Effective Risk Management Strategies in Outpatient Methadone Treatment: Clinical Guidelines and Liability Prevention Curriculum Module 9 Special Populations and Risk

Pregnancy The Office of Applied Studies indicated that in 1999 of 400,000 women admitted to OTPs 4% were pregnant.

Methadone Maintenance as the Standard of Care Since 1970’s, methadone accepted to treat opioid addiction during pregnancy Only opioid medication approved by the FDA Same effective maintenance treatment benefits Methadone reduces fluctuation in maternal serum opioid levels protecting fetus from withdrawal Comprehensive MMT must include prenatal care ▫Reduce obstetrical and fetal complications, in utero growth retardation, and neonatal morbidity and mortality (Finnegan, 1991)

Diagnosing Opioid Addiction in Pregnant Patients Establish admission priority for pregnant women ▫Federal waiver -1 year history of opioid addiction Establish pregnancy through onsite testing ▫Screening– UDS at admission and monthly ▫Confirmation testing Establish protocols to educate patients about the pregnancy risks and neuroendrocrine process

Medical and Obstetrical Concerns and Complications Greater-than-normal risk of complication if: ▫Abuse substances ▫Are opioid addicted ▫Lack prenatal care Common complications include: ▫Spontaneous abortion ▫Premature labor ▫Low birth weight

Detoxification During Pregnancy Rarely appropriate during pregnancy (ASAM 1990) ▫Same recidivism as non-pregnant (Finnegan, 1990) Withdrawal during pregnancy (MSW) for patients: ▫Refusing to be placed on MMT. ▫Living where MMT is not available. ▫Stable during treatment and requests withdrawal. ▫So disruptive to the treatment setting that removal from the program is necessary.

Methadone Dosage & Management Dose of methadone should be individually determined and adequate to control craving and prevent withdrawal syndrome As pregnancy progresses, the same dosage produces lower blood methadone levels: ▫Increased fluid volume ▫Larger tissue reservoir for methadone ▫Altered opioid metabolism placenta and fetus (Weaver, 2003).

MMT patients who become pregnant should be continued at established dose and titrated as indicated. Altered pharmacokinetics during the third trimester often requires an increases and a split dose to “flatten the curve” and improve maternal and fetal stability. Methadone Dosage & Management

No consistent correlation between maternal methadone dose and severity of neonatal withdrawal syndrome (Stimmel et al., 1982) Protocols are available for scoring signs of opioid withdrawal to guide use of medications to facilitate withdrawal of the passively addicted neonate (NAS) (Finnegan, 1985).

Breastfeeding on Methadone Mothers can breastfeed APA approved breastfeeding at any dose in 2003 Patients should be monitored for the use of both licit and illicit drugs and alcohol (Kalrenback et al. 1998)

Buprenorphine may be used in pregnant patients under certain circumstances. Buprenorphine recommended only when the physician believes potential benefits justify risks. ▫May continue on buprenorphine with careful monitoring. Buprenorphine During Pregnancy

Potential candidates: ▫Opioid addicted but cannot tolerate methadone ▫Program compliance difficult ▫Adamant about avoiding methadone

Buprenorphine During Pregnancy Patient’s medical record should clearly document that patient: ▫Refused methadone maintenance treatment or such services are unavailable ▫Has been informed of the risks of using buprenorphine ▫Understands these risks

When treating pregnant patients, providers should use buprenorphine monotherapy tablets (Subutex ®). Patients already maintained on buprenorphine- naloxone combination tablets, who become pregnant, can be transferred directly to buprenorphine monotherapy tablets. Buprenorphine During Pregnancy

Integrated Comprehensive Services Establish a relationship between the methadone provider and the OB/GYN, PCP and/or specialist Clear communications and linkages among all providers is a must ▫Collaboration for medication management and prenatal evaluation follow up ▫Case management assistance

Recommendations Establish a policy to see pregnant patients more often (especially in the third trimester) Establish continuous patient education around pregnancy and contraception Informed consent procedures Adequate dose

Co-Occurring Disorders Co-occurring disorder (COD) refers to a mental disorder that co-exists with at least one substance use disorder Sometimes COD patients exhibit behaviors or feelings that may interfere with opioid treatment The COD should be distinguished by type/category and addressed appropriately

Co-Occurring Disorders Categorized according to Axis I and II disorders, as defined by the DSM-IV ▫Axis I-Clinical disorders (include major mental disorders, learning disorders, and substance use disorders) ▫Axis II- Personality disorders and intellectual disabilities

Screening for Co-Occurring Disorders Admission and ongoing assessment routinely screen for co-occurring disorders Establish specific screening procedures for COD and cognitive impairment

Making & Confirming a Psychiatric Diagnosis Assure and confirm an accurate psychiatric diagnosis Continuous patient education to enhance understanding of their co-occurring disorder is essential

Prognosis for Patients with COD Early identification and accurate diagnostic evaluation, combined with psychiatric and substance addiction therapies, improve outcomes. Unidentified and untreated COD often lead to poor MAT outcomes.

Treatment COD patients not excluded from OTP treatment TIP 43 lists principles of care for COD Establish a protocol for identifying suicide and homicide risk Pharmacological treatment for COD when indicated Use of psychosocial interventions Collaborating with prescribing psychiatric team Understanding drug-drug interactions

In Summary Consult the TIP 43 for more specific information Be proactive in policy and action in assessing clients for special circumstances such as pregnancy and/or COD Educate patients