Our next lecture is on opioid use disorder and pregnancy. We have Dr. Dawn Hannah, who is an MFM specialist in Pensacola Florida. She was previously The director of MFM at West Florida Hospital and the associate program director for the OBGYN Residency... ...program at University of Central Florida. Her undergrad degree was obtained. At the University of Miami was a bachelor's in chemistry. She had her medical education at Nova Watching the Miami Hurricanes. Football game. Welcome Dr. Hannah. Thank you. Can you all hear me? Is this on? Okay perfect. Let me get set up here for a second. Well, thanks for having me again today. I was lecturing yesterday. We will talk about opioid use disorder in pregnancy. This is a topic that is near and dear to my heart. In Fellowship. We routinely did Journal club and a journal Club article that I presented led to us initiating a medication assistance. Assisted treatment program for our prenatal patients. It was an Endeavor to get started. I had graduated by time we were running but I did start the idea. So you know, a good bit about this. I have no conflicts to disclose. Here's a list of learning objectives. I won't run through all of them. So a little bit of just background information. In 2012 Health Care Providers, wrote for more than 259 million opioid prescriptions, two times The amount that have been written in 1998. from 2002 to 2012, admissions to substance abuse disorder, treatment programs had quadrupled. and then between 2000 and 2014. The rates death has so sated with opioid analgesics rose about 400%, we all know this is a huge problem Nationwide. There's also been a sharp rise. in rates of heroin use. 3,000 deaths in 2010. Had increased to 10,500 in 2014. Now we hear all about fentanyl that's the big problem. so it will be an ongoing issue. Opioid, use in pregnancy, paralyzed parallels, the opioid epidemic and the general population from 2000 to 2009 and a part of maternal opioid use increased fivefold. There's also a sharp increase in neonatal abstinence syndrome that goes along with that. There's one point five billion dollars and related... ...annual Hospital charges due to neonatal abstinence syndrome. So a big health Our cost. And then maternal mortality reviews in several States, identify substance use as a major risk factor for pregnancy Associated deaths. So, how do we Define opioid use disorder? It's a pattern of opioid use that's characterized by tolerance, craving, inability to control, use and continued use despite adverse consequences, it's chronic treatable disease and it can be managed... ...successfully by combining medications with... ...behavioral therapy and Recovery support. and enables the patient to control their health and their lives, So. DSM-5 has defined the criteria for diagnosis. There are 11 main symptoms of opioid use disorder... ...and you define the severity of opioid use disorder based on the number of recurring symptoms. So, mild. opioid, use disorders, two to three symptoms, moderate four to five and then severe would be six or more. I have listed here for you, all of the criteria. We will not walk through each of these individually, but some examples would be craving, strong, desire, or urge to use using opioids, and physically hazardous situations. And then tolerance, they need to increase the amounts, or they have a diminished effect with continued. Use of the same amount. So how should we be screening for opioid use disorder? So pregnancy provides an important opportunity for us to identify as well as treat. affects women of all racial ethnic and socio-economic... ...groups with rural urban Suburban populations. It is essential that screening is universal. So, you need to inform patients. That questions are asked of all pregnant women. It's not just a certain group, so you identify If I patients use a valid validated, screening tools, and this allows you as a physician to offer interventions and refer for Specialized Care of needed, obviously... ...maintain a caring and not non-judgmental approach. And then screen when the patient is alone, often times. They won't tell you as much if they have. Support people with them. So screening is based only on factors such as if it's only based on factors such as poor adherence, to prenatal care, or prior adverse pregnancy outcomes, you're going to miss cases. So and it adds to stereotyping and stigma. So try to avoid that. Okay, so I'm going to give you a couple examples of how you can screen. These are quick and easy. One is called the four P's. literally parents, partner, past and present so any of your parents have a problem with alcohol or other drugs. Does your partner in the past, have you had difficulties in your life with alcohol or other drugs, this would include prescription drugs, and then present and the past month. Have they had any drinks of alcohol, or used other drugs? So that's pretty easy. He doesn't take much time. And if any of those questions gives you, yes, that should prompt you to delve