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1
Hendrée E. Jones, PhD
Executive Director, Horizons ProgramProfessor, Department of Obstetrics and Gynecology
School of edicine, !niversity of "orth #arolina at #hapel Hill
Perinatal Quality Collaborative of North Carolina$earning Session % &aleigh, "# % ay '(, )*'+
Treating Wo en for !ubstan"e #se Disorders$Considerations during Pregnan"y and the Post%artu Period
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) c-no.ledgements
Study patients and infants
"ational /nstitute on Drug buse – &*' D s0 *'+12(, *'+134, *'1+'3,
*'+114, *'4('*, *'4('1, *'+1(','+43)
aternal Opioid 5reatment0 HumanExperimental &esearch 6 O5HE&7
Site P/s and investigative teams
Slide ' #redits0 8Husband nd Pregnant 9ife: by David #astillo Dominici; 8Side <ie. Of Pregnant 9oman: by imageryma=estic; 8 other /s&eading >oo- ?or Her >aby: by @omphong
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3 Disclosures
Discussing methadone and buprenorphine, labeled by the !S ?ood andDrug dministration 6?D 7 as #ategory # for use in pregnancy for thetreatment of maternal opioid dependence0 8 nimal reproduction studieshave sho.n an adverse effect on the fetus and there are no adeAuate and.ellBcontrolled studies in humans, but potential benefits may .arrant useof the drug in pregnant .omen despite potential ris-sC:
Pregnant .omen .ith opioid use disorders can be effectively treated .ithmethadone or buprenorphineC >oth these medications should not beconsidered 8offBlabel: use in the treatment of pregnant patients .ith opioiduse disorder @ones et alC, & J 'bstet (yne"ol C )*'(
&ec-ittB>enc-iser Pharmaceuticals for donated active placebo tablets andreimbursement for time and travel in )*''C
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( Ob=ectives
'C Participants .ill revie. the historical and currentcontexts of opioid use for .omen
)C Participants .ill compare and contrast the ris-sand benefits of methadone and buprenorphine givenduring pregnancy for the fetus, child, and mother
3C Participants .ill identify treatment componentsfor comprehensive treatment programs that providemedicationBassisted treatment
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+ Historical #ontext of Opioid !se during Pregnancy
Substance use during pregnancy in the!S has been a longBstandingimportant health issueC /n the '4**s0
• 22F1+ of individuals .ith opium usedisorders .ere .omen
• 9omen s most common opium source .as
medical prescriptions to treat pain• Physicians recognized neonatal opioid
.ithdra.al and the need to treat in uteroopium exposure .ith morphine in order toprevent morbidity and mortality
♦ ?ollo.ing the'I'( Harrison "arcotic ct, thetreatment of substance use disorders .assegregated from mainstream medicalpractice
6Jandall, !ubstan"e and shado) , 'II2C Earle, *edi"al !tandards , '444C7#redit0 Still from The Dividend , 'I'2C public domain .
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2
• /n )*'), an estimated )3CI million mericans aged ') or older 6IC) 7 ofthe populationKhad used an illicit drug or abused a psychotherapeutic
medication 6such as a pain reliever, stimulant, or tranAuilizer7 in the pastmonthC
• 5his number is up from 4C3 percent in )**)C
#urrent #ontext of Drug !se in the !S
National Survey on Drug Use and Health (NSDUH) 2012
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• ost common medications that aremisused
• Pain-illers containing0o Hydrocodone, such as
<icodin,o Oxycodone, such as Percoceto Oxycontin
• >enzodiazepines0o $orazepam 6 tivan7o lprazolam 6Lanax7
mericans consume 4* percent of the.orldMs supply of pain-illers BB morethan ''* tons of pure, addictiveopiates every yearC 5hat is 2(Percocet or <icodin per every !S#itizenC
#urrent #ontext of Drug !se in the !S
http://www.dailymail.co.uk/news/article-2142481/Americans-consume-8 -percent-worlds-pain-pills-prescription-dru!-a"use-epidemic-e#plodes.html$i#%%&a'"!()oA *+* 1/22/1, pioid painkillers widely prescri"ed amon! reproducti e a!e women
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4
Opioid Pain-iller Prescribing0 9here Nou $ive a-es aDifference@uly )*'(
Each day, (2 people die from an overdose of prescriptionpain-illers in the !SC
Health care providers .rote )+I million prescriptions forpain-illers in )*'), enough for every merican adult tohave a bottle of pillsC
'* of highest prescribing states for pain-illers are in theSouth .
