Tobacco Cessation and Substance Abuse Treatment in Women’s Healthcare

8. Therapeutic Substitution: The West Virginia Success Story

Byron C. Calhoun 

(1)

Department of Obstetrics and Gynecology, West Virginia University-Charleston, Charleston, WV, USA

Byron C. Calhoun

Email: Byron.calhoun@camc.org

Keywords

Neonatal abstinence syndromeTherapeutic substitutionOpioids

Introduction

Substance abuse in pregnancy has well-known deleterious effects on neonates. These effects differ with respect to the substance ingested and can include neonatal abstinence syndrome (NAS), low birth weight, intrauterine fetal demise, and structural abnormalities such as gastroschisis.

The national substance abuse rates have been estimated to be between 2.8 and 19 % [13].These reported rates vary based upon the population screened and the method of screening used. The lowest number reported in the study by Ebrahim and Gfroerer utilized a population survey of the entire United States [1] while the highest rates reported (19 %) by Azadi and Dildy utilized urine toxicology testing [3]. Chasnoff et al. developed a self-reporting screening tool that estimated that 15 % of the population studied continued to use substances of abuse after becoming aware of the pregnancy [2].

Opioid dependence, including methadone maintenance, has been linked to fetal death, growth restriction, preterm birth, meconium aspiration, and NAS [45]. NAS may be present in 60–90 % of neonates exposed in utero with up to 70 % of affected neonates with central nervous system irritability that may progress to seizures [5]. Up to 50 % of neonates may experience respiratory issues, feeding problems, and failure to thrive [6]. These issues are present as well in those infants whose mothers’ are on methadone maintenance [7]. However, with methadone the onset of NAS may be delayed for several weeks [7]. Some authors recommend 5–8 days of maternal hospitalization while their neonates’ undergo observation for NAS [8]. However, most insurance plans will not reimburse for the prolonged uncomplicated maternal stay while awaiting neonatal detoxification.

The incidence of opioid relapse in pregnant opioid abusing women is very high with 41–96 % relapsing. This mirrors the relapse rate of the general population at 1 month of 65–80 % [910]. Over 90 % of patients will relapse at 6 months after medication-assisted withdrawal [11]. Buprenorphine (Subutex™) appears to have no difference in outcomes with regard to treatment of opiate addicted women. The same NAS and neonatal affects are present [12].

Recent work published by Montgomery et al. 2006 compared the performance of meconium samples versus the testing of umbilical cord tissue [13]. This study showed concordance of the testing methods that correlated at or above 90 % for all substances analyzed. Follow-up work included a study in which umbilical cord samples were collected and tested if high-risk criteria for substance abuse were identified. Out of this cohort, 157 of 498 (32 %) cords tested positive for substances of abuse [14]. Stitely et al. 2010 found similar results in their study of cord samples in eight regional hospitals in West Virginia with 146/759 (19.2 %) of umbilical cord samples collected at delivery that were positive for either illicit substances or alcohol [15].

Assessment and Diagnosis of Opioid Dependence

The diagnosis of opioid use disorder is based on criteria outlined in the DSM-5. The criteria describe a problematic pattern of opioid use leading to clinically significant impairment or distress. There are a total of 11 symptoms and severity is specified as either mild (presence of 2–3 symptoms), moderate (presence of 4–5 symptoms), or severe (presence of 6 or more symptoms) within a 12-month period. Opioid use disorder requires that at least two of the 11 criteria be met within a 12-month period: (1) taking opioids in larger amounts or over a longer period of time than intended; (2) having a persistent desire or unsuccessful attempts to reduce or control opioid use; (3) spending excess time obtaining, using, or recovering from opioids; (4) craving for opioids; (5) continuing opioid use causing inability to fulfill work, home, or school responsibilities; (6) continuing opioid use despite having persistent social or interpersonal problems; (7) lack of involvement in social, occupational, or recreational activities; (8) using opioids in physically hazardous situations; (9) continuing opioid use in spite of awareness of persistent physical or psychological problems; (10) tolerance, including need for increased amounts of opioids or diminished effect with continued use at the same amount—as long as the patient is not taking opioids under medical supervision; and (11) withdrawal manifested by characteristic opioid withdrawal syndrome or taking opioids to relieve or avoid withdrawal symptoms—while not taking opioids under medical supervision [16].

