Pregnancy and Reproductive Care for Patients with SUD
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Today we're going to be talking about pregnancy and reproductive care for patients with opioid use disorder my name is Cassie Leonard I'm an OB GYN physician and I work for Hudson Headwaters Women's Health which is a Federally Qualified Health Center located in Glens Falls New York and I'm Neil Seligman I'm an associate professor at the University of Rochester in the division of Maternal Fetal Medicine next slide today our objectives will be to explain treatment options for pregnant patients with a history of opioid use disorder discuss pregnancy outcomes for patients with opioid use disorder who are not receiving treatment discuss reproductive care for patients with opioid use disorder discuss neonatal abstinence syndrome in terms of disclosures Dr Seligman and I have none to disclose next slide we're going to start by reviewing some of the substance use trends this information is taken from the CDC and the National Institute on Drug Abuse overdose deaths increased by 31 percent seen here from 2019 to 2020.
there have been an increase over these past two years this includes synthetic opioids other than methadone primarily fentanyl and psychostimulants such as methamphetamines cocaine and prescription opioids in 2020 82.3 percent of opioid involved overdose deaths involved a synthetic opioid most primarily fentanyl in 2021 there is an estimated 107 622 overdose deaths in the United States this is an increase of nearly 15 percent from 2020. as you can see overdose deaths is still increasing and remains a major problem next slide when looking at rural versus urban areas again from 1999 to 2019 rural death rate resulted in 390 increase per 100, 000 patients Urban death rate resulted in 244 increase per 100, 000 when we look at the overall death rate of urban versus rural the death rate is higher in an urban area however in rural areas it's still a very big concern and it's still on the rise and this continues to be a major health concern for Rural communities next slide according to the 2019 PRAMS data which is pregnancy risk assessment monitoring system which is part of the CDC 6.6
percent of patients reported using opioids during the pregnancy 21 percent of those reported misuse of opioids and 27 percent reported that they wanted or needed to cut down or stop using opioids 31 reporting not receiving any provider counseling on how opioid use could affect the infant obviously this shows that we still have major work to do as a provider and can do a better job in screening counseling and providing resources to our patients next slide this slide shows substance use and pregnancy trends from the National Survey on Drug use and Health in 2018. at the top left this shows all illicit drug use and it has been stable over the past two years including 2018-2019 also tobacco products have been shown to be about 10 percent in the year 2019 and and alcohol use around 10 percent as well when you look at illicit drug use it's broken down into marijuana use opioids and cocaine with marijuana still being the most common illicit drug used in 2019 5.4
percent of women reported use around 112, 000 patients opioids seen here outlined in the red box is still a major problem at 8, 000 women or 0.4 percent cocaine is also still reported although used at a lesser amount is still a major problem next slide when it comes to screening for substance use and pregnancy we want to emphasize the verbal screening tool in our office we screen all women at their first OB visit and in order to provide a private safe and non-judgmental atmosphere we do this with women one-on-one so we want the patient to feel that they're able to disclose anything about their medical history or substance use history and they're not going to feel like they're judged or they have to hide anything we feel that by having this one-on-one first visit it creates that kind of environment for the patient we inform the patients that this is done universally so despite their history or socioeconomic status or race every single woman is screened the answers are confidential and are not intended to be putative we want to make sure that everybody does understand the state laws however when it comes to screening for substance use disorder and pregnancy you want to make sure that when you're asking patients about their history that you're using open-ended questions you also want to make sure that you're addressing any kind of misinformation and dispel myths and this may be things like relieving their worries of their children being taken away by CPS if they report a history of use or current use even it's really important again to do early universal screening which is why we do it in our first OB visit and we also repeat it again around 28 weeks in the third trimester you want to make sure that you're using a universal and validated screening tool which we'll talk about in another slide and that you have that you're able to refer to treatment as needed in order to improve maternal and infant outcomes next slide so a screening tool that we use in our office and is a validated screening tool is the 4Ps you can find more information on ACOG's website for committee opinion 524.