#urrent #ontext of Drug !se in the !S
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I
"early (4,*** .omen died of prescription pain-iller overdosesbet.een 'III and )*'*C
Deaths from prescription pain-iller overdoses among .omen haveincreased more than (** since 'III, compared to )2+ among menC
?or every .oman .ho dies of a prescription pain-iller overdose, 3* goto the emergency department for pain-iller misuse or abuseC
Prescription Pain-iller Overdoses gro.ing epidemic, especially among .omen
@uly )*'3
#urrent #ontext of Drug !se in the !S for 9omen
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'*
• /nitiation of drug use
• Ho. she obtains her drugs
• 9here she uses her drugs• Ho. she recovers from drug
use
9hat Does ddiction $oo- $i-e /n 9omen
#ntreated addi"tion %la"es a )o an and her fetusat ris+ for ulti%le adverse "onse uen"es
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''
5he amount of time bet.een initial use and the
development of physiological problems is shorter for.omen than men
5he amount of time bet.een initial use and theseverity of the problems that develop from use of
alcohol and drugs is shorter for .omen than men
0 reen ield3 1 '5 6ucha et al.3 2 '5 7eters et al.3 2 &
5elescoping
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')
♦ 5he t.o most common drugsused by nonBpregnant .omenhave been alcohol and tobacco
♦ 5his same statement is true forpregnant .omen
♦ mong pregnant .omen in the!nited States, approximately'4 smo-ed cigarettes, IC(dran- alcohol, and + usedillicit drugs in the past month
"ational Survey on Drug !seand Health )*''B)*')
Past Month Use
6S HS Office of pplied Statistics, )*''B)*')7
& ong %regnant )o en,a%%ro-i ately . / used heroin,and .0/ used %ain relievers non1
edi"ally in the %ast onth
#urrent #ontext of Opioid !se during Pregnancy
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'3 #urrent #ontext of Opioid !se during Pregnancy "eonatal bstinence Syndrome 6" S7 often
results .hen a pregnant .oman uses opioids6eCgC, heroin, oxycodone7 during pregnancyC
Defined by alterations in the0
Central nervous syste9 highBpitched crying, irritability9 exaggerated reflexes, tremors andtight muscles9 sleep disturbances
&utono i" nervous syste9 s.eating, fever, ya.ning, andsneezing
(astrointestinal distress9 poor feeding, vomiting and loosestools
!igns of res%iratory distress9 nasal stuffiness and rapid breathing
" S is not ?etal lcoholSyndrome 6? S7
" S is treatable
5here are no -no.n longBterm conseAuences fromhaving " S or beingtreated for " S
6?innegan et alC, &ddi"t Dis C 'I1+; Desmond Q 9ilson, &ddi"t Dis C 'I1+7
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'(
retrospective, serial, crossBsectional analysisof a nationally representative sample ofne.borns .ith " SC#linical conditions .ere identified using /#DBIB# diagnosis codesC" S and maternal opiate use .ere described asan annual freAuency per '*** hospital birthsC
)*** )**3 )**2 )**I
)*** )**3 )**2 )**I $o. &espiratory edicaid>irth.eight Diagnoses #overage
in the United States – one infant every hour – suffers from neonatal a stinen!e syndrome (N"S)
#urrent #ontext of Opioid !se during Pregnancy
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'+
/n the !S, it is estimated that0
'** million people have chronic pain
)) million are living .ith addiction, and ofthose individuals
2 illion isuse %res"ri%tion edi"ations
#urrent #ontext of Opioid !se during Pregnancy
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'2 #urrent #ontext of Opioid !se during Pregnancy
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'1
9hy are more individuals, includingpregnant .omen, using opioids
5here has been an increase in the access tothese medications
Pain became the +th
vital sign in the early )'st
century
?ederal prosecutors allege in documents filedin !CSC District #ourt that #hris and @effGeorge from ?lorida dramatically increased