deeper into their use history or their past history. The next one, I'm sorry. There's a screen called CRAFFT This is good for both adolescents and young adults. C is car, R-relaxed. A-alone. F-forget F-Family. and T- trouble. So just kind of break those down. I won't again, go through each one individually, but have you ever ridden a car driven by someone... ...including yourself who has been using alcohol or drugs? Do you ever forget things you do while using alcohol or drugs? So again this is a good quick screen. to utilize. and again any of those are positive be sure to ask further questions. Urine drug testing little comment on that. So it's ultimately used to detect or confirm suspected... ...substance use it should be performed only when the patient's consented and in compliance with state laws. So you have to take that into consideration, you need to inform the patient regarding potential... ...ramifications of a positive test result there are mandatory reporting requirements. So routine urine drug screening is controversial, and confirmatory testing should be used as appropriate. So sometimes you, Can get false positive tests, keep that in mind. A study suggested improve rates of detecting, maternal substance use compared to with standard methods, did not include validated verbal screening tools. So the validated verbal screening tools, ultimately are your preferred screening option. It should be your initial screening option. Physicians again, you need to be aware of both your state and communities, legal requirements, 24 States, and the District of Columbia considered substance to use during pregnancy to be child, abuse under child, welfare, statutes, and three considerate. Grounds for a civil commitment, 25 states, require Health Care Professionals to report suspected prenatal, drug use. 17 States, including the District of Columbia provide pregnant people with Priority Access state-funded drug treatment programs. So. you need to know what your state has offer resources and Reporting requirements. I did include a link down here. I'm not going to obviously can't click on it. That gives each State's policies on substance abuse during pregnancy. It's https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy ...or so I encourage you to look at that and be familiar with your state requirements. It's a little bit about the physiology and pharmacology of opioid use. ultimately it diminishes, the intensity of pain signals. It's generally prescribed for the treatment of pain, some of them can be given for cough or diarrhea. It causes sense of euphoria which ultimately leads to their misuse. Say opioid, use disorder, may develop with repetitive use of any opioid and particularly in individuals with a vulnerability. That's underlying. So heroin a little bit about heroin, it is a rapidly... ...acting opioid can be injected smoked or inhaled has a short half-life. So physically dependent heroin user will need to take multiple doses daily to avoid withdrawal symptoms. These are a list of all the prescribed apis lengthy list. Keep in mind that all have the potential for misuse. They can also all be swallowed injected and easily... ...inhaled smoked chewed use a suppositories. the on scent of intensity. Of effect will vary based on the drug taken and its formulation. Opioid risks include respiratory, depression, overdose death injection. Risks would include cellulitis abscess formation at the injection site, sepsis, endocarditis, osteomyelitis. and then infections like Hepatitis B, C and HIV. risk. For many of these respiratory depression. Overdose is going to be greater with full opioid antagonists like Fentanyl. Partial opioid antagonists such as buprenorphine have less of a risk. So here is a lengthy list of all the signs of opioid withdrawal. Some of those include generalized pain, diarrhea sweating, runny nose, tremor, dilated pupils, these are all the things, which we'll go into that later that we assess for when we're transitioning. Patients from illicit drugs, to treatment, regular long-term use of any opioid leads to... ...predictable physiological dependence and this will result in symptoms of withdrawal upon discontinuation of the drug. So you do need to look for these. short-acting opioids, like heroin symptoms of withdrawal, typically develop within four to six hours of discontinuation. In those withdrawal symptoms, peak at one to three days. They subside over about a period of five to seven days. Now you're long acting acting employees like methadone the symptoms take about 24 to 36 hours to begin and they may last for several weeks. It's a really hard withdrawal. Opioid withdrawal, is rarely associated with severe morbidity and it can be readily treated so in the non pregnant patient It's something to be considered. So effects on pregnancy and pregnancy outcome. What does opioid use do? So there have been a number of observational studies, that evaluate the safety of avoids during pregnancy, specifically early pregnancy. They