the screening starts with the first P being parents I love starting with this question because it opens up the patient to talk about their childhood and maybe any kind of trauma that they've endured so you start by asking them if any of their parents have had a problem with alcohol or other drug use again it gives the patient the opportunity to disclose any hardships they may have had through their childhood and it can open the door to therapy or other referrals if needed just based on this one question the next P stands for partner does your partner have a problem with alcohol or drugs again this question is good not only to screen for substance use disorder but also to get a better idea of the environment that your patient is living in or subjective to again it could if this if this brings up a problem with domestic violence or an unsafe environment it could initiate a Care Management consult or other referrals the third question is about their past and in the past have they had any difficulties in their life because of Alcohol and Other Drugs including prescription medications again this question is great because if the patient has a has had trauma in the past or other issues it can open the door for referrals again for therapy or other outlets that the patient may need and then lastly the fourth P is for present in the past month have you drank any alcohol or used any other drugs and this obviously screens for any current substance use disorder in the patient next slide in terms of biochemical testing and toxicology we and overall do not recommend that this is your the kind of universal screening that you perform or routine screening first of all it does not detect many substances depending on the urine drug screen that you use also it only tests for recent use so if a patient has it used in a several days to a week it could miss somebody and you could potentially be missing an opportunity to to find out if that patient has substance use disorder a negative test again would not necessarily rule out sporadic use also false positives and negatives could occur as well and somebody that's not using could have a positive test result because of another medication she's taking you know and also if there is a positive test result it does it's not indicative of substance use disorder per se it may increase the chance of CPS involvement depending on your state laws and mandatory reporting and it's not a test of parenting ability or a safe environment if somebody has a positive test screen for marijuana for example that may have no bearing on whether or not that patient is able to parent correctly or is living in a safe environment best practices for providers we believe that you need to obtain a consent prior to toxicology screening even if your state laws do not require it so this is a conversation with a patient and maybe even a written consent asking if it's okay to perform a urine drug screen the importance of this is that proper counseling is done prior to test results again you depending on the state there may be mandatory reporting and therefore potential ramifications of a positive test and the patient needs to know that before our test is performed you also want to be familiar with what's in the toxicology panel and again because of all these things routine screening is not recommended next slide pharmacotherapy is also known as medication for opioid use disorder or MOUD for short the most common options for MOUD during pregnancy include methadone and buprenorphine methadone is dispensed as a liquid while buprenorphine is frequently prescribed as a buccal film or sublingual pill as either a mono product or in combination with naloxone methadone is only available at federally certified opioid treatment programs which requires daily attendance while buprenorphine can be prescribed in private offices while treatment with either methadone or buprenorphine is reasonable the choice of medication depends on a variety of factors such as access to treatment preference and treatment history the distinct properties of these medications on the opioid receptor gives the two medications a slightly different profile for example buprenorphine has a lower risk of overdose fewer medication interactions and the widely held belief that buprenorphine is associated with a lower rate in severity of neonatal absence syndrome on the other hand methadone may be easier to initiate has no ceiling effect it may reduce attrition recently in an effort to increase access to treatment the laws were changed allowing any provider with schedule III Authority on their DEA registration to prescribe buprenorphine for OUD if permitted by applicable state law and eliminated caps on the number of people that can be treated per provider there are many other aspects of MOUD that are outside the scope of this lecture such as choosing between the buprenorphine monoproduct versus the combination product with naloxone switching between buprenorphine and methadone or vice versa in dose tapering or detoxification next slide understanding opioid withdrawal has importance in many aspects of caring for patients with OUD such as knowing the maternal fetal risks of withdrawal and providing accurate evidence-based counseling initiation of MOUD and titration of dose differentiating between withdrawal and other conditions with overlapping symptomatology and evaluation and management of post-operative pain importantly concerns for fetal safety should not influence management decisions in over 1100 reported cases of withdrawal in the literature there was no increase in stillbursts when possible it's important to know which opioids a patient was taking the onset of withdrawal varies based on the half-life of the opioid a short-acting opioid such as fentanyl has an onset of withdrawal three to five hours after last use peak symptoms at 8 to 12 hours and resolution occurs in 45 days whereas for a long-acting opioid like methadone withdrawal symptoms may not start for 24 to 72 hours after last use symptoms will peak at four to six days and resolve 14 to 21 days after last use the most common symptoms withdrawal are diarrhea sweating restlessness anxiety yawning dilation of the pupils and gooseflesh other symptoms are listed on the right side of the slide withdrawal symptoms can be monitored using the clinical opiate withdrawal scale which was published by Wesson in 2003 and is available online from several sources treatment of withdrawal is a separate topic that is beyond the scope of the lecture but management may include initiation of MOUD or clonidine in treatment with added adjunctive medications such as hydroxyzine anti-diarrheal medications and antiemetics next slide opioid use disorder