the numbers of pain clinics in ?lorida androuted opioid pain medications to Jentuc-y,Ohio and South #arolina
#urrent #ontext of Opioid !se during Pregnancy
#redit0 8>ac- Pain During Pregnancy: by imageryma=estic
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'4 Summary of Historical and #urrent #ontext
18
♦ lthough less freAuent than alcohol and tobacco use,opioid misuse during pregnancy is nonetheless aserious and gro.ing issue
♦ 5his increase in use of opioids by pregnant .omenappears to be driving an increase in the incidence ofneonatal opioid .ithdra.al
♦ Opioid use by pregnant .omen is often complicated bypolydrug use, and often occurs intert.ined .ithcomplex personal, interpersonal, family, social, andenvironmental factors that can contribute to adverseconseAuences
♦ 9omen have uniAue needs for addiction treatment andmultiBfaceted interventions are needed to help preventand treat opioidBdependence among .omen duringpregnancy and their infants
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'I
/ssues facing drugBusing pregnant .omen and their children
• Exposure to violence andtrauma
• Generational drug use• $ac- of formal education• $ac- of =ob acAuisition and
maintenance s-ills• Gender ineAualityRmaleBfocused society
• $egal involvement
• ultiple drug exposures• $imited parenting s-ills and
resources• History of child abuse and neglect• ultiple psychiatric issues•
!nstable housing• $ac- of positive and supportiverelationships
• ?ood insecurity and lac- ofnutrition
These fa"tors )ith or )ithout drug use "aninfluen"e other and "hild out"o es
#urrent #ontext of Opioid !se during Pregnancy
#redit0 8Stress Definition /ndicates Explanation Pressures nd 5ension: by Stuart iles
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)*
6&evie. in Jaltenbach et alC, 'bstet (yne"ol Clin North & , 'II4C7
Pharmacotherapy for Opioid Dependence
• Prevention of erratic maternal opioidlevels lessens fetal exposure torepeated .ithdra.al episodes
• &educes maternal craving and fetalexposure to illicit drugs
• 9ith drug abstinence, other behaviorchanges can follo. .hich decreaseris-s to mother fetus of infection fromH/<, hepatitis and sexually transmittedinfections
• &educes the incidence of obstetricaland fetal complications and improvesoutcomes
#redit0 /mage in the public domain by SubDural')
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)'
21
9HO )*'( Guidelines0 8Pregnant .omen dependent on opioidsshould be encouraged to use opioid maintenance treatment .heneveravailable rather than to attempt opioid detoxificationC Opioidmaintenance treatment in this context refers to either methadonemaintenance treatment or buprenorphine maintenance treatmentC:
Guidance regarding maintenance versus medicationBassisted.ithdra.al has traditionally been based largely on good clinical
=udgmentedication follo.ed by no medication treatment has freAuently been
found to be unsuccessful, .ith relatively high attrition and a rapidreturn to illicit opioid use
aintenance medication facilitates retention of patients and reducessubstance use compared to no medication
>iggest concern .ith opioid agonist medication during pregnancy isthe potential for occurrence of neonatal abstinence syndrome 6" S7 Fa treatable condition
aintenance v C edicationBassisted 9ithdra.al
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)) 9hy !se Opioid edications 9ith opioid medications .e are not replacing one addiction for anotherCOpioid medications are longBacting medication that help .ith0
#& </"G
n individual s cravings are controlled
#O P!$S/O"
/ndividual is no longer compulsively using opioids
#O"5&O$
edicationBassisted treatment gives bac- control to the individual
#O"SE !E"#ES
edication assisted treatment helps the individual focus on rebuilding her life
&n individual re"eiving o%ioid %har a"othera%y ust be onitored by a edi"al teathat evaluates ade ua"y of edi"ation dosage and general health and )ell1being of theindividual.