do not show an increased risk of birth defects. After prenatal exposure, to oxycodone, propoxyphene meperidine. There was a study by Broussard, et al. in 2011, a retrospective study that did show an increased... ...risk of several birth defects with the use of prescribed opioids in the month before pregnancy or during the first trimester. And then Yazdy et al. in 2013 says there's a possible association between opioids in the first trimester and open neural tube defects. So. observed birth defects are rare, and it's a minute increase in absolute risk with exposure. Let's see. Here's Zedler in 2016 is a meta-analysis that compared methadone and buprenorphine buprenorphine which we'll talk a little bit later as kind of our go-to treatment in pregnancy. There's no difference between the groups with respect to congenital malformations, incidence of anomalies, reported or similar to what we've expected in the general population. So we can use both methadone and buprenorphine for treatment, but. most of the time we try and be preneur theme, you have to weigh the potential. Increased risk of birth defects associated with... ...opioid a guess pharmacotherapy against the clear risks associated with continuing their illicit drugs. So heroin use in pregnancy is associated with a many things, lack of prenatal care, often occurs, fetal, growth restriction, placental abruption, IUFD preterm labor and then babies will often pass meconium. also, they have engagement in high-risk activities. So have an increased risk of STIs, violence legal consequences. So. there's definitely a lot to consider. Other things, obviously, many of these patients are going to have issues with mental health disorders, depression, it will have history of trauma. Post-Traumatic Stress Disorder, anxiety, often are using other substances smoking marijuana. Cocaine is another popular one often have poor... ...nutrition and they don't have great support systems, so they often need Social Service help. So we have to think about alternative pain therapies for these patients. Especially there are pregnant women that have chronic pain. So you want to include strategies that minimize opioids. Things to consider would be exercise, Physical Therapy, acupuncture, massage, yoga. And then there are behavioral therapy approaches including relaxation, therapy. Hypnosis, there are some non-opioid pharmacologic treatments obviously. Tylenol is an option Cymbalta's an ssnri and then muscle relaxer flexural, you should limit opioid use there are some scenarios where to you could potentially use it minimally. So cautious approach to prescribing, opioids has to be balanced with the need to address their pain. So we're talking about treatment of pain, just... ...outside somebody who's having an opioid use disorder, pregnancy is not a reason to avoid treating acute pain. Especially. don't be concerned about causing misuse or neonatal... ...abstinence syndrome if they don't already have a problem. So you know, patient comes in 18 weeks, you diagnosed with kidney stones or she's in some MBA as traumatic injury. Make her suffer. The pain. You can't read her, it's going to be for acute pain. It's not going to be long lasting. This won't be a long-term issue for the pregnancy. You should still tell them about the risks of... ...opioid use that they can become dependent if they misuse, and then there's a small possibility. and it'll abstinence syndrome. If it's short term, that's not going to be an issue. and then review the treatment goals. How long you anticipate them needing the medication and a plan for discontinuing. All right, so a little bit about opioid agonist therapy. This is a really important topic. It's also known as medication not mediation medication-assisted treatment, I'm associate program director of a residency in, during our interviews, almost all the medical students asked, do you have an MAT program? So, it's kind of a big thing right now that they want to learn about since since the seventies, I mean, to you, with Methadone in combination with counseling, As in the standard treatment for heroin addiction, however, recent years has been methadone or buprenorphine used for the treatment. Again, you'll see go into a little bit more about why we use buprenorphine more now, So ultimately, it's going to prevent their withdrawal symptoms. It's going to prevent complications of non-medical, opioid use, right? So we're hopefully reduce our early relapse risk, and its consequences. and improves adherence to prenatal care, and addiction treatment programs. And then in combination with prenatal care is going to, hopefully reduce your risk of obstetric complications, local treatment programs for opioid use disorder are available. I included a little website down here. Again I can't Click it. (dpt2.samhsa.gov/treatment/directory.aspx) That gives you can look for facilities near you... ...that you could utilize its. samhsa.gov, literally. a directory of treatment programs. I will tell you that they're