is associated with a range of adverse outcomes some of these are specific to the root of use for example injection drug use is associated with infectious complications such as HIV hepatitis cellulitis bacteremia and endocarditis other aspects are related to the type of drug here I'll use the example of heroin versus prescription opioids purchasing heroin risks arrest and or incarceration and activities involved in securing heroin sometimes include prostitution or trading sex for drugs in these respects misuse of illicitly obtained opioid prescription is vastly different during pregnancy untreated opioid use disorder can result in poor prenatal care preterm birth and lower birth weight while numerous complications have been reported it is difficult to tell what is due to the opioids themselves other concomitant exposures or coexistant in medical problems or psychosocial comorbidities all opioids even those used to treat opioid use disorder associated with neonatal absence syndrome a lot of attention is focused on NAS which will be reviewed further on another side but on a positive note neurodevelopmental outcomes with the antenatal exposure to opioids are generally favorable the social implications of opioid use disorder should also not be overlooked without engagement in treatment opioid use disorder will prompt a referral to Child Protective Services which in rare cases may result in removal of the child from the home next slide replacement with either methadone or buprenorphine plus psychosocial treatment is the preferred approach to the treatment of opioid use disorder during pregnancy treatment of OUD improves the patient obstetrical and neonatal outcomes mentioned on the prior slide benefits include better attendance at prenatal care appointments and reducing illicit opioid use thus preventing some of the sequelae of illicit opioid use such as exposure to infectious diseases like hepatitis C syphilis and HIV which also reduces the potential for transmission to the baby treatment with MOUD also reduces the risk of maternal mortality and severe morbidity in a review of opioid related maternal deaths in Michigan it was found that among 82 deaths not one of them was treated with MOUD other favorable effects include higher gestational age and weight and larger head circumference at delivery patients in treatment that maintain abstinence are also less likely to have CPS involvement and are at lower risk for being separated from the infant next slide unless the diagnosis of substance use disorder is already known all pregnant patients should be screened for the use of illicit drugs tobacco and alcohol using a validated questionnaire the details of screening were covered earlier by Dr Leonard for patients who screen positive a thorough drug history is important the components of the drug history are easily remembered using the acronym DRUG which stands for the drug name route of use used how much and how often and lastly the G stands for gotten how polysubstance abuse is common with rates of 35 to 37 percent reported in the literature promoting patient and family engagement can be accomplished by reducing the stigma that stems from the shame that pregnant patients with OUD often feel and the glutter misinformation propagated through the internet by through the internet by providers and inpatient forums it's important for providers to be aware of evidence-based practices and to appropriately train office staff including everyone from the person who arrives a patient to the person rooming the patient use of a common language that emphasizes that OUD is a chronic medical condition is essential and words matter for example a patient who abstains from illicited drugs shouldn't be referred to as clean because the opposite is dirty and it's better to say they tested positive or negative for opioids counseling should include information about pain management during labor and postpartum while typical pain regimens are adequate following vaginal delivery patients undergoing cesarean section experience much greater levels of pain that are often refractory to treatment due to hyperalgesia and tolerance these patients frequently appear that their pain won't be adequately managed patients should also be encouraged to attend their regularly scheduled prenatal care appointments medical complications are variable a thorough history and physical exam is important all patients should be screened for HIV Hepatitis B and sexually transmitted diseases untreated mental health conditions are common and are associated with greater severity of opioid use disorder the prevalence of co-occurring mental health conditions ranges from 27 to 78 percent with the most common diagnosis being anxiety and depression patients should be offered referral to a mental health provider as indicated in psychotropic medication should not be withheld if needed for treatment lastly providers caring for pregnant patients are encouraged to create a resource map which includes among other things the treatment providers and programs in their geographic area next slide not all patients are equal and by this I mean that there are differences between the patient that uses IV heroin and now has a prosthetic valve secondary to endocarditis versus the patient who developed opioid use disorder while being prescribed opioids after surgery and has been in remission for several years however most patients with opioid use disorder benefit from care by a multi-disciplinary team including an obstetrician the patient's treatment provider Psychiatry and social work the medical complexity of the patient the experience of the provider will dictate whether or not there's an indication for inclusion in maternal fetal medicine and Internal Medicine antenatally the role of Pediatrics is to provide counseling about the surveillance and management of NAS and other issues that may influence neonatal outcomes such as the safety and utility of breastfeeding in some communities this multi-disciplinary approach is accomplished through creation of comprehensive prenatal care programs that specialize in the management of opioid use disorder during pregnancy next slide as I mentioned earlier there is a lot of emphasis placed on neonatal absence syndrome which is the term used to describe the pattern of withdrawal symptoms when opioids are abruptly discontinued at birth NES has a tremendous impact on hospital resources and health care costs with an average length of stain and if you of roughly two weeks and a cost of sixty three thousand dollars mirroring the trends seen during the opiate epidemic there has been a five-fold increase in neonatal absence syndrome with 32, 000 babies born with this syndrome in 2014.