Immediate clinical priority ought to include identifying and making appropriate referral for any urgent or emergent medical or psychiatric problem(s), including drug related impairment or overdose. The medical history should include screening for concomitant medical conditions, infectious diseases (hepatitis, HIV, and tuberculosis [TB]), acute trauma, and pregnancy. Physical examination should be completed as a comprehensive portion of the thorough assessment process. The prescriber (the clinician authorizing the use of a medication for the treatment of opioid use disorder) ought to conduct this physical examination him/herself, or, in accordance with the ASAM Standards, ensure that a recent and accurate physical examination is found within the patient medical record prior to the initiation of a new medication for the treatment of his/her addiction.

Initial laboratory testing consists of a complete blood count, liver function tests, hepatitis C and HIV. Expanded panels of testing for TB and sexually transmitted infections should also be considered. Hepatitis A & B vaccination should be offered, if appropriate.

The assessment of women presents special considerations regarding their reproductive health. All women of reproductive age should be tested for pregnancy, and all women of childbearing potential and age should be counseled regarding methods of contraception, since increase in fertility may result from effective opioid use disorder treatment.

Patients being evaluated for addiction involving opioid use, and/or for possible medication use in the treatment of opioid use disorder, should undergo (or have completed) an assessment of mental health status and possible psychiatric disorders (as outlined in the ASAM Standards).

Opioid use often co-exists with other substance related disorders. An inquiry into past and current substance use and an evaluation of all of the substances involved in the addiction should be conducted.

The use of marijuana, stimulants, or other addictive substances should deter opioid use disorder treatment. However, evidence demonstrates patients who actively abuse other non-prescribed substances during opioid use disorder treatment have a poorer prognosis. The co-abuse of benzodiazepines and other sedative hypnotics may be a reason to suspend agonist treatment due to safety concerns related to respiratory depression and death.

A tobacco questionnaire and counseling on tobacco cessation ought to be completed routinely for all patients, including those who present for evaluation and treatment of opioid use disorder.

ASAM Standards also suggest an assessment of social and environmental factors be conducted to identify facilitators and barriers to addiction treatment, and especially for pharmacotherapy. Prior to a decision to initiate a course of pharmacotherapy for the patient with opioid use disorder, the patient should receive a multidimensional assessment in fidelity with The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-occurring Conditions (the “ASAM Criteria”). Addiction may be considered a bio-psycho-social-spiritual illness, for which the use of medication(s) is but only one component of overall treatment.

Diagnosis of opioid use disorder is confirmed by the provider prescribing medications, and who recommends medication use. Diagnosis must be obtained before pharmacotherapy for opioid use disorder commences. Opioid use disorder is primarily diagnosed on the history given by the patient and a thorough assessment including a physical examination. Validated clinical scales that measure withdrawal symptoms, for example, the Objective Opioid Withdrawal Scale (OOWS), the Subjective Opioid Withdrawal Scale (SOWS), and the Clinical Opioid Withdrawal Scale (COWS), may be used to assist in the evaluation of patients with opioid use disorder. Urine drug testing during assessment process, and frequently during treatment, is recommended. The frequency of drug testing is determined by multiple factors: patient compliance, the type of treatment including medications, and the treatment setting: inpatient or outpatient.

Pregnant women constitute a special population in opioid use disorders. In the evaluation of pregnant women for opioid use disorder, obstetrical conditions that require immediate referral for clinical evaluation should be determined. This may include referral to a maternal–fetal medicine specialist. Complete medical examination and psychosocial assessment is paramount when evaluating pregnant women for opioid use disorder. Obstetricians and gynecologists should be alert to signs and symptoms of opioid use disorder [17]. Pregnant women with opioid use disorder often seek prenatal care late in pregnancy, miss appointments, experience poor weight gain, may have small for gestational age fetuses, undergo preterm labor/delivery, have placental abruption, or exhibit signs of withdrawal or intoxication.

