Anne Merewood PhD MPH IBCLC Associate Professor of Pediatrics, Boston University School of Medicine Consultant to the Rocky Mountain Tribal Leaders Council

A growing problem across the US; health care workers struggling to meet the challenges On some reservations, the problem is overwhelming in both hospital and community No easy answers but raising awareness is critical Illicit drug use in adolescents and pregnant women

Illicit substance use around the time of birth: Broader implications Not just a “maternal” problem Domestic violence Suicide

Illicit substance use around the time of birth: Broader implications Child neglect/abuse Multiple drug use; alcohol use Law enforcement and custody issues Financial issues; poverty; hunger Medical issues – Hepatitis C; HIV; mental health, etc

Illicit substance use around the time of birth Ongoing ‘tension’ of personal ‘stance’… A moral issue? A medical issue? Emotional and complex when infants/young children are involved Even more complex among health care professionals who may have been exposed to the same issues

Illicit substance use around the time of birth Beliefs of health care workers may impact how they react; lead to conflict Policies are critical to ensure consistent treatment Health care workers often from the same community – pressures, confidentiality? Burnout/compassion fatigue among health care professionals

Illicit substance use around the time of birth Small communities with complex relationships Some clinicians experience pressure from patients (“we need opiates”) which conflicts with current work to reduce iatrogenic- induced opiate dependency

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) Rockville, MD

SAHMSA report (2013) 9.4% of the US population over 12 had used illicit drugs in the month prior to the survey Marijuana was the most commonly used illicit drug (7% of population, or 80% of users used marijuana) 2 million Americans addicted to prescription opioids

Drug use by race/ethnicity Asians – 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%

Trauma increases chance of use Among women in treatment, 84% reported history of childhood sexual abuse or neglect Adolescents 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 2003

SAHMSA data: 2013

Drug Availability: Prescription Opioid Statistics in US

Drug use in pregnancy 5% illicit drug use overall 11% rate in same group, not pregnant 15% among pregnant year olds 9% among pregnant year olds 3% among pregnant year olds

 5.6 infants/1,000 births, nationally  9/1000 in Montana  30%+ on some MT reservations Opioid use in pregnancy

Treatment for pregnant women who use opioids Maintenance therapy: ACOG’s standard of care Methadone 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 withdrawal

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)

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 patients

Increase in NAS 2000 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 statistics/infographics/dramatic-increases-in-maternal-opioid-use-neonatal- abstinence-syndrome

Typically hours after birth but can surface as late as 7 days after birth 60-70% require medication treatment – standard of care is morphine Inability to predict/not dose related Inpatient monitoring period of at least 5 days NAS

SystemSymptoms 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 Center

SystemSymptoms Gastrointestinal System Poor feeding Vomiting Diarrhea Excessive sucking Respiratory System Tachypnea Apnea Respiratory distress Slide credit: Elisha Wachman, MD, Boston Medical Center

System Symptoms Autonomic Nervous System Sneezing Nasal stuffiness Yawning Mottling Fever Sweating Slide credit: Elisha Wachman, MD, Boston Medical Center

Central Nervous System Disturbances Metabolic, Vasomotor, and Respiratory Disturbance Gastrointestinal Disturbance Excessive High Pitched Crying – 2 Continuous High Pitched Crying - 3 Sweating – 1Excessive 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) – 1Regurgitation – 2 Projective Vomiting – 3 Mild Tremors Disturbed – 1 Mod – Severe Tremors Disturbed – 2 Mottling – 1Loose Stools – 2 Watery Stools – 3 Mild Tremors Undisturbed – 3 Mod – Severe Tremors Undisturbed - 4 Nasal Stuffiness – 1 Increased Muscle Tone - 2Sneezing (>3) – 1 Excoriation – 1Nasal Flaring – 2 Myoclonic Jerk – 3Respiratory Rate (>60) – 1 Respiratory Rate (>60 with Retractions) – 2 Seizures – 5 Finnegan’s scoring tool

Protective/ameliorating factors Breastfeeding Skin to skin care Maternal stability and presence at the bedside Low light/stimulation Prematurity

Breastfeeding and illicit substance use Breastfeeding and illicit substance use All 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 use

A complex context Many AI/AN women live in settings where breastfeeding is the norm and rates are high ‘Policing’ breastfeeding is unrealistic Not breastfeeding adds to health risks Stories emerge about women breastfeeding on drugs and infants dying So what do we advise?

“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 2015

Where can I get a “definitive” answer? There are no definitive answers, but LactMed is an excellent source of information htm LactMed is a service of the NIH and it updates with new evidence as it comes in

In conclusion…. Illicit drug use/opioid use in the perinatal period is a complex and growing problem There are effective treatments but these are not always made available in Indian Country Education is key to assessing options This webinar skimmed the surface – questions and suggestions for additional information?