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Importance of Treating Opioid Disorder During Pregnancy

Risks of Opioid Misuse During Pregnancy

Untreated opioid use disorder during pregnancy can have life-threatening effects for the unborn baby. Frequent changes in opioid levels for the mother can expose the baby to multiple periods of withdrawal, which can be harmful for placenta function.

Other direct physical risks include but are not limited to the following:

  • Neonatal abstinence syndrome
  • Stunted growth
  • Preterm labor
  • Fetal convulsions
  • Fetal death

Other indirect fetal risks include:

  • Increased risk for maternal infection (I.e.: HIV, HBV, HCV)
  • Malnutrition and poor prenatal care
  • Dangers drug-seeking behavior (I.e.: violence, incarceration) 

What is Neonatal Abstinence Syndrome?

Neonatal abstinence syndrome or NAS occurs when an infant becomes dependent on opioids or other drugs used by the mother during pregnancy. The infant can experience symptoms of withdrawal that can include tremors, diarrhea, fever, irritability, seizures, difficulty feeding, and death.

NAS has increased nearly fivefold nationally between 2000 to 2012, which is in correlation with rising rates of opioid use disorder overall.

Medically Driven Solutions

Evidence-Based Treatment

Buprenorphine and methadone have been proven as safe and effective methods of treatment for opioid use disorder for pregnancy. While NAS may still occur for babies born by mothers receiving these medications, it has shown less severe than in the complete absence of treatment. Research does not support reducing medication dose to prevent NAS, as it may lead to increased illicit drug use by the mother. Which will result in greater risk to the fetus.

Methadone vs. Buprenorphine

While recent studies have shown an associated higher treatment retention rate with methadone, buprenorphine has shown better results for the fetus. Those findings are listed below:

  • 10 percent lower incidence of NAS
  • Decreased neonatal treatment time by 8.46 days
  • Less morphine needed for NAS treatment by 3.6mg

Patients should work closely with their doctor to determine the best form of treatment for them.

Breastfeeding During Treatment

While breastfeeding statistics are typically low with mothers suffering from opioid use disorder, studies have shown that breastfeeding can decrease the length of hospital stay as well as lowering the need for morphine treatment for infants. Unless there are specific medical concerns such as maternal HIV infections, mothers are encouraged to breastfeed and swaddle newborns to ease infant NAS symptoms and improve bonding.

Methadone and Buprenorphine Can Effectively Treat Opioid Use Disorder During Pregnancy

Since the 1970s methadone has been used to treat pregnant women with opioid use disorder and has been recognized as the standard for care by 1998. However, studies have shown that buprenorphine is a feasible alternative treatment. The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine support both methadone and buprenorphine treatment as the best treatment options for pregnant mothers with opioid use disorder.

Benefits of Treatment During Pregnancy

Methadone or buprenorphine treatment improves infant outcomes by the following:

  • Stabilizing fetal levels of opioid, therefore, reducing repeated prenatal withdrawal
  • Providing mothers with infectious diseases (I.e.: HIV, HBV, HCV) access to treatment, therefore, reducing the likelihood of transmission of disease to the unborn baby
  • Providing more stabilized opportunities to better prenatal care improving the long-term health outcomes for both mother and baby

When compared to mothers who were left untreated, women who are treated with methadone or buprenorphine generally have infants with:

  • Lower risk of NAS
  • Less severe NAS
  • Shorter treatment time
  • Higher gestational age, weight, and head circumference at birth

Solutions Driven Science

Increasing Treatment Prescribing

NIDA-funded studies are evaluating the key barriers and facilitators to prescribing methadone and buprenorphine for pregnant mothers suffering from opioid use disorder. Current projects include:

  • Validating reliable screen tools to identify pregnant women in need of treatment
  • Analyzing infant outcomes to inform medication selection for mother suffering from opioid use disorder
  • Evaluating behavioral interventions for misuse of opioids during pregnancy 

Improving Treatment Strategies

Treatment with either methadone or buprenorphine does have some risk for infants developing NAS. Dividing dosing with methadone such as taking smaller doses more often – reduces fetal exposure to potential withdrawal periods between doses. Mothers treated with divided doses often deliver babies with a lower NAS severity. Currently, the study is also examining buprenorphine during pregnancy and how to improve the dosing regimens.

Improving Engagement in Treatment

  • The stigma and bias often shown from healthcare providers can result in under-reporting of drug use and insufficient medication dosing which often leads to the delay or infectiveness of treatment
  • Eighteen states classify maternal drug use as child abuse and three states consider it as reason for involuntary hospitalization, therefore, decreasing the likelihood of women seeking treating.
  • Studies have shown to the contrary that women who are allowed to stay with their children during treatment are more likely to successfully undergo treatment for the duration of the pregnancy and to maintain abstinence afterward.

Supporting Access to Treatment

Health insurance providers that cover treatment for substance use disorder are required to provide coverage equivalent to what is provided for other health conditions. Dr. Buscema, has made it the mission of Addiction Alternatives to help pregnant women suffering from opioid use disorder to not only provide treatment but to also find access to gynecologists and obstetricians in the area inclined to help these mothers during and after pregnancy.