Psychosocial treatment should be offered in the treatment of pregnant women with opioid use disorder. Counseling and testing for HIV should be a routine part of care. Testing for hepatitis B and C along with liver function is highly encouraged. Hepatitis A and B vaccination should be considered for those whose hepatitis serology is negative. Urine drug testing may be utilized to detect or confirm suspected opioid and other drug use with informed consent from the mother, realizing that there may be adverse legal and social consequences of her use. State laws differ on reporting substance use during pregnancy. Laws that penalize women for use and for obtaining treatment may prevent women from obtaining prenatal care and worsen outcomes. A comprehensive assessment of mental health, including determination of the patient’s present mental health status, should evaluate whether the patient is emotionally and psychologically stable enough for opioid therapy. Patients with suicidal or homicidal ideation ought to be referred immediately for treatment and hospitalization. Management of patients at risk for suicide should include: decreasing imminent risks; modulating underlying factors associated with suicidal ideation; ongoing monitoring of psychological status, and follow-up by mental health professionals. As in a non-addicted population, patients with psychiatric disorders should be asked about suicidal ideation, suicidal plans/intent, and behavior. Patients with a history of suicidal ideation or suicide attempts should have opioid use disorder, and psychiatric medication use, monitored closely by the healthcare team. Frequent visits may be necessary to insure compliance and good clinical outcomes. Evaluation for psychiatric disorder should occur at the very beginning of agonist or antagonist treatment prior to initiating drug therapy. Reassessment using a detailed mental status examination should occur after stabilization with methadone, buprenorphine, or naltrexone. Pharmacotherapy in conjunction with psychosocial treatment should be considered for patients with opioid use disorder and a co-existing psychiatric disorder. Providers caring for women should be acutely aware of potential interaction between medications used to treat co-occurring psychiatric conditions and opioid use disorder. Possible community treatment should be considered for patients with co-occurring schizophrenia and opioid use disorder who have a recent history of, or are at risk of, repeated hospitalization or homelessness.

Adolescents and Opioid Use Disorders

The American Academy of Pediatrics categorizes adolescence as the totality of three developmental stages—puberty to adulthood—which occur between 11 and 21 years of age. Eleven young people within this age group—adolescents—present for treatment with a broad spectrum of opioid use disorder severity and with co-occurring medical and psychiatric illness. Therefore, providers will need to respond with a full range of treatment options, including pharmacotherapy. This is especially challenging in the pregnant adolescent. Unfortunately, there is limited evidence regarding the efficacy of opioid withdrawal management in adolescents [18]. Pharmacological therapies have been almost exclusively developed through research with adult populations and not adolescents [19]. The treatment of adolescents with opioid use disorder presents many unique medical, legal, and ethical dilemmas that may complicate treatment. Due to these unique issues, adolescents with opioid use disorder often benefit from services designed specifically for them. Also, the family, provided they are not part of the problem, should be involved in treatment whenever possible. The “Confidentiality in Treatment” is one issue that may be of particular importance to consider in the treatment of adolescents. Adolescents themselves have reported that they are less likely to seek substance use disorder treatment if services are not confidential [20]. Confidential care, particularly with respect to sensitive issues such as reproductive health and substance use, has become a well-established practice [2122]. These issues are an area governed by both Federal and state laws. Moreover, defined age ranges of “adolescence” vary. A variety of clinical and legal responsibilities may be involved if confronted by a young person’s request for confidentiality. More than half of the states in the United States, by law, permit adolescents less than 18 years of age to consent to substance use disorder treatment without parental consent. State law should also be consulted. An additional resource in decision-making regarding the implications on coordination of care, effectiveness of treatment without parental communication, and other key issues are more completely elucidated in a publication of the Substance Abuse and Mental Health Services Administrations (SAMHSA), Center for Substance Abuse Treatment, Treatment Improvement Protocol (TIP) #33 [23].