however NAS is both expected and treatable and the evidence has shown that it does not lead to long-term complications when managed appropriately perhaps more than any other aspect of opioid use disorder during pregnancy misinformation abounds regarding the NAS and can be found even on reputable medical sites for example a major medical news source stated considering the extensive negative implications for of NAS for both the mother and the baby and then continued but statements like this have led some patients to stop treatment providers to withhold treatment or dose adjustments and the
practice of tapering or decreasing the dose of MOUD to avoid or minimize withdrawal there's mixed data on the association between an MOUD dose particularly for Methadone and the risk of neonatal absence syndrome to begin with but the evidence is very clear that tapering or detoxification results in higher rates of recidivism which negates the benefits of MOUD particularly given the lack of harm from appropriately treated NAS next slide areas outside of New York City have relatively higher rates of NAS which parallels other statistics observed during the opioid epidemic such as the higher
rates of overdose deaths in rural versus urban areas mentioned earlier by Dr Leonard but rural communities were amongst the areas that saw the highest increases in the rate of NAS the trends observed in rural areas can at least in part be explained by a greater imbalance between the need for treatment and the availability of treatment providers in these areas next slide pregnant patients with opioid use disorder should be provided with anticipatory guidance about their care in the care of being since it's important to monitor all infants with opioid exposure for NAS consultation with a
Maternal Fetal Medicine provider or pediatrician familiar with the evaluation and management of NAS should be offered as mentioned earlier these consults are typically done in the third trimester nearer to anticipated delivery counseling about NAS may also address factors that are known to improve the incidence and severity of NAS up to 95 percent of pregnant patients with opioid use disorder smoke cigarettes while and while pregnancy motivates many pregnant patients to quit smoking this trend is not seen in opioid use disorder despite the complexity of managing dual dependencies smoking
cessation when achievable has a favorable effect on NAS similarly favorable effects on NAS have been observed when rooming in is encouraged and accommodations for the patient are made after discharge when the infant needs to remain in the hospital for continuing treatment of NAS the room should be kept quiet and dimly lit breastfeeding is encouraged unless otherwise contraindicated consistent with recommendations from both ACOG and the American Academy of Pediatrics both methadone and buprenorphine are compatible with breastfeeding and passed into the breast milk in very small amounts the
beneficial effects probably stem more from the act of breastfeeding itself or the skin-to-skin contact than the presence of medication in the milk the newborn environment and breastfeeding are foundational elements of the eat sleep console approach to management of NAS which has been shown to dramatically decrease the length of treatment many other factors also influence NAS and these should likewise be addressed with the patient as part of comprehensive care next slide these next two slides include links to several other resources that you may find helpful in caring for pregnant patients
with opioid use disorder next slide next slide if you're interested in additional information on an opioid use disorder during pregnancy please contact the UR Medicine Recovery Center of Excellence at the information on the slide.
Neil Seligman, MD & Cassie Leonard, MD
This module provides participants with education about treatment options for pregnant patients with a history of opioid use disorder (OUD), pregnancy outcomes for patients with OUD, reproductive care for patients with OUD, and neonatal abstinence syndrome (NAS).