Lack of screening, access and coordinated care hinder the implementation of effective treatment

The Beauty of Pregnancy, by Jelle Druyts

The Beauty of Pregnancy, by Jelle Druyts

The National Survey on Drug Use and Health reports that in 2011-2012, approximately 5.9% of pregnant women reported using an illicit drug in the past 30 days, up from 3.7% in 2001.  While marijuana use accounts for a large proportion of those women, opioid use claims its share as well, both heroin and opioid pain medication used recreationally.

Many indicators show that drug use during pregnancy is trending upward.  According to the most recent Treatment Episode Data Set (TEDS), the percentage of pregnant treatment admissions reporting drug abuse but not alcohol abuse increased from 51.1% in 2000 to 63.8% in 2010.

Last year, the Journal of the American Medical Association reported that every hour an infant is born with symptoms of opioid withdrawal.  This is more than triple the rate reported in 2001.

Using opioids in an uncontrolled way during pregnancy can cause serious problems, including the death of the unborn baby and/or mother.  Even taking medication with codeine, which commonly lines bathroom cabinets of many a family, is contraindicated and has been associated with congenital heart problems in newborns.

As I’m expecting a baby any day now, these issues resonate with me strongly.  We have effective treatments for opioid use during pregnancy and ongoing research is expanding our menu of options.  Screening, access to treatment, and coordination of care are essential elements to preventing and curbing the impacts of opioid use during pregnancy.

What do we know?  Research and treatment guidelines

In June 2013, SAMHSA released the draft update to the Federal Guidelines for Opioid Treatment (henceforth know as “draft Guidelines”), which was last published in 2007, and opened it for public comment. Since the 2007 Guidelines, we’ve learned more about opioid use during pregnancy.

One of the most important documents to emerge since the 2007 Federal Guidelines were published is the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion for treating pregnant women using opioids in a hazardous or risky way.

I should mention that the intended audience and purpose of the ACOG position and the draft Guidelines are different. First and most obviously, the ACOG document comprises a set of clinical recommendations and is targeted to a much wider audience, including not only opioid treatment programs but also primary care providers, obstetricians, and pediatricians. The draft Guidelines have a much narrower scope and a much more specific purpose: to provide standards for accreditation of opioid treatment programs.

Maintenance preferred over detox

That being said, there are many important ways in which the two documents agree. Both recommend that patients who are pregnant and are diagnosed with opioid addiction be offered medication-assisted treatment (MAT) rather than detox services. In fact, it occurs to me that opioids are really the only substance where abstinence during pregnancy is not the recommended clinical practice.

As I’m expecting a baby any day now, these issues resonate with me strongly. We have effective treatments for opioids use during pregnancy…

Consider the woman who has recently discovered she is pregnant and consumes alcohol, or marijuana, or nicotine in a harmful or risky manner. Best medical practice is to help that woman stop consumption of any and all of these substances, as safely and as soon as possible.

But with regard to opioids, the Guidelines clearly state “detoxification during pregnancy is not recommended or considered the best practice.”

At first this might seem counterintuitive; how could continuing to consume opioids (albeit methadone or buprenorphine rather than than illicit ones) be better than stopping altogether?

First, it can be extremely difficult to abstain from opioids. Relapse during the pregnancy would be a constant concern. Second, withdrawal from opioids, especially during certain periods of pregnancy, is associated with serious problems for the fetus. Without structured MAT maintenance, it’s possible for a fetus to undergo withdrawal multiple times during gestation, a very dangerous situation. (If withdrawal is indicated, the draft Guidelines advise to attempt this only during the second trimester of pregnancy.)

Research on methadone v. buprenorphine still inconclusive

While the two documents are in agreement on MAT maintenance, they diverge on the issue of which MAT medications are suitable. Consistent with their 2007 position, the draft Guidelines recommend methadone alone as the treatment of choice for pregnant women who have opioid addiction.

