Moms on Meds Substance Abuse During Pregnancy: Jennifer Anderson Maddron, M.D.

Prescription Painkiller Overdoses. July 2013 Approximately 18 women die every day of a prescription painkiller overdose in the US. More than 6,600 deaths in 2010 Deaths from prescription painkiller overdoses among women have increased more than 400% since 1999, compared to 265% increase among men Prescription painkillers are involved in 1 in 10 suicides among women. For every woman who dies of a prescription painkiller overdose, 30 go to the ER for painkiller misuse or abuse “Prescription Painkiller Overdoses”. (2013). Retrieved on August 4, 2013, from

Prescription painkiller overdose deaths are a growing problem among women

2010 National Survey on Drug Use and Health 4.4% of pregnant women reported use of an illicit substance within the past 30 days Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: summary of national findings. NSDUH Series H-41. HHS Publication No. (SMA) Rockville (MD) SAHMSA: 2011

Deliveries at LeConte Medical Center

NICU Transfers To East Tennessee Children’s Hospital

Maternal Complications of Substance Abuse Many barriers exist for pregnant substance abusers Lifestyle issues may result in pregnant women engaging in high risk behavior –Prostitution –Sharing of IV needles –Intimate Partner Violence –Theft and other criminal activities

Maternal Complications of Substance Abuse Confounding variables of substance abuse Socioeconomic status Ethnicity Access to prenatal care Poly-substance abuse

Substances Most Commonly Abused During Pregnancy Tobacco Alcohol Marijuana Opiates Cocaine Benzodiazepines Amphetamines Hallucinogens

Opioid Addiction Oxycodone Hydrocodone Methadone Roxicodone Heroin Fentanyl Meperidine Hydromorphone Propoxyphene

Opioid use in Pregnancy: Maternal Complications Altered Mental Status Somnolence Respiratory Depression Death IV Use may result in –Hepatitis B & C –HIV –Skin infections –Endocarditis –Sepsis

Opioid Effects on Pregnancy Antenatal Complications Preterm Delivery Growth Restriction Low Birth Weight Placental Abruption Fetal Death Neonatal Effects Neonatal Abstinence Syndrome (NAS)

 Constellation of withdrawal symptoms  Central Nervous System Inconsolability, high-pitched crying, skin excoriation, hyperactive reflexes, tremors, seizures  Gastrointestinal System Poor feeding, excessive sucking, feeding intolerance, loose or watery stools  Autonomic/metabolic Sweating, nasal stuffiness, sneezing, fever, tachypnea, mottling

Treatment options Holistic Multidisciplinary Approach to treatment of Neonatal Abstinence Syndrome –Non-pharmacological Cuddler Environmental Diet –Pharmacological Narcotics Non-narcotics

Pharmacological Treatment Approximately 67% of babies –Are weaned from opioid in about 20 days –Do not require adjuvant treatment –Stay in the NICU approximately 24 days Approximately 33% of babies –Require weaning time of 60 days (range up to 155 days) –Require adjuvant treatment with up to two additional medications –Stay in the NICU for about 68 days (some up to 155 days)

Mother’s TennCare status at time of delivery for NAS children

TennCare cost associated with treatment of NAS infants

Treatment of Substance Abuse During Pregnancy

Screening Universal Screening of all women before and during pregnancy Identify women currently using illicit substances & women at risk Toxicology testing: Urine Drug Screens

Intervention Multidisciplinary approach needed to address Physical, Psychological and social issues –Obstetrical and Neonatal Care –Addiction Medicine Specialist –Mental Health Services –Social Services

Treatment of Opioid Addiction in Pregnancy For Opioid addicted Pregnant patients: –Detoxification Relapse rates are high and dangerous –Opioid Replacement Therapy Methadone versus Buprenorphine –Alcohol and Drug Counseling –Treatment of Co-existing Mental Health Disorders

Treatment of Opioid Addiction in Pregnancy “Comprehensive care provided at one location is cost effective and produces better outcomes for both mother and child.” Early Start Program at Kaiser Permanente, California Patients who were screened, assessed and treated had lower rates of preterm delivery, low birth weight, and neonatal-assisted ventilation Wong, S. (2011, April). Substance Use in Pregnancy. Journal of Obstetrics and Gynaecology Canada. 33(4):

American College of Obstetrics & Gynecology Committee Opinion in 2004 wrote that “using a protocol for universal screening, brief intervention, and referral to treatment…results in a mean net savings of $4644 in medical expenses per mother/ infant pair.”

Treatment Cost Considerations One year in prison$51-$73/day$25,900 Outpatient$15/day x 120 days$1,800 Intensive Outpatient9 hrs/week x 6 months maintenance $2,500 Methadone Maintenance $13/day x 300 days$3,900 Short term residential treatment $130/day x 30 days + $400 x 25 weeks $4,400 Long term residential treatment $49/day x 140 days$6,800 Reference: Position Paper on Drug Policy published by the Physician Leadership on National Drug Policy January, Data source: Center for Substance Abuse Treatment, Federal Bureau of Prisons National Treatment Improvement Evaluation Study Annual treatment cost for a person with drug addiction

Pregnancy is an ideal time to provide intervention to women with substance abuse problems, as motivation to modify harmful behavior is increased.