1. Supported in part by Arkansas Blue Cross and Blue Shield
and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP)
Continuing Education Credit: TEXT:
Event ID:

2. Addiction During Pregnancy
Shona Ray-Griffith, MD
Assistant Professor
University of Arkansas for Medical Sciences

3. Disclosures I receive clinical trial support from Neuronetics.
I have received clinical trial support from Sage Therapeutics.
Neither will be discussed today.

4. Objectives Overview of substance use disorders during pregnancy
Prevalence
Obstetrical and Fetal Complications
Treatment Options
Information about ANGELS and Giving AR MORE
Present ‘real world’ case

5. 10 Drug Classes Alcohol Caffeine* Cannabis Tobacco Opioids Inhalants
Sedatives, hypnotics, and anxiolytics
Stimulants
Hallucinogens
Other

6. Substance Use Disorder Diagnosis
4 Major Areas
Impaired control
Social impairment
Risky Use
Pharmacological criteria
Severity
Mild = 2 or 3 symptoms
Moderate = 4 or 5 symptoms
Severe = More than 6 symptoms

7. Diagnosis Impaired control Social impairment
Use in larger amounts or over a longer period than originally intended
Persistent desire to cut down or regulate use or multiple unsuccessful efforts to decrease or discontinue use
Spending a great deal of time obtaining, using, or recovering from use
Intense desire or urge for the drug
Fail to fulfill major role obligations at work, school, or home
Continue use despite persistent or recurrent social or interpersonal problems
Important social, occupation, or recreational activities may be given up or reduced

8. Diagnosis Risky use Pharmacological criteria
Recurrent use in situations where it is physically hazardous
Continued use despite persistent or recurrent physical or psychological problem
Tolerance
Withdrawal
Neither are necessary for diagnosis
Symptoms of tolerance/withdrawal occurring during appropriate medical treatment with prescribed medications are specifically not counted when diagnosing a substance use disorder

9. Substance Use During Pregnancy
Up to 5% of pregnant women report illicit drug use within the past 30 days
High rate of substance abuse in teen pregnancy
Estimated annual pregnancy exposures in the U.S.
Illicit ~200,000 per year
Licit ~1.1 million per year

15. Screening and Assessment
Universal screening at the first prenatal visit, during each trimester, and first postpartum visit
Gate Questions:
In the last year, have you ever drunk alcohol or used drugs more than you meant to?
Have you felt you wanted to or needed to cut down on your drinking alcohol and/or drug use in the last year?

16. Legal Issues
Maternal substance use is addressed in the Child Maltreatment Act (Arkansas code Annotated et seq) (i.e. Garrett’s Law)
Mandatory reporting if identified in mother at labor & delivery or if in the neonate
Division of Child and Family Services opens investigation

17. Garrett’s Law in Arkansas
Number of reports has steadily increased from 2006 to present

19. Management of SUD during Pregnancy
Sobriety

20. Management of SUD during Pregnancy
Psychosocial interventions
Individual and/or group therapy
Inpatient rehabilitation
NA, AA, Celebrate Recovery
Opioid Use Disorder
MAT is gold standard (buprenorphine or methadone)
Tobacco Use Disorder
Nicotine replacement and/or bupropion
Alcohol and/or Benzodiazepine Use Disorder
Inpatient detoxification with lorazepam may be necessary
Identification and Treatment of Co-Occurring Psychiatric Illness

21. Management of SUD in Pregnancy
Referral to local Area Service Provider
Specialized Women’s Services
Referral to Women’s Mental Health Program at UAMS
provides medication assisted treatment for opioid use disorder during pregnancy and postpartum
AR Cares Program through Methodist Family Health
residential program for mom and her children

22. Women’s Mental Health Program
Psychiatrists
Shona Ray-Griffith, MD
Jessica L. Coker, MD
Program Manager
Bettina Knight, RN
Research Assistants
Amber Thomas
Rebecca Stallmann
Contact Us/Referrals:
(501) OR

23. Giving AR MORE (Maternal Opioid Rural Expansion)
Initiative to expand access to MAT for OUD in rural AR for pregnancy and postpartum adolescent and adult women
Collaborate with local substance use treatment providers to provide MAT and treatment of mental illness via telemedicine

24. Antenatal and Neonatal Guidelines, Education and Learning Systems (ANGELS)
angels.uams.edu or
24/7 consultation service with WMHP
Updated evidence-based guidelines annually

25. Questions about the Topic
Continuing Education Credit: TEXT:
Event ID:

26. Case Conference and Feedback
Continuing Education Credit: TEXT:
Event ID:

27. Real Case Presentation Name and Details have been altered

28. Case Presentation – Ms. Piper
HPI: 29 y.o. G3P2 at 25 weeks gestation who presents with history of drug use since age 16. Parents gave her opiates. Court ordered for treatment as a teenager due to truancy. She wouldn't go to school as she didn't feel well without opiates.
Most recently, she was treated at another MAT program X 2-3 months - stopped going due to financial problems. Relapsed a month later. Husband filed Act 10 2 months later. Completed 21 days at QuaPaw and then 2 weeks at Carlie's House. 1 week later, she relapsed at Carlie's House. KOC in May 2017 during time at Carlie's House.
Motivation: She does not want to use and wants to get clean, but is having trouble staying clean. Goal: to be able to take care of her children and family. Husband is unaware that she is currently using again.

