use in the perinatal period Prevalence and treatment strategies Anne Merewood PhD MPH IBCLC Associate Professor of Pediatrics Boston University School of Medicine Consultant to the Rocky Mountain Tribal Leaders Council ID: 544743
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Opioid use in the perinatal period: Prevalence and treatment strategies
Anne
Merewood
PhD MPH IBCLC
Associate Professor of Pediatrics, Boston University School of Medicine
Consultant to the Rocky Mountain Tribal Leaders CouncilSlide2
A growing problem across the US; health care workers struggling to meet the challengesOn some reservations, the problem is overwhelming in both hospital and community No easy answers but raising awareness is criticalIllicit drug use in adolescents and pregnant womenSlide3
Illicit substance use around the time of birth: Broader implications Not just a “maternal” problemDomestic violenceSuicideSlide4
Illicit substance use around the time of birth: Broader implications Child neglect/abuseMultiple drug use; alcohol use Law enforcement and custody issuesFinancial issues; poverty; hungerMedical issues – Hepatitis C; HIV; mental health, etcSlide5
Illicit substance use around the time of birthOngoing ‘tension’ of personal ‘stance’…A moral issue?A medical issue?Emotional and complex when infants/young children are involvedEven more complex among health care professionals who may have been exposed to the same issuesSlide6
Illicit substance use around the time of birthBeliefs of health care workers may impact how they react; lead to conflictPolicies are critical to ensure consistent treatmentHealth care workers often from the same community – pressures, confidentiality?Burnout/compassion fatigue among health care professionalsSlide7
Illicit substance use around the time of birthSmall communities with complex relationshipsSome clinicians experience pressure from patients (“we need opiates”) which conflicts with current work to reduce iatrogenic-induced opiate dependencySlide8
Prevalence of illicit drug use in the US Illicit drug use SAMHSA: Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MDSlide9
SAHMSA report (2013)9.4% of the US population over 12 had used illicit drugs in the month prior to the surveyMarijuana was the most commonly used illicit drug (7% of population, or 80% of users used marijuana) 2 million Americans addicted to prescription opioidsSlide10
Drug use by race/ethnicityAsians – 3.1%Hispanics – 8.8%Whites – 9.5%Blacks – 10.5%AI/AN – 12.3% Native Hawaiians/Pacific Islanders – 14%
2 or more races – 17.4%Slide11
Trauma increases chance of use Among women in treatment, 84% reported history of childhood sexual abuse or neglectAdolescents who had experienced physical or sexual abuse/assault
3 x
more likely to
report
past or current substance
abuse
>70% adolescents receiving treatment for substance abuse reported a history of trauma exposure
Frederick S. Cohen and Judianne Densen-Gerber J.D., M.D
Funk RR, McDermeit M, Godley SH, Adams
L.
Child Maltreat
2003
National Survey of
Adolescents 2003Slide12Slide13
SAHMSA data: 2013Slide14
Drug Availability: Prescription Opioid Statistics in USSlide15
Drug use in pregnancy5% illicit drug use overall11% rate in same group, not pregnant 15% among pregnant 15-17 year olds9% among pregnant 18-25 year olds3% among pregnant 26-44 year oldsSlide16
5.6 infants/1,000 births, nationally9/1000 in Montana
30%+ on some MT reservations
Opioid
use in pregnancySlide17
Treatment for pregnant women who use opioidsMaintenance therapy: ACOG’s standard of careMethadone or buprenorphine
commonly prescribed, backed by testing and counseling
Goal: Dose just high enough to stop use and block cravings
Dose may need adjustment during pregnancy
Dose unrelated to severity of infant withdrawalSlide18
Positives of opioid maintenance For pregnant woman:
Prevents
detox
/relapse cycle
Reduces
illicit drug use and related complications
For the fetus/baby:
Prevents in
utero
opioid
peaks/depressions
Decreases preterm delivery and IUGR
Decreases morbidity
/
mortality
Still likely to suffer NAS (Neonatal Abstinence Syndrome)Slide19