probably not all in there so it's a good place to start. But I wouldn't just stop there if you don't find a program locally on that list. So let's talk about just methadone as our opioid agonist therapy. So if that is the medication that is chosen or patient... ...comes to you on methadone from an MAT program. Typically its dispense daily by registered opioid treatment program. It's part of part of their treatment, plan includes Addiction, Counseling family therapy they get education on... ...nutrition and they are offered other medical... ...and psychosocial Services. their dosage oftentimes has to be adjusted throughout their pregnancy. To avoid withdrawal symptoms. There are significant pharmacokinetic interactions with some other medications to including antiretroviral agents that you should consider. And if you combine them, sometimes you have to worry about prolongation of the QT interval, and... ...it chances of that happening are going to go up. As your dosage increases, sometimes a single daily dose is not enough to control their withdrawal, symptoms of the third trimester so sometimes their... ...dosage will be split up into a twice daily dose. And not all women require this increases. So it doesn't happen across the board is just something you need to be aware of. So what if you want to begin treatment while pregnant? So way it works, is a dosage should be titrated until the patient is asymptomatic. There are safe induction, protocols, that centers have. inadequate dosing can result in mild to moderate... ...opioid withdrawal and that can cause fetal, stress, and maternal, drug cravings, and then you have an increased likelihood of relapse and treatment discontinuation. The incidents and duration of neonatal abstinence... ...syndrome does not differ based on maternal dosage of methadone. So, does it mean that if moms on a higher dose that they be as an increased risk for NAS Compared to somebody who's on a smaller days, you have to take into consideration, mom's metabolism babies metabolism of the medication. So you can't always predict from one mom to the other who's going to have an issue, or which baby's going to have an issue. So, attempting to minimize. Their methadone dose, is not indicated. If you're wanting to Decrease NAS symptoms. And then some studies actually suggest that you may have lower rates of NAS. If you do them split dosage schedule, So does currently illegal for physician prescribed... ...Methadone for the treatment of opioid use disorder... ...outside of a license treatment program where the medications are expended or dispense now in the hospital setting. So let your your patients admitted for labor and any other indication you can prescribe their methadone dose while they're admitted. I encourage you to check with their treatment... ...facility to get their correct dosage while they're hospitalized. Don't take their word for it. Buprenorphine. Buprenorphine. So this medication acts on the same. Mu opioid receptor as heroin and morphine it's a partial Agonist. So overdose less likely there are. Fewer drug interactions. and Outpatient Treatment does not require daily... ...visits to an MAT program less need for dosage adjustments. There are some disadvantages though so there are some rare reports of liver, dysfunction, lack of long-term data on infant and child. Effects. There's more risk of an induction precipitated withdrawal. and risk of diversion which is just sharing are selling their medication. So, you probably hear about subutex and Suboxone. So, the mono product of buprenorphine is subutex, but you can also get it combined with naloxone, which is the Suboxone. Naloxone is an opioid antagonist and it is used to reduce diversion, Suboxone causes severe withdrawal symptoms when it's injected. naloxone is not orally active. So withdrawal symptoms. Don't occur when it's used sublingually, Subutex the mono product. has been recommended during pregnancy to avoid any potential prenatal exposure to no locks and especially if it's injected. So you don't hear about suboxone being used frequently in pregnancy. Although sometimes patients come to pregnancy on Suboxone. and then they have looked at the two suboxone and Subutex in in comparison. And there doesn't seem to be a difference in outcomes. It may be prescribed for the treatment of opioid use disorder by trained and US DEA approved. Health care providers in a medical office setting. This allows for increased availability of the medication and a reduced stigma. There are courses. I think past eight hour course that you would take online to allow you to prescribe, although I just had one of my residents got checked off on her DEA without doing that. So I think that may have changed. I haven't looked into that, to be honest. So maybe it'll be a lot easier for all of us to prescribe in the future. So there are currently more than 37,000 Healthcare... ...Providers across the country that can prescribed Subutex. So there's a lot of individuals out there. So