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Medication Assisted Treatment MAT in Pregnant Women

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MAT=Medication Assisted Treatment in context of substance abuse treatment ... Methadone/buprenorphine as prescribed medications rather than drugs of abuse ... – PowerPoint PPT presentation

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Title: Medication Assisted Treatment MAT in Pregnant Women


1
Medication Assisted Treatment (MAT) in Pregnant
Women
  • Susan F. Neshin, M.D.
  • Medical Director
  • JSAS Healthcare, Inc.
  • Asbury Park, NJ
  • E-mail jsasmd_at_aol.com

2
Overview of Presentation
  • What is MAT?
  • Rationale for MAT
  • Importance of Dose Adequacy
  • Impact of MAT
  • The Medications
  • Womens Issues/PREGNANCY
  • Addressing Stigma

3
What is MAT?
  • MATMedication Assisted Treatment in context of
    substance abuse treatment
  • EUPHEMISM for opioid maintenance therapy
  • Methadone
  • Buprenorphine
  • Broaden definition
  • Naltrexone
  • Medication for other drug dependencies
  • Medication in the treatment of chronic disease

4
Medications Development Division
  • Branch of National Institute on Drug Abuse (NIDA)
  • Developing new medications
  • Addiction as a brain disease
  • Drug craving as a physiologic phenomenon

5
Rationale for MAT/OMT For Chronic Opioid
Dependence
  • Doles concept of metabolic derangement
  • Current concept of neuronal adaptations to
    repeated exposures of the drug
  • Pre-existing vulnerability and/or consequence of
    opioid use
  • Corrective, not curative

6
On/Off - Non-Tolerant Drug States
Overdose Intoxication Euphoria
Normophoria
Dysphoria
ON Drug Effect
Mood/Effect Scale
OFF No Drug Effect Normal
6
Opioid Maintenance Pharmacotherapy - A Course for
Clinicians
7
Heroin Simulated 24 Hr. Dose/Response With
established heroin tolerance/dependence
Loaded High
Abnormal Normality
Normal Range Comfort Zone
Dose Response
Subjective w/d
Sick
Objective w/d
Time
0 hrs.
24 hrs.
7
Opioid Maintenance Pharmacotherapy - A Course for
Clinicians
8
Methadone Simulated 24 Hr. Dose/Response At
steady-state in tolerant patient
Loaded High
Abnormal Normality
Normal Range Comfort Zone
Dose Response
Subjective w/d
Sick
Objective w/d
Time
0 hrs.
24 hrs.
8
Opioid Maintenance Pharmacotherapy - A Course for
Clinicians
9
Goals for Pharmacotherapy
  • Prevention or reduction of withdrawal symptoms
  • Prevention or reduction of drug craving
  • Prevention of relapse to use of addictive drug
  • Restoration to or toward normalcy of any
    physiological function disrupted by drug addiction

10
Importance of
  • Dose Adequacy!

11
Recent Heroin Use by Current Methadone Dose
Heroin Use
Current Methadone Dose mg/day
J. C. Ball, November 18, 1988
12
Retention in Treatment Relative to Dose
80 mg 60-79 mg Adapted from Caplehorn Bell - The Medical
Journal of Australia
13
Impact of Maintenance Treatment
  • Reduction death rates (Grondblah, 90)
  • Reduction IVDU (Ball Ross, 91)
  • Reduction crime days (Ball Ross)
  • Reduction rate of HIV seroconversion
    (Bourne, 88 Novick 90, Metzger 93)
  • Reduction relapse to IVDU (Ball Ross)
  • Improved employment, health, social
    function

14
DEATH RATES IN TREATED AND UNTREATED HEROIN
ADDICTS
Annual Death Rates
Slide data courtesy of Frank Vocci, MD, NIDA -
Reference Grondblah, L. et al. ACTA PSCHIATR
SCAND, P. 223-227, 1990
14
15
Impact of MMT on IV Drug Use for 388 Male MMT
Patients in 6 Programs
100
100
81.4
63.3
41.7
LAST ADDICTION PERIOD
PERCENT IV USERS
ADMISSION
28.9


0
Pre- 1st Year 2nd Year
3rd Year 4th Year Admission
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
16
Crime among 491 patients before and during MMT at
6 programs
Crime Days Per Year
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
17
HIV CONVERSION IN TREATMENT
18 month HIV conversion by treatment
retention Source Metzger, D. et. al. J of AIDS
61993. p.1053
18
OMT as Treatment of Choice for Chronic Relapsing
Opioid Addict
  • Concept of prolonged abstinence
  • Hyper-reactivity to stress
  • Dysphoria/craving increase vulnerability to
    relapse