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)3
• /n the 'I1*s , a positive relationship bet.een maternal methadonedose and " S severity .as reported
• &ecommendations to maintain pregnant .omen on methadonedoses bet.een )* to (* mg
• 3 decades of research sho.s an inconsistent relationship bet.eenmaternal methadone dose and " S severity
• 5he latest systematic revie. and metaBanalysis concluded that the8Severity of the neonatal abstinence syndrome does not appear todiffer according to .hether mothers are on highB or lo.Bdose
methadone maintenance therapyC:
6&evie. in #leary et alC, &ddi"tion, )*'*7
ethadone0 Dosing during Pregnancy
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)(
Split Dosing
6aternal esults – increase drug negative urines during treatment – /ncreased adherence .ith treatment – decrease .ithdra.al symptoms in mother
– "o change in maternal heart rate, vagal tone or s-in conductance
(etal esults – inimizes the reduction in breathing
– inimizes the reduction in movement – ?etal movementBfetal heart rate coupling less suppressed
ethadone0 Dosing during Pregnancy
6DePetrillo et alC, 'II+; S.ift et alC, 'I4I; 9ittmann et alC,'II'; @ansson et alC, )**I; c#arthy7#redit0 8Human ?etus: by ddpavumba; 8Smiling Pregnant ?emale Holding Her 5ummy: by imageryma=estic
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)+
2,
Methadone-asso ciated N AS++BI*
T 2*
(+ to 1) hrs
(* to ')* hrs
" S signs
&eAuiring medication
" S appears
" S pea-s
ost common medication for treatment is morphine
ost common assessment tool is a 8modified: ?inneganscale
"o current standard uniform protocol for treatment
ethadone0 " S
#redit0 8Sleeping sian >aby: by hin)++
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)2
>reastfeeding in
ethadoneBStabilized othersethadone detected in breast mil- in very lo. levels
ethadone concentrations in breast mil- are unrelated tomaternal methadone dose5he amount of methadone ingested by the infant is lo.
5he amount of methadone ingested by the infant remainslo. even 2 months later Several studies sho. relationships bet.eenbreastfeeding and reduced " S severity and durationHepatitis # is not a contraindication for breastfeeding
#ontraindications0 H/<U, unstable recovery
6DM polito, )*'3; P )*'); c ueen et alC, )*''; @ansson et alC, )**1; @ansson et alC, )*'*7
ethadone0 >reastfeeding
#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong
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)1
2;
&esearch focusing on the effects of prenatal exposure to
methadone has been inconsistent$ongBterm effects on physical gro.th have not been demonstrated
lthough some research has sho.n that methadoneBexposed schoolBage children to be less interactive, more aggressive, and sho.ingpoorer achievement than children not so exposed, other research hasfailed to sho. any differences in either cognitive or socialdevelopment
5he issue is confounded by the fact that children exposed tomethadone in utero may experience a nutritional, family, andparenting history Auite different than children not so exposed
)*'( metaBanalysis sho.ed 8no significant impairments for cognitive,psychomotor or observed behavioual outcomes for chronic intraButerine exposed infants and preBschool children compared to nonBexposed infants and childrenC:
6>aldacchino et alC, 3*C Psy"hiatry )*'(; >ehn-e et alC, Pediatri"s , )*'3; ?arid et alC, Curr Neuro%har , )**47
ethadone0 #hild Development
#redit0 8$ady Doctor easuring Girls Height: by David #astillo
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)4
45 years of do"u ented benefits of ethadone during
%regnan"y
• /nduction is relatively simple
• deAuate doses are needed to prevent .ithdra.al and other
opioid use• /ndicators of fetal .ellBbeing are less compromised .ith splitB
dosing
• " S is .orse .ith heavier smo-ing
• >reastfeeding is compatible .ith methadone
ethadone0 Summary
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)I >uprenorphine
derivative of the opioid al-aloid thebaineSchedule /// opioidμBopioid receptor partial agonist
primarily antagonistic actions on κ- opioid andδ- opioid receptorsHalfBlife estimated to fall in the range of )(B2*hours
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion , )*')7
h d
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3*