how do you decide what? What am I going to use? Buprenorphine, or methodone? So. Patient must be able to self. Administer the drug safely and maintain adherence to treatment program. If you're going to choose Subutex or buprenorphine. So it might not be an appropriate choice for patients who require more intensive structure and supervision. If a pregnant woman is already receiving methadone therapy. She should not transition to Subutex because of significant risk for precipitated withdrawal. So, do not change her from Methadone to Subutex. However, there's not a similar risk of withdrawal. When you transition from Subutex to methadone, So, per ACOG. pharmacotherapy with methadone or buprenorphine, is the recommended therapy for pregnant women, and is preferable to medically supervised withdrawal. So, how do we do this? This opioid Agonist therapy and action. I do not recommend, anybody do this, unless you have some degree of training and Performing this, whether it's in your residency program or fellowship or. where you're working is routinely done. Some obstetric services will initiate opioid Agonist... ...therapy with methadone or buprenorphine in an inpatient setting. That's how I do it. Everybody has to be admitted for my practice if we're going to initiate an opioid agonist. Is it allows for closer monitoring of medication exposure, but this is not always necessary. There are programs that do outpatient transitions. UPMC in Pittsburgh. I believe has an outpatient program at least one. I was in training, they did methadone. impatient initiation. You need to make arrangements before they go home for the next day so that they can get their methadone and so they don't miss dates because they could have withdrawal. If you do that with buprenorphine, you can give them a prescription until their appointment with a license. Buprenorphine prescriber, you need to still identify though, their ongoing... ...prescriber and schedule an appointment before they get discharged. You want to make sure they have the necessary follow-up. So this is how I do buprenorphine initiation again. I don't recommend you go to take this to your hospital. You should have protocols and approved by Pharmacy, buprenorphine is typically used in 2 mg sublingual tablets, we use the COWS, the clinical opioid withdrawal scale scoring to guide the dosing. So an example of the initiation protocol you get an initial COWS score. If it's less than 8 you're going to give them two milligrams of the Subutex sublingual. If the COWS score is greater than 8, you're going to give them 4 milligrams. For every dose you need to make sure the patient places, the Subutex under their tongue, they cannot eat or drink anything for 10 minutes after the Subutex is given. And then after 10 minutes, you need to observe that the pill is dissolved or have the patient swallow the residue. Now obviously nursing staff can do all of this but it's really important that this is done. Then you print working two mg sublinguals given every two hours as needed for moderate pain or a COWS score of greater than 6. So it's pretty intensive. Nursing staff has to be committed to doing the COWS score every two hours to make. Sure your patient doesn't go into precipitated withdrawal. You cannot or should not exceed 12 milligrams in 24 hours. I know you probably can't see this but this is the COWS scoring system that we utilize at my... ...institution so. they get scored based on their score down at the bottom. Mild is 4 or 5-12, moderate 13-24. if they have more than 36 score than that is a... ...severe withdrawal is concerning but things are looking at is their pulse rate sweating GI upset, restlessness pupil size, achiness and enjoy. So, lots of things that they have to be scored on. So, in order to minimize the risk of precipitated withdrawal, Subutex should be started when their withdrawal symptoms are mild. So, if they're coming in and they're a rip-roaring withdrawal, that might not be a great time to initiate. You need to have all of these medications prescribed... ...to give them support of care during their withdrawal. They're going to have symptoms. Tylenol, Zofran. Clonidine. clonidine is given if you're concerned for precipitated withdrawal. Obviously hold, if their systolic is less than 90. Hydroxyzine dicyclomine. Loperamide and Maalox that we have an order set my hospital. This is gets ordered on everybody that we're doing a subutex and initiation on. So a little bit about medically supervised withdrawal, this is not the preferred therapy. There are high relapse rates anywhere from fifty nine to more than 90%. their poor outcomes and a lot of risk associated with it. Again, you have communicable disease, transmission accidental, overdose obstetric complications, and then lack of prenatal care. You can consider it and women who do not accept treatment with an opioid, antagonists or treatments unavailable. I understand that in some areas at this country... ...and treatment programs was not available. It