Pharmacotherapeutic options for adolescents include the opioid agonists (methadone and buprenorphine) and antagonists (naltrexone) for treatment of opioid use disorder in adolescents. However, efficacy studies for these medications have largely been conducted in adults. Their recommended use is based on the consensus opinion of the Guideline Committee [24]. There are virtually no data comparing the relative effectiveness of these treatments in adolescents with adults. Methadone and buprenorphine are the agonist medications indicated for the treatment of patients who are aged 18 years and older. The Federal code on opioid treatment—42 CFR § 8.12—offers an exception for patients aged 16 and 17, who have a documented history of at least two prior unsuccessful withdrawal management attempts, and have parental consent [25].

There are no controlled trials evaluating the efficacy of agonists and partial agonists in adolescents, such as methadone for the treatment of opioid use disorder in adolescents under the age of 18. Descriptive trials support the apparent effectiveness of treatment with methadone in supporting treatment retention in adolescent heroin users [26]. The usefulness of treatment with buprenorphine with heroin use in adolescents has been demonstrated in two RCTs. Studies have, however, not included adolescents under the age of 16 [2728]. Buprenorphine is not US FDA-approved for use in patients less than 16 years old. Buprenorphine is more likely to be available in programs targeting older adolescents and young adults. No direct comparison of the efficacy buprenorphine versus methadone has been conducted in adolescent populations.

The opioid antagonist naltrexone may be considered for young adults aged 18 years and older who have opioid use disorder. Naltrexone has no physical dependence and is simpler to discontinue usage. Oral naltrexone may be particularly useful for adolescents who report a shorter duration of opioid use. Extended-release injectable naltrexone is administered monthly and may be delivered on an outpatient basis. Only one small case series demonstrated the efficacy of extended-release injectable naltrexone in adolescents [29]. The safety, efficacy, and pharmacokinetics of extended-release injectable naltrexone have not been established in the adolescent population to allow its use without close observation.

Psychosocial treatment is recommended in the treatment of all adolescents with opioid use disorder. Useful treatments based on the consensus opinion of the Guideline Committee include family intervention approaches, vocational support, and behavioral interventions to incrementally reduce use. Holistic risk-reduction interventions emphasizing healthy life-choices, which promote practices to reduce infection, are particularly important in the prevention of sexually transmitted infections and blood-borne viruses. Treatment of concomitant psychiatric conditions is also critically necessary in this population. Adolescents often benefit from specialized treatment facilities that provide multiple services combined in a single, focal setting.

Pregnancy and Opioid Use Disorder

Care for pregnant women with opioid use disorder should be considered a particularly vulnerable population and ideally be comanaged by an obstetrician and an addiction specialist physician. Unfortunately, in many areas, this is simply not possible due to a paucity of trained addictions specialists and active programs for pregnant patients. As per normal procedures, release of information forms needs to be completed to ensure communication among healthcare providers.

The common dictum is that pregnant women who are physically dependent on opioids should receive treatment using methadone or buprenorphine monoproduct rather than withdrawal management or abstinence. However, substitution, without working toward abstinence from opioids, does not address the problems of NAS in the neonates after delivery. As previously noted, methadone and buprenorphine both have significant issues with NAS.

If treatment with methadone is initiated, it should commence as early as possible during pregnancy. Hospitalization during initiation of methadone and treatment with buprenorphine may be advisable due to the potential for adverse events, especially in the third trimester. Generally, adverse events may be avoided by routine employment of fetal monitoring protocols with non-stress testing or biophysical profiles to ensure fetal well-being. If an inpatient setting is chosen, methadone should be started at a dose range of 20–30 mg/day. Incremental doses of 5–10 mg may be given every 3–6 h, as needed, to treat withdrawal symptoms. After clinical induction, clinicians may increase the methadone dose in 5–10-mg increments per week if needed. The goal is to maintain the lowest dose that controls withdrawal symptoms and decreases the desire to use additional opioids. Twice daily dosing appears more effective and has fewer side effects than single daily dosing. However, it may not be practical if the methadone is dispensed in an outpatient clinic.