• Since 'II+, over (* publishedreports of prenatal exposure to buprenorphinemaintenance
• pproximately 1+* babies prenatally exposed tobuprenorphine 6number of cases per report rangedfrom ' to '+I; *edian V'(7
• Dose range *C( to 3) mg• 44 reported concomitant drug use
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7
>uprenorphine and Pregnancy
3' h l
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3'
&esearch .ith buprenorphine not as extensive as .ith
methadone9ellBtolerated and generally safe/n contrast to the research .ith methadone, little researchhas compared buprenorphine to an untreated control
group&ather, buprenorphine has been compared in bothretrospective and prospective studies to methadone
a=ority of research .ould suggest that maternaloutcomes are not in any .ay different than for methadone
>uprenorphine0 aternal Outcomes
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7
3) hi 0 ? l O
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3) >uprenorphine0 ?etal Outcomes
% V C*I+
% W C*'
6Salisbury et alC, &ddi"tion , )*')7
33 hi 0 " S
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33
• /ncidence rate for " S is estimated to be +* F about the same as formethadone
• " S onset approximately (4 hours• Pea-ing .ithin approximately 1)BI2 hours• Exceptions to this onset history have been the fe. neonates .ith " S
onset of 4B'* days postnatal age- such a protracted .ithdra.al syndrome may to be due to . ithdra.al from
concomitant drug exposure 6eCgC, benzodiazepines7 rather than a directeffect of buprenorphine .ithdra.al
• #orrelation bet.een buprenorphine dose and " S severity has beeninconsistent
• 5ime of first dose of " S treatment medication has been sho.n to belater .ith buprenorphine than methadone 6 1' hrs vs 3( hrs, respectively7
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')C; Gaalema et alC, D&D, )*'37
>uprenorphine0 " S
3( hi 0 f di
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3(
>uprenorphine is found in breast mil- ) hours postBmaternal
dosing#oncentration of buprenorphine in breast mil- is lo.
mount of buprenorphine or norbuprenorphine the infant receivesvia breast mil- is only '
ost recent guidelines0 8the amounts of buprenorphine in human
mil- are small and unli-ely to have negative effects on thedeveloping /nfant:85he advantages of breast feeding prevail despite the ris-s of aninfant opiate intoxication caused by methadone orbuprenorphine C:
6 t-inson et alC, 'II*; arAuet et alC, 'II1; @ohnson, et alC, )**'; Grimm et alC, )**+; $indemalm et alC, )**I; @ansson et alC, )**I; Xller et alC, )*''7
>uprenorphine0 >reastfeeding
#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong
3+ > hi 0 #hild D l t
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3+
• &esearch on the neonatal conseAuences of prenatalexposure to buprenorphine is Auite limited
• "ot enough births have been follo.ed for a sufficientperiod of time to collect convincing data regardingfactors such as cognitive and social development
• Same issue of confounding parental and family factorsin teasing apart developmental effect
6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7
>uprenorphine0 #hild Development
32 O5HE&0 Si
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32 O5HE&0 Sites
6ead !ite @ohns Hop-ins !niversity P/0 HC @ones>ro.n !niversity P/0 >C $ester 5homas @efferson !niversity P/0 JC Jaltenbach!niversity of <ermont P/0 SC Heil
!niversity of <ienna P/0 GC ?ischer !niversity of 5oronto P/0 PC Selby<anderbilt !niversity P/0 PC artin9ayne State !niversity P/0 SC StineCoordinating Center !niversity of aryland P/0 C rria
31 O5HE&0 > hi C th d
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31
• #ompared .ithmethadoneBexposed
neonates, buprenorphineBexposed neonates – &eAuired 4I less&eAuired 4I less
morphine to treat " Smorphine to treat " S – Spent (3 less time in theSpent (3 less time in the
hospitalhospital
– Spent +4 less time in theSpent +4 less time in thehospital being medicatedhospital being medicatedfor " Sfor " S
• >oth medications in thecontext of comprehensivecare produced similar
maternal treatment anddelivery outcomes
&;
Notes$ Significant results are encircledC Site .as a bloc-ing factor in all analysesC 5he O >rienB?leming Y spending function resulted in Y V C**I' for the inferential tests of the edication#ondition effect for the + primary outcome measures at the conclusion of the trialC