should be done under the direct care of physician, who's experienced in perinatal addiction, and it requires an informed consent. If the patient's going to choose to do that, in order to be successful, they typically require prolonged and patient care and intensive behavioral therapy. So that's why they're just generally not successful. I had a patient recently who's on a very small dose of illicit. Oxycodone. I recommended that she get transition to Subutex, she declined. She felt at certain that she could withdraw herself. So she was and she was on such a small dose discouraged her from that she did it. She lasted for about a month and then she came and said, you know what you were right? I relapsed and now I'm on an even greater dose and I was previously. and she found out when she finally got herself into a treatment program that. her medications had been laced with fentanyl. So she was really upset about that, so they're also don't know what they're getting, so talk to them about those. So there's some early case, reports had raised... ...concern that if you withdraw them when they're... ...pregnant that it can lead to feel stress and Fetal death, more recent Studies have shown that there is no... ...clear evidence of an association between medically... ...supervised withdrawal and fetal death or preterm delivery. Obviously, there is some need for long-term follow-up. It's just really lacking. I anticipate that in time, there will be more information regarding whether or not this is something we should do again more research. Is needed regarding its safety, efficacy, and long-term outcomes. So, a little bit about some other medications that you would need to know about. Naltrexone is a non-selective. If you avoid receptor antagonist, it blocks the euphoric effects of opioids and therapeutic amounts. It helps in the non-pregnant population, to maintain abstinence their oral forms. Demonstrate poor adherence injectable long-acting forms. However, more effective in maintaining abstinence. data of Naltrexone, use in pregnancy is limited, their peers. Have been normal birth, outcomes, reported. the concerns that exist with its use in pregnancy is that ultimately there are unknown fetal effects. There's a risk of relapse and treatment Dropout with subsequent return to avoid, use and overdoses risks. So, Naltrexone is not something we routinely use in pregnancy. Naloxone is a short-acting opioid antagonist. It rapidly, reverses the effects of it. We always would probably all heard. I'm the lock so Narcan, it can be life say to saving in the setting of opioid overdose so it should be used in pregnant women in the case of maternal, overdose to save her life. Induced withdrawal, May contribute to fetal stress. So, so it's something you should consider, it can be given intravenously or subcutaneously by Healthcare. Care providers, even family members can administer it or bystanders. If an overdose is suspected. That's done in prepackaged nasal spray obviously, that's not injected. individuals. At high risk of Overdose should have a prescription for naloxone. So oftentimes the pharmacy will require that they have a prescription. So, how do we care for them outside of just having them on these medications? What does antepartum care look like? So, obviously, you should test for STIs, HIV. Hep B/C screen for depression and other behavioral, health conditions screen for other substance to use Alcohol, Tobacco, offer cessation Services, ultrasound evaluation. So typical first trimester dating ultrasound detailed, Anatomy ultrasound should be performed at 18 to 22 weeks. Interval ultrasound of fetal weight in the third trimester. Especially if there's a concern for growth abnormalities, there is an increased risk for that. It's important to consult with your anesthesia team addiction medicine. Specialist if available in your area, pain management Pediatrics, MFM Behavioral Health Nutrition and Social Services. These patients really do require a multidisciplinary approach to their care. Close communication between OB and Peds is critical, especially before delivery. So that the Pediatric team can optimize management of the neonate. I would consider a neonatal consultation prenatally to discuss post-delivery care of the infant. If your hospital offers that or if that's available, Intrapartum care. So, methadone or Subutex maintenance dose in, should be continued during labor delivery and postpartum. So do not withhold their medication. They should also receive additional pain relief. So don't know. You can't have Percocet or Dilaudid after their... ...C-section because you're on methadone or Subutex. Now there are some medications that you should avoid for labor pain management. You want to avoid opioid agonist antagonist, drugs because those can precipitate an acute withdrawal. So that would include Medications like butorphanol, nalbuphine, and pentazocine. and Subutex should not be given to a patient who takes methadone. So. let's say they come in. They're