Obstetrician/Gynecologists caring for opioid use disorder pregnant patients should be aware that the pharmacokinetics of methadone clearance is affected by pregnancy. With advancing gestational age, plasma levels of methadone progressively decrease and clearance increases. Increased or split doses may be needed as pregnancy progresses. After child birth, doses may need to be adjusted back to lower levels.

Buprenorphine monoproduct has become a possible alternative to methadone for pregnant women. There appear to be no concerns with the combination buprenorphine/naloxone formulation but there is inadequate data to recommend its use at this time. If a woman becomes pregnant while she is receiving naltrexone, it appears reasonable to stop the medication if the patient and doctor agree that the risk of relapse is low. If the patient is highly concerned about relapse and wishes to continue naltrexone, she should be informed about the risks of staying on naltrexone. Informed consent for ongoing treatment should be obtained with a signed document of understanding. If the patient wishes to discontinue naltrexone, but then reports relapse to opioid use, it may be reasonable to consider treatment with methadone or treatment with buprenorphine. Naloxone therapy is generally not recommended for use in pregnant women with opioid use disorder except in life-threatening overdose. Mothers receiving methadone and buprenorphine monoproduct for the treatment of opioid use disorders may breastfeed without any concerns to the neonate since only small amounts of drug are released in breast milk.

West Virginia

The number of newborns treated for NAS has increased dramatically in West Virginia. In data collected from the Cabell Huntington Hospital in Huntington, WV, the number of neonates treated for NAS increased from 25 in 2003 to 70 in 2007 [30]. The cost difference in the care of an otherwise healthy neonate with NAS compared to a normal full-term healthy neonate was estimated to be $3934 in the Cabell-Huntington cohort. Because of the added costs associated with the increased risk of prematurity, the average cost of all infants with NAS was $36,000 compared to $2000 for a normal neonate [30].

Staff of Charleston Area Medical Center (CAMC) , West Virginia’s only free-standing Women and Children’s Hospital, knew they were providing care to around 130 babies born annually with positive substance screens (4 % deliveries) based on risk factor screening at the time of presentation and delivery. However, the actual numbers were much more startling. We obtained new information for our hospital from Stitely et al. 2010 that indicated a much higher abuse rate [15]. A cross-sectional hospital study was initiated in eight West Virginia hospitals in 2009 to examine the prevalence of substance use in pregnant patients at delivery and CAMC participated [15]. Segments of umbilical cords were collected anonymously from 759 deliveries (regardless of risk factors) at the eight regional hospitals during the month of August, 2009. A reference laboratory screened all cord segments for the presence of substances using commercially available enzyme-linked immunoabsorbent (ELISA) kits, with confirmatory testing by gas chromatography/mass spectrometry were used for 6 of the drugs. Buprenorphine was tested using liquid chromatography/mass spectrometry (LCMSMS). Phosphatidylethanol (a metabolite of ethanol testing was based on high-pressure liquid chromatography/mass spectrometry (HPLCMS). CAMC’s overall positive screening rate was 16 % for non-prescribed and illicit drugs and 8 % for alcohol) out of the total of 133 patients screened. These findings of positive screening by cord blood samples were four times higher than our rate of 4 % when we screened based on risk factors. In addition, results from the study indicated that multiple drug use was common [15].

Most recent data from CAMC presented by Hensel et al. 2012, found with universal urine screening for illicit substances in the CAMC obstetric and gynecologic residency clinic in West Virginia, that, 32 % of pregnant patients at CAMC were positive for illicit substances including 11 % positive for multiple substances [31].

Prior to the August, 2009 study, CAMC received a grant in the spring of 2009 from the Appalachian Regional Commission to address the alleged 4 % substance abuse rate by risk factor screening alone for delivery at our institution and explore the issues in substance abuse in pregnancy as part of their initiative for “Partnering for a Drug-Free America.” The proceeds from the grant were utilized by the Drug Addicted Mom and Babies (DAMB) task force which had been developed 2 years prior, to address the growing issue of women and babies affected by addiction and substance abuse during pregnancy and the time of delivery.