6@ones et alC, N Engl J *ed C )*'*7
% V C***')
% V C******')
< >uprenorphine< ethadone
O5HE&0 >uprenorphine v C ethadone
34 O5HE&0 > hi C th d
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34
#linically
meaningfulattrition rate inbuprenorphinecondition$o. rates ofillicit drug useduringpregnancyand at delivery
aternaloutcomessimilar in the )study conditions
&8Note$ >onferroni s principle .as used to set family.ise Y V C**3')+6nominal Y V C*+R'27 for the secondary outcome measuresC
< ethadone < >uprenorphine
6@ones et alC, N Engl J *ed C )*'*7
O5HE&0 >uprenorphine v C ethadone
3I O5HE&0 > prenorphine C ethadone
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3I
/ncidence of " S signs
ll neonates in each medicationcondition had at least one total " Sscore greater than * at some point duringthe observation period
5hree individual signs .ere observed
significantly more often in thebuprenorphine than in the methadonecondition0 sneezing, loose stools, andnasal stuffiness
5here .ere no signs that .ere observedsignificantly more often in the methadonecondition than in the buprenorphinecondition
% = . 2
Heil et alC, &ddi"tion , )*')
O5HE&0 >uprenorphine v C ethadone
(* O5HE&0 >uprenorphine vC ethadone
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(
Severity of " S Signs
ethadoneBexposed neonates hadhigher mean " S total score, andhigher mean scores for hyperactive
oro reflex, disturbed tremors,undisturbed tremors, failure tothrive, and excessive irritability
ll %s Z *C*(
>uprenorphineBexposedneonates had higher meanscores on sneezing
Heil et alC, &ddi"tion , )*')
O5HE&0 >uprenorphine v C ethadone
(' Summary0 >uprenorphine
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(
O5HE& provided the first  data to support the safety and efficacy ofmethadone
aternal outcomes are similar bet.een medications
Pain management and breastfeeding recommendations are similarbet.een medications
/n terms of " S severity, buprenorphine can be a frontBline medication
option for managing opioidBdependence for pregnant .omen .ho are ne.to treatment or maintained on buprenorphine preBpregnancy
" S, its treatment and elucidating factors that exacerbate and minimize it,remains a significant clinical issue for prenatally opioidBexposed neonates
#urrently there is great variation in terms of medications and use of toolsC
Summary0 >uprenorphine
() " S0 ?actors
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()
Other factors that contribute to severity of " S in
neonates exposed to opioid agonists in utero0
Genetics
Other Substances-
#igarette smo-ing- >enzodiazepines- SS&/s
Hospital Protocols
B5he " S assessment and medication initiation and .eaning protocols- "ot breastfeeding- &ooming in or separating mother and baby
#redit0 89oman Smo-ing EBcigarette: by patrisyu; 8Embryonic Development: by dream designs
6@ansson and <elez, Curr '%in Pediatri"s , )*')7
S0 ?actors
(3 Smo-ing and "eonatal bstinence Syndrome 6" S7
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&ES!$5S
Higher average daily number ofcigarettes smo-ed in the past 3* days.as
U related to in"reasing 0
• 5otal amount of morphine needed to treat" S
• "umber of days neonate .as medicatedfor " S
• "eonatal length of hospital stay
B related to de"reasing 0
• "eonatal .eight at birth
O$S and Poisson regression analyses .ere used to test average daily number of cigarettes smo-ed in the past 3* days at YV C*+, ad=usting for bothedication #ondition and SiteC >elo.Baverage cigarette smo-ing .as defined as 2 cigarettesRday 6B' !D 7, average cigarette smo-ing as '(cigarettesRday 6 ean7, and aboveBaverage cigarette smo-ing as )' cigarettesRday 6U' !D 7C 6@ones et alC, D&D, )*'37
Smo-ing and eonatal bstinence Syndrome 6 S7
SelfBreported past 3*Bday daily average number of cigarettes smo-ed,measured at study entry, .as used to predict neonatal and maternaloutcomes in '3' pregnant participants in the O5HE& studyC
(( >uprenorphine vC ethadone
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44
>uprenorphine v C ethadone
(+ Program #omponents for 9omen
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#onsiders the needs of .omen in all aspects of program designand delivery, including location, staffing, program development,program content, and program materials