supposed to be on methadone, we are hospitals to have it, which I can't foresee that. Then you give them Subutex. That's going to be a bad situation. again, notify the pediatricians of all infants exposed to opioids. Whether it's illicit or prescribed so that they can scream baby for neonatal abstinence syndrome. Generally they're going to require higher doses of analgesia with opioids. It's because of their tolerance with their maintenance therapy, women taking Subutex, generally require about 47% more analgesia and women who don't take it. Adequate pain relief, can be achieved with short-acting opioids and NSAIDs so oftentimes, we'll start with an injection of Toradol after... ...delivery and then you can escalate from there as needed. Also consider multi-modal pain, control with neuraxial analgesia, Tylenol is typically needed to also provide effective postpartum pain relief. Also, let anesthesia know that this is going to potentially be a situation. They can tailor plans for each patient. Postpartum breastfeeding is really beneficial. There was a physician in my practice that didn't realize that was telling of all of his patients, do not breastfeed. If you're on Subutex for Methadone, please encourage... ...them to especially if they're stable on an opioid Agonist. Now, they shouldn't be using list of drugs, they shouldn't breastfeed after doing that. But if they have no other contraindications, it's important. It does decrease the severity of neonatal abstinence syndrome this lessens the need for pharmacotherapy and a shorter, Hospital stay for the infant and it also provides immunity to the infant and helps for the attachment between Mom and baby. There is the transfer method and oh, Subutex through breast milk is fairly minimal. now, you should tell them if they relapse, they should discontinue breastfeeding. And it's not recommended while using medications like, codeine or tramadol because there can be serious... ...adverse effects in the infant due to opioid overdose, so moms on codeine or Tramadol, she should not breastfeed. Now, once they're delivered, what about their methadone or Subutex? Remember sometimes you have to increase the dose during pregnancy to make sure they don't withdrawal. Sometimes you're gonna have to decrease their dose and significant dose reduction, should not be done routinely. You're going to monitor their signs and symptoms and titrate accordingly. So they're going to be sedated. if they're taking too much typically that happens about 26 hours after their dose. Most women will stay on their same dose of Subutex. in general. Again, we don't increase those dosages. A lot during the pregnancy, Also use other sedation medications with caution so your benzos Ambien antihistamines like Benadryl try to steer clear of those because they can add to your risk of maternal respiratory depression. The relapse risk is going to be higher postpartum, there's a lot of triggers, right? You're sleep-deprived, they have a new baby that demands further caring. They can have insurance issues, access to treatment issues. And then also, they can be concerned about loss of custody of their child. Again, screen for postpartum depression. A lot of times will be an issue. They may have access issues to adequate psychosocial support services, so help them find them. Including substance use disorder treatment and relapse prevention programs. They should also receive overdose training and again, give them a prescription for naloxone. Unintended pregnancy rates are huge, 80% higher among with substance use disorders to make sure there is a reliable contraceptive form. discuss all potential options. Immediate postpartum LARCs are great options, are effective and they're convenient. So we offer those pretty routinely at my hospital. So a little bit about neonatal abstinence syndrome. It's ultimately a drug withdrawal syndrome that results from chronic maternal opioid use during pregnancy. It's expected and tradable. So it happens in about 30 to 80 percent of infants, when Mom is taken an Opioid Agonist. So, babies will often have disturbances with GI autonomic and central nervous systems which includes they're often irritable just difficult to console high-pitched cry. They don't sleep well they don't suck well, sometimes are feeding issues. and symptoms can occur really anywhere in the first few weeks of life. So sometimes they get sent home and then they can have symptoms, they usually the appear within 72 hours of birth and can last several days to weeks. Some babies end up hospitalized for many weeks and sometimes months in general, Subutex-exposed infants have less symptoms but they... ...generally will develop NAS within 12 to 48 hours of birth. It Peaks at about 72 to 96 and resolves by seven days. That's why we like to utilize Subutex a bit more now because they're relapse risk, is a little bit diminished and in general last a shorter period of time, Other substances nicotine, ssris. Benzos, can increase the incidence of