Neonatal Abstinence Syndrome (NAS)An infant with NAS suffers from ‘withdrawal’ symptoms resulting from maternal opioid use in pregnancy
NAS affects 60-80% of exposed infants
20% of NAS babies in MT are low
birthweight
(compared to 9% in non NAS)
$53,000 per infant; 80% Medicaid patientsSlide20
Increase in NAS2000 to 2012 saw a 5-fold increase in the proportion of US babies born with NAS In 2012, 21,732 US infants born with NAS – 1 every 25 minutes http://www.drugabuse.gov/related-topics/trends-statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal-abstinence-syndromeSlide21Slide22
Typically 48-72 hours after birth but can surface as late as 7 days after birth60-70% require medication treatment – standard of care is morphineInability to predict/not dose related
Inpatient monitoring period of at least 5 days
NASSlide23
System
Symptoms
Central Nervous
System
Tremors
Irritability
Sleep disturbance
High pitched crying
Hypertonia
Hyperactive reflexes
Myoclonic Jerks
Generalized convulsions
NAS
Slide credit: Elisha
Wachman
, MD, Boston Medical CenterSlide24
System
Symptoms
Gastrointestinal System
Poor feeding
Vomiting
Diarrhea
Excessive sucking
Respiratory System
Tachypnea
Apnea
Respiratory distress
Slide credit: Elisha
Wachman
, MD, Boston Medical CenterSlide25
System
Symptoms
Autonomic Nervous System
Sneezing
Nasal stuffiness
Yawning
Mottling
Fever
Sweating
Slide credit: Elisha
Wachman
, MD, Boston Medical CenterSlide26
Central Nervous System DisturbancesMetabolic, Vasomotor, and Respiratory DisturbanceGastrointestinal Disturbance
Excessive
High Pitched Crying – 2
Continuous High Pitched Crying - 3
Sweating
– 1
Excessive Sucking – 1
Sleep < 1
Hr
After Feeding – 3
Sleep < 2
Hr
After Feeding – 2
Sleep < 3
Hr
After Feeding – 1
Fever < 101 (37.2 – 38.3
C) – 1
Fever > 101 (38.4 C) – 2
Poor feeding – 2
Hyperactive
Moro Reflex – 2
Markedly Hyperactive Moro Reflex – 3
Frequent Yawning (>3) – 1
Regurgitation
– 2
Projective Vomiting – 3
Mild
Tremors Disturbed – 1
Mod – Severe Tremors Disturbed – 2
Mottling
– 1
Loose Stools – 2
Watery Stools
– 3
Mild Tremors
Undisturbed – 3
Mod – Severe Tremors Undisturbed - 4
Nasal Stuffiness – 1
Increased Muscle
Tone - 2
Sneezing (>3) – 1
Excoriation
– 1
Nasal Flaring – 2
Myoclonic
Jerk – 3
Respiratory Rate (>60) – 1
Respiratory
Rate (>60 with Retractions) – 2
Seizures
– 5
Finnegan’s scoring toolSlide27
Protective/ameliorating factorsBreastfeedingSkin to skin careMaternal stability and presence at the bedside
Low light/stimulation
PrematuritySlide28
Breastfeeding and illicit substance useAll IHS OB facilities gained Baby-Friendly™ designation by 12/2014
“Baby-Friendly” is a WHO initiative which promotes breastfeeding and optimal MCH practices in the hospital
Many IHS OB hospitals have high breastfeeding rates
During the IHS Baby-Friendly initiative, the question arose – how to handle breastfeeding and illicit substance useSlide29
A complex contextMany AI/AN women live in settings where breastfeeding is the norm and rates are high‘Policing’ breastfeeding is unrealisticNot breastfeeding adds to health risks
Stories emerge about women breastfeeding on drugs and infants dying
So what do we advise?Slide30
“Despite the myriad factors that may make breastfeeding a difficult choice for women with substance use disorders, drug-exposed infants, who are at a high risk for an array of medical, psychological, and developmental issues, as well as their mothers, stand to benefit significantly from breastfeeding.” Academy of Breastfeeding Medicine Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015Slide31
Where can I get a “definitive” answer?There are no definitive answers, but LactMed is an excellent source of informationhttp://toxnet.nlm.nih.gov/newtoxnet/lactmed.htmLactMed is a service of the NIH and it updates with new evidence as it comes inSlide32
In conclusion….Illicit drug use/opioid use in the perinatal period is a complex and growing problemThere are effective treatments but these are not always made available in Indian CountryEducation is key to assessing options
This webinar skimmed the surface – questions and suggestions for additional information?