Provides safe and comfortable environments in .hich .omendevelop supportive relationships that allo. them to address theirrecovery needs
Services need to include0Outreach and engagementScreeningDetoxification#risis intervention
ssessment5reatment planning#ase management
Program #omponents for 9omen
Progra should be a""redited by an outside body li+e C&78 or JH&C'
Substance use counseling and education 5rauma specific and informed services edical and mental health care
Pharmacotherapy Drug monitoring #ontinuing care
(2 Substance !se Disorders during Pregnancy
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Substance !se Disorders during Pregnancy
?e. medications are successful in the treatment of anysubstance use disorders, except for alcohol and opioidsC
Opioid medications such as methadone and buprenorphine canbe successful components in treating opioid use disorder, bothin the general population and in pregnant .omenC
Opioid medications are best provided in the context of acomprehensive treatment plan that includes behavioral
treatment li-e individual counselingC comprehensive treatment plan is developed follo.ing anassessment that determines .hich life areas have been affectedby drug use and to .hat extent they have been affectedC
5he patient and provider then develop specific goals for
improved life functioning in each life area and a plan for ho.and .hen the goals .ill be metC
Part of the plan may eventually include .ellness indicators of.hen patients can taper off of their medicationC
ScreenScreen
ssessssess
PlanRPlanR5reat5reat
EvaluateEvaluate
(1 ?actors to $oo ?or in Good 5 Program
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?actors to $oo- ?or in Good 5 Program
Do they use the merican Society of ddiction edicine 6 S 7standards for opioid treatment .ith opioid medications in alldecisions regarding the initiation and continuation of themedication for substance use treatment
Do they use evidenceBbased instruments .hich include at aminimum0
the memberMs report of physical and emotional comfortan instrument to assess for possible .ithdra.al symptomsurine toxicology screen results and any other laboratoryfindingsan instrument for assessing impairment
(4 ?actors to $oo- ?or in Good 5 Program
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?actors to $oo- ?or in Good 5 Program
Do they perform regular toxicology screening0
minimum of eight 647 tests per year .ill be performed per patient&andom testing for each patient&eAuires specific drugsRclasses .ill be tested including methadoneand SH s 6sedatives, hypnotics, anxiolytics7; testing should alsoinclude those substances in the memberMs personal history and thosecommon in the region!se certified labs and accepted technologies for appropriateinterpretation of results .ill be used to validly interpret test results
#an they sho. you a staffing plan for recruitment, training anddevelopment
9hat standards can they sho. to document that they are facilitatingrecovery
Do they have a plan for case management in place 9hat are its mainfeatures
(I ?actors to $oo- ?or in Good 5 Program
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?actors to $oo- ?or in Good 5 Program
5he case management factors are lin-ed to successful outcomes0
ssigned case manager to individual patient
#larity about the role of the case managers
/nterventions recommended meet identified care needs
schedule for the patient to meet .ith the case manager
5he case manager actively collaborating .ith the other
providers
5he case manager empo.ers patients to be an active
participant in her care
+* #ontinuum of ?amilyB>ased Services
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6E9E6 :$ Services for .omenC 5reatment plan includes family issues, 5reatment9ith family involvementC Goal0 improved outcomes for .omenC
6E9E6 $ #hildren accompany .omen to treatmentC 9omen s #hildren participatein child care but receive no 5reatment 9ith therapeutic servicesC Only .omen have#hildren Present treatment plansC Goal0 improved outcomes for .omenC
6E9E6 ;$ #hildren accompany .omen to treatmentC 9omen s and 9omen andattending children have treatment #hildren s plans and receive appropriateservicesC Goals0 Services improved outcomes for .omen and children, betterparentingC
