Opioid Addiction in Pregnancy by yurtgc548


									Leslie A. Pires, MS, PharmD
Women & Infants Hospital of RI
   Acknowledgements:
     Cathy Friedman MD
     Lynn Hess PhD

   Disclosures:
     I have no financial conflicts to disclose
   Retail heroin is
    increasing in purity
   Retail heroin is
    decreasing in price
   Heroin is a pure mu
    receptor agonist
   Heroin may be injected,
    smoked, inhaled
Short-Term Effects:       Long-Term Effects:
 “Rush”                   Addiction
 Depressed respiration    Infectious diseases
 Clouded mental               HIV/AIDS
  functioning                  Hepatitis B and C
 Nausea and vomiting        Collapsed veins
 Suppression of pain        Bacterial infections
 Spontaneous abortion       Abscesses
                             Infection of heart lining
                              and valves
                             Arthritis and other
                              rheumatologic problems
   13-17% higher mortality rate both genders

   Differences in women:
     Women experience more depression, anxiety, somatic
      complaints and substance abuse than men
     Women seek treatment more rapidly
     33% opioid dependent individuals are child bearing age
     56-73% of opioid dependent pregnant women suffer from a
      major psychiatric disorder according to DSM-IV
        ▪ Harmful health behavior during pregnancy
        ▪ Increase risk of post partum depression
        ▪ Adversely effect mother child interaction
Reference 12: Unger
   Heroin in pregnancy
     lack of prenatal care
     reduced birth weight
      ▪ future developmental delays
     withdrawal can cause fetal death
     NAS: neonatal abstinence syndrome
   Plus the adverse effects of illicit drug abuse in
    general population
     increase in all cause mortality
   Recognized as a compelling care issue,
    especially during labor and delivery, for
    maternal maintenance and acute pain control
   Neonates suffer neonatal abstinence
   Multidisciplinary team formed
     Obstetrics, psychiatry, pediatrics, social services,
     nursing, pain management, anesthesia, pharmacy
   Don’t detoxify
     Maintain homeostasis for mom & fetus
     Maintain with buprenorphine or methadone
     Use adequate doses
      ▪ Assure retention in treatment program
      ▪ Prevent use of illicit drugs.
   Methadone - ample evidence to support use
     Pure mu agonist
     Reduction of complications of pregnancy, childbirth
      and infant development
     Years of clinical experience
   Buprenorphine
     Partial mu agonist
     Strong affinity for receptor – binds tightly
      ▪ Disassociates slowly from receptor
     Low intrinsic activity – less effect

   Only available thru       Available from MD office
    programs                    MD special training
   Pure full mu agonist      Partial mu agonist
   NAS                       NAS
   More experience in          Milder severity
    pregnancy                   Shorter duration
                              Fewer drug interactions
                              May precipitate withdrawal
                               in opiate tolerant patient
                              Induction timing critical
   Compare neonatal NAS in babies who’s
    mom’s received either buprenorphine or
   Multicenter trial
     WIH one of the sites
     Dr Mara Koyle
     Dr Jacob Canick

NEJM 12-2010
   Primary Endpoints:
    1. # neonates requiring NAS treatment
    2. Peak NAS score
    3. Amount of morphine needed
    4. Length of hospital stay
    5. Head circumference
Endpoints reaching       difference           methadone              buprenorphine
significance                                    group                    group

total morphine dose        89%                 10.4mg                      1.1mg
required to treat the     p<0.009
neonate’s NAS
durations of neonates’      43%                17.5 days                   10days
hospital stay             p<0.009

                             drop out numbers              drop out rate
         methadone                    16/89                    18%
         buprenorphine                28/86                    33%
   Obstetric delivery is not a planned event.

   Planned GYN surgery, may take off
    buprenorphine and put on IR opiate
    preceding surgery
   Buprenorphine human opioid receptor
    occupancy is dose-related
     @ 2mg/day: 27-47% occupancy rate
     @ 32mg/day: 89-98% occupancy rate

   CSF concentration buprenorphine = 15-25% of
    plasma concentration
     spinal morphine used for Cesarean sections will have
     ability to work
   Dosing interval for addiction q24hours

   Dosing interval for analgesia q8hours

   Metabolism revs up in the third trimester of
     May need even shorter dosing interval
     May need higher doses
   Maximize non opioids
     Ibuprofen (maximum = 2400mg)
     Acetaminophen (maximum = 4grams)
     Give together, alternating
   Maximize buprenorphine dose
     40mg in divided doses
   Lastly, give pure mu agonist
     May require higher doses to see effect
     Watch respiration
   Buprenorphine is poorly bio-available, so there is
    minimal exposure to the neonate

   APP considers buprenorphine to be compatible with
   Neonates born to mom’s using opioids
     Monitor using Finnegan’s Score
     Expect longer hospital stay after birth
     Comfort with non-pharmacologic measures
     Treat with morphine in a taper fashion
     Admit to NICU as needed
     Connect with social service resources
   Management of WIH peri-operative and
    laboring patients receiving buprenorphine
   Researching the feasibility of inpatient
    admission for induction opioid withdrawal
     Federal Opioid Treatment Standards
     42 CFR 8.12
"Oh, jab me with your needle a hundred times

     And a hundred times I will bless you,
              Saint Morphine"

                 Jules Verne

                (1828 - 1905)

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