The DAMB task force is a multidisciplinary group including nursing personnel from the inpatient obstetrical and NICU areas and the outpatient clinical areas, a substance abuse counselor, physicians, a nursing educator, and a research associate. The director of a local halfway house for women recovering from substance abuse is also included on the task force for community representation.

Outpatient Therapeutic Substitution

In response to the substance abuse issue among pregnant women, an outpatient treatment program with therapeutic substitution was created to provide individual and group based substance abuse intervention with a certified substance abuse counselor (see Appendix 1 for dosing). Patients were identified for substance abuse by referral, previous substance abuse history, and urine drug screening.

The substance abuse literature suggested the avoidance of detoxification during the second and third trimesters of pregnancy due to concerns about harms to the fetus [432]. Recent literature, however, does not substantiate these claims [53235]. Luty et al. 2003 studied 101 opiate-dependent women who underwent a 21-day gradual opiate withdrawal with no adverse effects found [35]. Stewart et al. 2013 utilized a slow methadone inpatient taper for pregnant inpatients [36]. They found that in 53/96 (56 %) of patients could successfully be detoxified. Further, the hospital stays for those with inpatient detoxification lasted 10 days longer than those who did not detoxify (25 versus 15 days). They also found that maternal demographics and drug histories did not influence successful inpatient detoxification. Their findings suggested that opiate detoxification ought to be offered to all pregnant women willing to undergo detoxification [36].

Finally, Hensel et al. 2015 cared for 92 screen-positive patients and achieved abstinence in 39/92 (42 %) patients at delivery with outpatient management with oral therapeutic opioid substitution with decreasing dosages while including contingency addictions care by a certified addictions specialist. [37] They found collaborative and intense group therapy with a certified addictions counselor was a mainstay of successful achievement of abstinence [38].

Patients in the CAMC resident clinics who received obstetrical care from 6/30/2010–3/31/2013 were enrolled in our multidisciplinary care in the CAMC obstetrics and gynecology resident outpatient obstetric clinic areas. Our plan of care included a certified substance abuse counselor, obstetrical staff/resident physicians, trained nursing personnel, and a nursing educator. Key in the management of our obstetrical patients’ care was routine screening of patients’ initial urine for illicit and non-prescribed substances. All patients who tested positive for non-prescribed, or illicit substances, were enrolled in our abstinence-based addictions program including our contingency management program for substance abuse staffed by a certified addictions specialist. The CAMC program consisted of a 12-week course of group therapy and addictions counseling by our certified addictions counselor. Weekly visits to the high-risk obstetrical clinic were included. Testing of patients’ urine for illicit substances continued throughout their obstetrical care. Patients who took opiates, and were at risk for acute opiate withdrawal, received therapeutic substitution with oral opioid medications to obtain abstinence. The program used medical care including outpatient therapeutic substitution with decreasing dosages of opiates with weekly group meetings, which focused on improving coping skills and increasing distress tolerance. Patient’s urines were tested weekly to insure compliance with care and dosage verification by mass spectrometry analysis with patient BMI and urine specific gravity.

The therapy component of the program consists of both psycho-educational and cognitive-behavioral therapy. Information is provided on the disease concept of addiction, Step One, the recovery process, relapse prevention, and the effects of drugs on the baby. A contingency management program, an evidence-based practice with roots in Motivational Interviewing, was utilized to keep patients engaged in their abstinence process. Contingency management therapies are a type of psychosocial intervention where the clients receive rewards in the form of vouchers or prizes if they demonstrate changed behaviors. Data supports contingency management therapy in cocaine and opioid abuse [3940]. It has also been shown to be effective in the vulnerable populations of co-occurring psychological disorders and in pregnant women.

Analysis of the delivery outcomes in patients screening positive for substance abuse in pregnancy was performed for our CAMC patients. Variables analyzed from urine drug data were linked to addiction intervention program.