NAS. So this typical way that NAS is detected is with Finnegan scoring, there are standardized treatment protocols with pediatricians for babies, lives include methadone or morphine and these are associated with improved outcomes for baby. Again, there are many perinatal collaborative... ...quality initiatives across the country Three that have developed resources for health care providers, that can optimize diagnosis and treatment. So I encourage you to get in contact. If your state does have one of those perinatal collaborative quality initiatives, see if they have one for opioid use disorder, they're often utilizing something called Vermont Oxford Network or the Ohio perinatal quality collaborative has some great resources to you. There is a program called Eat Sleep Console. I don't know if many will have heard about it yet, this is something we've initiated at my hospital. It's a family-centered evidence-based model for the treatment of NAS, it focuses on the comfort and care of baby. And they want to maximize nonpharmacologic methods. There are three key areas that they're looking at - 1. baby. Are we eating feeding normally? Sleep? Are we able to sleep between feedings and then console can the baby? Consoled or comforted within 10 minutes of crying. They're ultimately wanting to transition away from the Finnegan scoring system. When we use eat sleep console, the use of nonpharmacologic... ...treatments would include vertical rocking swaddling singing, the mom, Maria swings, all of those are really helpful and consoling baby, this program has been shown to decrease the length of stay cost savings and decrease medication. Used for baby, there can be up to 79 percent reduction in the use of pharmacologic treatment for These infants, when you use eat sleep, console, it is pretty intensive, mom, dad? Really need to be committed because they're going to be the ones. Providing a lot of that, you know, care to Baby sometimes. The nursing teams available to provide some that when Mom and Dad are too tired, but it's it requires quite a commitment. Long term, infant outcomes, overall handsome. Most Studies have not found significant differences in cognitive development between children up to 5 years of age. If they've been exposed to Methadone in utero, when you compare them to control groups, ultimately studies are challenging, right? Because it's hard to isolate the effects of the opioids because they're often confounding factors. Other substances environmental exposures other... ...medical risk factors like poor prenatal, care preventive, interventions or Equally beneficial to many of... ...these families to end up having some interventions support to Mom and other caregivers are helpful and Rich early learning experience. It's important and then Improvement of the quality of the home environment. I wanted to mention the PDMP, the prescription drug monitoring programs. These are electronic databases attracts controlled... ...substance prescriptions in each state every state has. When I think that might be one state that does not, they provide information to you pretty much in real time about prescribing and patient behaviors. It's ultimately to decrease or contribute to reducing the opioid epidemic. So you should know what your state. Requires as far as the PDMP. most States will require you check it before you prescribed an opioid, or any narcotic medication to your patient. Now, I have cases here for my residence. Oh. That is. a conclusion for multidisciplinary long-term. Follow-up is needed for all of our patients with opioid use disorders. in general. This multidisciplinary approach without criminal... ...sanctions as the best chance of helping your... ...babies and moms. with our ethical responsibility to our patients, to discourage separation of parents from their children, especially if it's just solely based on substance abuse disorder. So that concludes our lecture. Here are the references that I use for the topic today. Any questions. What about the use of Tramadol either stand alone or in combination addiction potential? And the other question is. met, a couple mind like regular and other hard time hearing you. I don't know if it's an echo in here. I know you mentioned tram at all. Yeah. And then the other drug is we used regularly and frequently. But can you use for pain relief as well. in combination with somebody who's addicted to narcotics? We want to. Refrain from Tramadol specifically. If we're breastfeeding. postpartum that can be an issue for baby during the pregnancy, I would limit it to use when it can be used, and then. you know, long term, it's a good option. You can utilize it with the medication if they're not pregnant but you got a caution it when they're... ...breastfeeding and during the pregnancy. Any other questions? Thank you so much.

opioid use disorder

pregnancy

neonatal abstinence syndrome

universal screening

multidisciplinary approach

alternative pain therapies

opioid agonist therapy

postpartum care