks gestation or Beyond... ...viability because of the risk of placental abruption and again interdisciplinary care, Cannabinoids may affect fetal, brain development, and child behavior. The treatment is the same for a non-pregnant patient, it's supportive care and interdisciplinary care. So we're going to talk a little bit about neonatal abstinence syndrome, so this is the neonate that suffering from withdrawal symptoms. So the babies now been born and the substance that they're used to being exposed to has been withdrawals. So we primarily see it in people who abuse opiates or use opiates. But we also see it in people who are in benzodiazepines people that have been drinking barbiturates antidepressants. Some ssris can cause this and so can nicotine the onset of symptoms depends on the substance. And there's a Area of symptoms depending on the substance. They can have CNS effects, such as irritability hypertonia hyperreflexia, seizures GI effects include diarrhea, vomiting abnormal sucking and poor feeding poor weight gain respiratory effects like to kidney and respiratory alkalosis, and autonomic effects like sneezing. Lacrimation, yawning sweating hyperpyrexia, and if you've ever seen a baby that's withdrawing from Methadone. They have this very high-pitched cry. That's very recognizable. Delayed effects may be seen for four to six months. So there's some evidence that babies that have... ...neonatal abstinence syndrome are at increased risk for SIDS. The treatment is primarily symptomatic. Now, they've... ...started to differentiate between neonatal abstinence... ...syndrome and neonatal opioid withdrawal syndrome. They're calling that now's. The treatment is still the same. You want to decrease environmental, stimuli dim lights, quiet rooms. Give them soothing Botanicals Behaviors frequent, feedings IV, fluids tight. Swaddling, when supportive measures fail, I have morphine is used here but it depends on what they're withdrawing from, but they can use medications. The one question moms always, ask me is what's going to happen to my baby when it's born because if I'm in treatment now every state is different, every jurisdiction is different so I can only... ...speak for my jurisdiction my state, but I called... ...children and youth services in Lancaster County, Pennsylvania. and they stated that they cannot open a case on a child that has not been born yet. Therefore, you don't have to report that a mom is using substances, but if you fear, there is another Child in the home at risk due to maternal drug use, then you might have to report, you know, childline for that in general moms who are in... ...treatment are looked upon more favorably than... ...moms that continue to abuse substances. My experience has been, you know, they'll follow up with me. They'll call me a week, two weeks, three weeks after the baby's born and say, hey, I just want to check in with you. This is what the patient's telling me. This is the medicine, the wrong. This is how often they're seeing you. And I say, yep, all of that is true. And they go great. And And as long as they're doing what they're supposed to be doing, typically the case gets closed and you know, CYS is no longer involved, but that's for women that are in treatment and only using the substances they're supposed to be using like, buprenorphine, you know, now if their drug test is popping for other things than, that's a different story. There are 13 states that have legislation to terminate parental rights, due to maternal drug. Use these include Florida, Illinois, Indiana, Ohio, Maryland, Minnesota, Nevada, Rhode, Island South Carolina, South Dakota, Texas, Virginia, and Wisconsin, and eight states require reporting of drug testing, including Arizona, Illinois. Iowa, Massachusetts. Michigan. Minnesota, Utah and Virginia. So know, your state know, your local jurisdiction, and know your legal requirements. And those are my references. So, that is it for this presentation. If you have any questions about any of this, I'm happy to talk to anybody. My contact information will be available and I look forward to hearing from you. Thank you very much.

addiction

pregnancy

treatment protocols

substance abuse

comprehensive care

risks

withdrawal symptoms

interdisciplinary collaboration