6E9E6 <$ #hildren accompany .omen to treatment; ?amily Services .omen andchildren have treatment plansC Some services are provided to other familymembersC Goals0 improved outcomes for .omen and children, better parentingC
6E9E6 4$ ?amilyB#entered 5reatment Each family member has a treatment planand receives individual and family servicesC Goals0 improved outcomes for.omen, children, and other family members; better parenting and familyfunctioningC
#ontinuum of ?amilyB ased Services
+' odel of #are for 9omen and #hildren
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odel of #are for 9omen and #hildren
Trauma andAddiction
Treatment
Childcare and Transportation
VocationalRehabilitation
Housing
Legal aidParentingEducation and
EarlyIntervention
Medical Care!"#$%
Psychiatry
Case Management%utritionLi&e '(ills
6other and *hildMother and Child
+) !"# Horizons Program
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Horizons Strategy
Generate "e.Jno.ledge
5each andDisseminateJno.ledge
Provide #linicalExcellence for 9omen
and #hildren
! g
+3 5a-eBhome essages
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> Opioid addiction is a treatable illness> Pregnant .omen .ith opioid use
disorders have medication optionsfrom .hich to choose as a part of acomprehensive treatment program
> 9omenBcentered treatment programsthat focus on the needs of the.omen, her fetus, and her familyoffer the promise of addressing themultiple and complex needs of.omen .ith opioid use disorders
g
#redit0 8balanced stones: by Pa-hnyushchyyC
+( &esources
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> http0RR...CyoutubeCcomR.atch vV3Hsmuxts>[4
> D& # "eonatal bstinence Syndrome
> http0RRpcmchConCcaR$in-#lic-Caspx filetic-etV@5tIlpgEb"* 3DQtabidV(*
> http0RR...CneoadvancesCcomRindexChtml
> http0RR...CvtoxfordCorgRhomeCaspx
> http0RR...ChealthCAldCgovCauRAcgRdocumentsRg\nas+B*Cpdf > http0RR...CuvmCeduRmedicineRvchipRdocumentsR<#H/P\+"EO" 5 $\G!
/DE$/"ESCpdf
> http0RRpediatricsCaappublicationsCorgRcontentR'*'R2R'*1ICfull
> http0RRstoreCsamhsaCgovRproductR5/PB+'BSubstanceB buseB5reatmentBddressingBtheBSpecificB"eedsBofB9omenRS '3B(()2
> http0RRstoreCsamhsaCgovRproductR ethadoneB5reatmentBforBPregnantB9omenRS *IB(')(
++
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+2 5reatment of Substance !se Disorders during Pregnancy
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Substance Treatment Approaches Comments
Tobacco
• Nicotine Replacement Therapy (NRT): nicotine gum, transdermal nicotinepatches, nicotine nasal spray, nicotine lozenge, and nicotine inhaler
• Bupropion• arenicline• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,
contingency management• $As (As%, Ad!ise, Assess, Assist, Arrange) as a Brie# &nter!ention
] ery limited data #or NRT and bupropion usein pregnancy, and no data a!ailable #or !arenicline,both o# "hich are ' A pregnancy category C
] oucher based rein#orcement has been pro!ene##icacious as a beha!ioral treatment
Alcohol
• *edication assisted "ithdra"al #rom alcohol use #or pregnant "omen#re+uently uses a benzodiazepine (e g , diazepam) as pharmacotherapy
• -sychosocial treatment should be considered as an integral component o# any "ithdra"al strategy
] -harmacotherapy (e g , acamprosate, naltre.one,disul#iram) should generally not be used inpregnancy due to ris% to the #etus
] Beha!ioral treatments ha!e been #ound to be in#erior topharmacotherapy in non pregnant "omen
Cannabis •
Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management ] No %no"n e##icacious pharmacotherapy
Cocaine • Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,
contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy
Amphetamines/*ethamphetamines
• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy
Benzodiazepines
• 0radual taper "ith a long acting benzodiazepine (e g , diazepam) "ith the goal
o# being benzodiazepine #ree at birth• -sychosocial treatment should be considered as an integral component o# anydose reduction strategy
] Beha!ioral treatments are thought to be in#erior topharmacotherapy
1pioids• 1pioid agonist pharmacotherapy: *ethadone, Buprenorphine• 1pioid antagonist pharmacotherapy: naltre.one• *edication assisted "ithdra"al (deto.i#ication)
] *edication assisted "ithdra"al has a %no"n high#ailure and may only be appropriate in certaincases
] Beha!ioral treatments ha!e been #ound to be in#erior topharmacotherapy
g g y