29. Ms. Piper
ETOH: Last used a year ago. Use is rarely at once a year. Use 5 shots/day.
Marijuana: Last smoked 2 days ago. She uses marijuana rarely - once every 3-4 mos.
Tobacco: 1/2 ppd
Methamphetamines: 1-3 times a year. Last used March Has used IV.
Cocaine: denies
Benzodiazepines: Reports being prescribed benzodiazepines for sleep until 3 months ago due to losing insurance. She would run out of prescription early and then would take off the street. Routinely, she would take clonazepam 2mg 5 X day. Currently, using once a week when she cannot find opiates. She took alprazolam (3 tablets) last night.
Opiates: Took suboxone yesterday morning at 9AM. She typically uses hydrocodone ER 160mg/daily. She prefers buprenorphine. +IV drug use, including heroin. Last used heroin in March Current withdrawal symptoms - nausea, vomiting, diarrhea, sweaty palms, feeling aching.

30. Ms. Piper
SH: Lives in Hot Springs with husband and 2 daughters (8 and 9 y/o). Unemployed. Grew up in Ohio and raised by mom and stepdad after age 9. Child was 'okay.' She reports multiple step parents. She has a history of childhood sexual abuse by stepfather.
PMH: Surprise but wanted. BB. Decent PNC with 3 visits and referred to UAMS - first appointment tomorrow. Newly diagnosed Hep C. Negative for HIV. Previously pregnancies - took methadone throughout first pregnancy off the streets. DHS was involved but she has current custody after completing rehab. Second pregnancy - she was clean. Both vaginal deliveries at full term. No surgeries.
FH: Parents with substance abuse disorder – primarily opiates
PPH: No formal outpatient care. PCP prescribed benzodiazepines previously. She has been in and out of psychiatric hospitals due to suicidal ideation

33. Ms. Piper PMP: Reviewed and consistent.
UDS: Positive for buprenorphine, benzodiazepines, THC, and morphine
Plan:
Admit to PRI
Initiate PNV daily
Initiate subutex 4mg po daily
Monitor for opioid withdrawal using COWS and adjust subutex accordingly
Monitor for benzodiazepine withdrawal using vitals and CIWA.

34. Ms. Piper
First outpatient appointment:  She was stabilized on subutex 4mg po TID. Today, she reports feeling mildly achy and having some rhinorrhea. She also reports anxious and restless. The above happen about an hour between doses. Cravings are gone - no thoughts of using.
SCID: Bipolar disorder - MRE depression as well as alcohol, stimulant, and sedative dependence. She denies feeling depressed or sad today. Denies anhedonia.
Denies alcohol or drug use. Nicotine patch as well as 1 cigarette use.

35. Case Presentation – Ms. Piper
1 months 30w6d weeks gestation  
Pt took xanax bar after last appointment. She does not recall events and woke up in the hospital. Family called 911 as she could not get out of bed. In hospital overnight, she got 2 pints of blood. Concern for baby - low fetal heart rate. Ob appointment tomorrow. She is embarrassed and shamed. 
ETOH denies
Marijuana denies
Tobacco 1/2 pack in 2 days + nicotine patch

36. Ms. Piper She did well and advance to phase 3 (monthly appointments).
@ 3 weeks postpartum returns. Delivered via vaginal delivery Baby had 2 week stay in NICU for NAS and treated with morphine. DHS was called by NICU staff due to concerns of intoxication. DHS has done an investigation - UDS and home visit. Case to be closed.
Since delivery, she reports being depressed and not doing well. Other symptoms include feeling guilty. She discussed the above, in length, in group.

37. Ms. Piper
Patient is still in treatment. During pp period, she continued to use drugs – most often methamphetamines. A drug she had previously not used frequently. Fob/husband was also using meth.
Ultimately, we tapered to prepare for inpatient rehab. She ended up hospitalized in PRI and placed back on BUP.
Recently, she is doing well. Sober and advanced in the program. She is attending AA/NA/Celebrate Recovery meetings weekly outside of program.