Where Can I Get More Information?

If you or someone you care about is pregnant and has opioid use disorder:

Call Addiction Alternatives at (772) 618-0505

Visit our site at www.addictionalternatives.org

Statistical information provided by:

https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy/treating-opioid-use-disorder-during-pregnancy

https://www.stanfordchildrens.org/en/topic/default?id=neonatal-abstinence-syndrome-90-P02387

https://archives.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine-during-pregnancy-reduces-neonate-distress

https://www.hindawi.com/journals/jp/2014/906723/

https://www.jognn.org/article/S0884-2175(16)30208-8/pdf

Opioid Use Growing Among Pregnant Women (via Psychiatry Advisor)

Opioid Use Growing Among Pregnant Women (via Psychiatry Advisor)

An estimated 55% to 94% of newborns whose mothers used opioids while pregnant experience neonatal abstinence syndrome.

Neonatal abstinence syndrome (NAS) has quintupled in the past 12 years, with an incidence of 21 732 newborns in 2012, a trend mirrored in England, Canada, and Western Australia, according to a recent review article in the New England Journal of Medicine.

In light of the increase, the article reviews the epidemiology, clinical features, outcomes, prevention strategies, risk identification and management NAS.

“The increase in cases of the neonatal abstinence syndrome corresponds with the reported rise in opioid use during pregnancy, which is attributed to the more liberal use of prescribed opioids for pain control in pregnant women, illicit use of opioids such as oxycodone and heroin, and a dramatic increase in opioid-substitution programs for the treatment of opioid addiction,” wrote Karen McQueen, RN, PhD, and Jodie Murphy-Oikonen, MSW, PhD, of Lakehead University in Thunder Bay, Ontario, Canada. “The pattern of opioid use has also shifted from an inner-city, low-income population to a more socioeconomically and demographically diverse population that includes pregnant women.”

According to research by Babywearing International, an estimated 55% to 94% of newborns whose mothers used opioids while pregnant experience NAS, also called neonatal drug withdrawal syndrome and neonatal withdrawal. The investigators note that some researchers’ use of these terms to refer to non-opioid substances can cause confusion, particularly since tools for assessing the syndrome were developed only for opioid exposure.

“The inconsistent terminology can lead to challenges in understanding the magnitude and complexity of the syndrome, the presenting signs, and the most effective treatment strategies,” they wrote. The researchers describe true, opioid-related neonatal abstinence syndrome as primarily involving the central and autonomic nervous systems and the gastrointestinal system. When symptoms appear, typically within the first few days after birth with variations in timing, they can include mild tremors and irritability on the milder end up to fever, excessive weight loss, and seizures in more severe cases.

Primary prevention may need to start with initiatives targeting opioid prescribing practices in women of childbearing age with an emphasis on balancing risks and benefits, particularly since serotonin reuptake inhibitors (SSRIs) and benzodiazepines can exacerbate NAS. Once women already have an addiction, it can be difficult but not impossible to treat. Illegal use of opioids often comes with a chaotic lifestyle that complicates women’s ability to seek, receive, or commit to medical and social services. Although the most commonly prescribed treatment for opioid addiction in pregnancy is methadone, buprenorphine may involve less severe neonatal withdrawal, according to emerging evidence.

Management of NAS in infants should prioritize promoting normal growth and development while averting or minimizing negative outcomes, “including discomfort and seizures in the infant and impaired maternal bonding.” Too little data on nonpharmacologic care exists to inform guidelines, but the approach to the care of the mother-infant dyad is at least as important as treatment itself.

“Ideally, care should be multidisciplinary, collaborative, nonjudgmental and based on the identified needs of the infant-mother dyad so that care of the infant does not occur in isolation from the mother,” the investigators write. “Creating a compassionate, safe environment for the mother is important, since many mothers feel stigmatized and guilty regarding substance use and the neonatal abstinence syndrome, which can lead to impaired communication with health care providers.” The wic florida is now offering its people the liberty to apply for it online from the convenience of being at home. 

Supportive care in a low-stimulation environment should comprise initial infant care, with rest, swaddling, non-nutritive sucking opportunities and adequate nutrition. If pharmacologic treatment is needed, as in the case of 60% to 80% of newborns with the syndrome, its primary goal is “to relieve moderate-to-severe signs such as seizures, fever, and weight loss or dehydration.”

Although oral morphine solution or methadone is generally accepted as first-line pharmacotherapy, with emerging evidence for sublingual buprenorphine, no universally accepted standards exist regarding dosage, weaning protocols, and supplementary medications. Yet, “recent evidence suggests that the use of a standardized protocol for pharmacologic treatment of the neonatal abstinence syndrome may be more important than the choice of drug.” Adjunctive second-line drugs may include phenobarbital or clonidine but, again, without consensus on when and how to introduce polypharmacy.

The researchers concluded with a brief discussion of long-term outcomes, which are more challenging to track and manage, and a call for more research to fill in the many gaps in the prevention and management of NAS.

Source: Psychiatry Advisor