Results of Outpatient Therapeutic Substitution in West Virginia

Inclusion criteria were met by 1164 patients in our CAMC tertiary medical center women’s health clinic. Tobacco use is around 50 % and alcohol around 7 % in the clinic. Three hundred fifteen (27 %) women tested positive on urine drug screens for substances. Three hundred nineteen (27 %) women tested positive on urine drug screens for substances. Substances found in decreasing frequency: marijuana—241 (76 %), opiates—68 (21 %), benzodiazepines—32 (10 %), methadone—17 (5 %), cocaine—15 (5 %), and amphetamines—10 (3 %). Forty-three (13 %) women tested positive for more than one substance. Of the 68 women positive for prenatal opiate use, 51 gave birth at our facility of which 21 (41 %) achieved abstinence. As a result of abstinence at birth, there was an estimated savings of over $700,000 in abstinence therapy ($34,000 per neonate) in NICU costs alone.

Postoperative and Postpartum Care in Opioid Patients

A final word must be shared in the care of opioid tolerant pregnant patients that often goes unnoticed: postoperative and postpartum care. The care of opioid tolerant patients must consider:

·               Pain is frequently undertreated

·               May require longer postoperative treatment

·               Usually require more than replacement dose

·               Ought to avoid antagonist/agonist or partial agonist meds (buprenorphine, butorphanol, pentazocine)

Generally should continue previous meds or equivalent chronic pain medications in the acute postoperative stages. Usually increase postoperative, procedural dose, etc. by 25–50 % of baseline dosing. Key questions to ask the opioid tolerant/addicted patients are what medications they are receiving (dose, duration, route) and whether or not they are taking any neuropathic meds (neurontin, etc).

For postoperative pain in opioid tolerant individuals, the following is suggested to insure adequate pain coverage:

1.

2.

3.

For acute pain relief in postoperative pain in opioid addict in recovery (not taking any opioids), consider pain relief as below:

·               Utilize local or regional blocks when able

·               Don’t force meds on patients

·               If possible, avoid drug of abuse

·               In emergencies, use what you need

·               Optimize nonsteroidals (i.e., toradol IM/IV)

·               Start with standard opiate doses

Further considerations for opioid tolerant-opioid maintenance therapy patients (on opioid medications) must be dealt with for postoperative pain. Methadone patients should be treated:

·               Treated the same as chronic opioid patients.

·               Maintain their baseline of methadone and supplement with standard opioid dose and titrate accordingly. May give IM methadone as well.

·               If unable to tolerate PO/IM, convert to IV morphine equivalents. Give 25–50 % of total dose as baseline.

·               Adjust according to PCA protocols.

·               Avoid partial agonists or opioid antagonists.

Buprenorphine (Suboxone/Subutex) ought to be prescribed to maintain postoperative pain relief by considering these principles:

·               ×30–×40 more potent than morphine on an mg per mg basis

·               Generally less hemodynamic effects than traditional opiates

·               May dose SQ

·               Dose every 6–8 h

Dosing for buprenorphine for postoperative pain relief should include:

·               Dosing for pain 3–4 times per day SC/IV.

·               Patient may use own SL medication (if approved by treatment doctor) administrated by nurse.

·               Good for same day surgery patients as well as hospitalized.

·               Dose 0.3 mg SC/IV every 6–8 h for postoperative pain.

·               Can use standard scheduled dose of IV morphine/hydromorphine Q4–6 h and adjust as needed.

The pain relief doses for buprenorphine may be converted to morphine dose equivalents by using the following information:

·               Total mg of buprenorphine SL × 50 = total daily oral morphine dose.

·               8 mg/2 mg/day (1 strip) × 50 = 400 mg/day oral morphine.

·               Initiate 25–50 % of calculated dose as a PCA baseline, then adjust per protocol.

·               100–200 mg/day divided Q4–6 h+ prn doses oral morphine.

To assist in the postoperative care of our opioid tolerant and opioid naïve patients, we developed order sets for labor and delivery for intrapartum pain relief, post-vaginal delivery pain relief, and postoperative (cesarean section) pain relief (see Appendices 2–4). These order sets are provided for illustrative purposes to allow a framework for development of order sets pertinent to the healthcare system and pertinent to the local practices of the various providers.

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