In contrast, the ACOG states in its Committee Opinion that there are advantages to treatment with buprenorphine, including “ lower risk of overdose, fewer drug interactions, the ability to be treated on an outpatient basis without the need for daily visits to a licensed treatment program.” Disadvantages as compared to treatment with methadone include “reports of hepatic dysfunction, the lack of long-term data on infant and child effects, a clinically important patient dropout rate due to dissatisfaction with the drug, a more difficult induction with the potential risk of precipitated withdrawal, and an increased risk of diversion (ie, sharing or sale) of prescribed buprenorphine.”

Like so many other treatment decisions, it really comes down to considering the individual circumstances of the patient, as Karol Kaltenbach, co-author of the 2010 study in the New England Journal of Medicine, said in an interview with Join Together. While hers and other studies have suggested that buprenorphine might actually be as good or better a treatment for some pregnant women, the recent draft Guidelines state that “the level of evidence supporting buprenorphine maintenance during pregnancy is not as compelling as the evidence supporting methadone maintenance for pregnant women.”

Still, Dr. Kaltenbach notes that if a woman has been maintained on buprenorphine and then becomes pregnant, it would be clinically reasonable to continue to provide buprenorphine to her.

Just last month, a Cochrane review found that methadone seems superior in retaining pregnant patients in treatment whereas buprenorphine seems to produce fewer neonatal abstinence symptoms.  However, the authors concluded that the body of research is too small to draw firm conclusions about which medication works better for pregnant opioid users.

Neonatal abstinence syndrome is an expected and treatable condition that occurs in babies born to many women who are addicted to illegal or prescription drugs or who have been treated with methadone during their pregnancy.  It is characterized by a hyperactive autonomic and central nervous system in the newborn: high pitched crying, tremors, fever, poor feeding, seizures, and slow weight gain, among other symptoms.

The infant is undergoing opioid withdrawal a few days after birth:

With immediate detection and treatment, this condition amazingly resolves within several weeks.  These babies’ ability to survive and continue developing along a normal path is a testimony to the power of recovery.

Although there is some evidence to suggest that using buprenorphine rather than methadone to treat opioid addiction during pregnancy is associated with less severe and lengthy presentation of neonatal abstinence syndrome, the long-term effects of buprenorphine during pregnancy upon infant development and beyond are largely unknown—again, a reason for further research.

Clearer treatment protocols for opioid use than for other substances

It’s striking that treatment protocols for women who use alcohol, cocaine, nicotine, or any other drug are not nearly so well developed as those for women who use opioids.  Smoking cessation is the first-line intervention for pregnant smokers.  Detoxification and treatment services, including evidence-based psychosocial treatment, are recommended for maternal alcohol use disorders.

And treatment protocols for neonatal abstinence are also well-established.  Treatment for babies born with fetal alcohol spectrum disorder or low birth weight as a result of maternal nicotine use has not been mapped out nearly so thoroughly in the research literature.   We simply know a lot more about how to effectively address maternal opioid use.

As is often the case, the issue is not a shortage of research; it is the process of implementing our research findings in practice.  In this case, utilizing effective, research-based treatment modalities for a pregnant woman who use opioids and her developing fetus requires the removal of barriers to treatment, implementation of screening protocols, and a more comprehensive coordination of care.

Treatment access and coordination of care

It can be difficult for pregnant women to gain access to medication-assisted treatment.  The prejudices regarding substance use during pregnancy can be so discouraging as to snuff out the higher levels of motivation for treatment that we tend to see in pregnant women.

And barriers to treatment-seeking can certainly exceed  fear of condemnation: they can include realistic concerns about criminal prosecution and removal of children by legal system or regulatory agencies, an absence of adequate child care resources for existing children, a lack of transportation services, poor access to obstetrical care, and a lack of treatment services addressing women’s issues.

Here, a speaker at ASAM’s 2013 conference describes her difficulty getting approval from her insurance company to continue buprenorphine treatment while pregnant. It’s a pretty shocking story:

Here in Pittsburgh, Gateway Health Plan has been pushing to improve treatment for pregnant women addicted to opiates.  Not only is access an issue for these women, but integrated care is also virtually nonexistent.

Why coordinate care?

According to Dr. Michael Madden, Medical Director at Gateway, pregnant women with substance use disorders are often treated as two separate patients: the addict and the pregnant woman.  Coordination between the two seldom occurs, even though it is considered a best practice by the ACOG.

Why is this necessary?

Consider this: if the obstetrician has no communication with the doctor or facility treating the addiction, then she may not know the methadone dosage that the patient is receiving—or even that the patient is being treated for addiction with methadone at all. No plans will be made for the impending neonatal abstinence syndrome. Likewise, with no communication from the obstetrician, the medical professional in charge of treating the addiction may have no knowledge of any complications to the mother or the child in the pregnancy, and no guidance whether adjustment to dosage might be necessary.

With the immediate detection and treatment, [neonatal abstinence syndrome] amazingly resolves within several weeks. These babies’ ability to survive and continue developing along a normal path is a testimony to the power of recovery.

Add to the mix the fact that many pregnant women with substance use disorders also have mental health disorders, and the communication breakdown between healthcare providers potentially creates more serious consequences. It’s not unusual for a pregnant woman with a co-occurring disorder to distrustfully avoid prenatal care or have difficulty planning and caring for their infants. Co-occurring disorders in pregnant women require coordinated efforts from multiple services: OB-GYNs, mental health professionals, social workers, addiction treatment professionals, and pediatricians.

In response, Gateway is working with local hospitals to integrate both medical and behavioral treatment.  And Gateway is not alone: a growing number of clinics have evolved to treat addiction and provide obstetric care and counseling for pregnant women addicted to opioids.

The Dartmouth Hitchcock Medical Center Addiction Treatment Program is another example of coordinated care to address maternal substance use and addiction, including the use of Screening, Brief Interventions and Referral to Treatment (SBIRT).

Screening

The fact is that pregnant women are using these substances often without realizing they are pregnant.

This is one of the many ironies I have noticed about pregnancy: that some of the most critical and vulnerable periods of fetal development occur before a woman knows she is pregnant.

The earlier problems can be identified the better.  This is where screening comes in.

The draft Guidelines and the ACOG opinion support screening for pregnancy in potential MAT patients, and screening for substance use in pregnant patients, respectively. Several validated screening tools exist, including the 5Ps for substance use as well as the TWEAK questionnaire on alcohol use, which are targeted specifically to pregnant women.

While organizations like the West Virginia Perinatal Partnership have put forth policies recommending screening for all pregnant women during each trimester, those policies don’t exist everywhere nor are they always implemented in practice.

And there have been recent outcries about supposed calls for mandatory drug-testing for all pregnant women that have confused the issue, and prompted push-back that precludes the questionnaire screens that can help with early detection and treatment.

I think it’s fair to say that we could do a better job of screening pregnant women for opioid use. In my admittedly limited personal experience, I do not recall ever being directly asked whether I was using any opioid medication at any of my prenatal appointments and I’ve certainly never been administered a validated screening tool.  Additionally, a number of years ago after a minor surgery I was offered an opioid pain medication without being asked whether I might be pregnant.

Granted, these may be just two unrelated and random experiences of one person, but they may also be an indication of a system that could do better.

Resources

The Addiction Treatment Forum FAQ section Health and Nutrition During Medication-Assisted Treatment addresses pregnancy

Screening instruments for pregnant women and women of childbearing age, a list created by the Virginia Dept. of Behavioral Health and Developmental Services

The TEDS Report: Trends in Substances of Abuse among Pregnant Women and Women of Childbearing Age in Treatment (2013) is a nice one-pager

WHO will reportedly release guidelines on the management of substance use disorders among pregnant women in 2014

 

dawnDawn Lindsay, PhD, is IRETA’s Director of Evaluation Services. She completed her graduate work in clinical psychology at the University of Cincinnati in 2002 and was on the faculty in the Department of Psychiatry at the University of Pittsburgh before coming to IRETA. She has eight years of experience conducting NIDA- and NIAAA-funded research in the area of adolescent substance use disorders. She is a member of the American Psychological Association and the American Evaluation Association.  Click here for a list of her publications