19
Relapse to IV drug use after MMT 105 male
patients who left treatment
Percent IV Users
Treatment Months Since Stopping Treatment
Adapted from Ball Ross - The Effectiveness of
Methadone Maintenance Treatment, 1991
20
The Medications
  • Methadone
  • Long-acting full opioid agonist
  • Orally effective
  • Can be taken once a day
  • Prescribed and dispensed at licensed OTPs

21
The Medications
  • Buprenorphine
  • Approved by FDA in October, 2002
  • Result of DATA 2000
  • Long-acting partial opioid agonist
  • Sublingually effective
  • Can be taken once a day or less frequently
  • Prescribed by private practitioner with waiver

22
The Medications
  • Naltrexone
  • Long-acting opioid antagonist
  • Orally effective
  • Can be taken once a day or less frequently
  • Benefits subgroups of opioid addicts

23
Addiction as a Biopsychosocial Disease
  • OMT addresses the biological aspect
  • Psychosocial aspects addressed
  • Substance abuse counseling
  • Mental health treatment
  • Support and self-help groups
  • Accreditation standards
  • Should improve treatment
  • Eliminate gas and go model

24
Womens Issues
  • Higher levels of dual diagnosis than men
  • Childcare
  • Transportation
  • Domestic Violence
  • Educational/Vocational
  • Financial
  • Pregnancy

25
How to Address Womens Issues
  • Accreditation standards
  • Variable levels of resources
  • Womens Set-Aside funds
  • One-stop shopping

26
Dual Diagnosis
  • Depression/mood disorders
  • Anxiety disorders/PTSD
  • Eating disorders
  • Symptoms
  • Guilt and shame
  • Low self esteem

27
Dual Diagnosis
  • Train counseling staff
  • Availability of therapist
  • Availability of psychiatrist
  • Staff with expertise in survivor issues
  • Lifetime prevalence of drug abuse 4 times
    greater in women who report history of sexual
    assault
  • Support/therapy groups

28
Childcare Issues
  • Most women in treatment are of childbearing age
  • Children as barrier to treatment
  • Services to address
  • Children welcome
  • On-site child care
  • Parenting classes

29
Transportation Issues
  • Lack of transportation as barrier to treatment
  • Clinics in out of the way areas
  • Services to address
  • Use of medical transportation for Medicaid
    patients
  • Site program close to public transportation
  • Give take-homes when earned
  • Van service
  • Home medication/family member pick-up for
    homebound patients

30
Domestic Violence
  • Train staff
  • Facilitate referral to shelter when appropriate
  • Support/therapy group

31
Educational/Vocational Issues
  • Most women in treatment are undereducated and
    underemployed
  • Services to address
  • Train staff about community resources/state-funded
    programs
  • On-site vocational counselor
  • Address sex for drugs issues

32
Financial Issues
  • Treatment is expensive
  • Proprietary vs. publicly-funded non-profit
    programs
  • Services to address patient issues
  • Accept Medicaid as payment
  • Allow for reduced fee/indigency
  • Counsel on budgeting
  • Counselor referrals to/interventions with local
    service agencies

33
Financial Issues
  • Program issues
  • Fund raising
  • Lobbying for higher state/federal funding

34
Considerations for Treatment of Pregnant Opiate
Addict
  • Tolerance level
  • Chronicity of use
  • Route of administration
  • Pregnancy history
  • Motivational level
  • Recovery environment
  • Ideal vs. Reality

35
OMT/MAT as Standard of Care
  • Steady levels of opiates normalize neuroendocrine
    functioning and prevent fetal distress
  • Decreases rates of pregnancy complications, e.g.
    miscarriage, stillbirth, IUGR, abruptio placenta,
    infection, hemorrhage
  • Improves prenatal care
  • Allows for psychosocial interventions to improve
    level of functioning

36
Perinatal Addiction
  • Importance of pregnancy testing at intake
  • Priority admission should be given to pregnant
    patients
  • Family planning as counseling issue with periodic
    pregnancy testing, especially during medically
    supervised withdrawal
  • Dose of methadone should be individually
    determined and adequate to control craving and
    prevent withdrawal syndrome

37
Perinatal Addiction
  • MMT patients who become pregnant should be
    continued at established dose. A mid-trimester
    reduction may be appropriate in anticipation of
    3rd trimester dose increase.
  • Altered pharmacokinetics during 3rd trimester
    often require dose increases and often a split
    dose to flatten the curve and improve maternal
    and fetal stability.

38
Perinatal Addiction
  • There is no consistent correlation between
    maternal methadone dose and the severity of
    neonatal withdrawal syndrome (Stimmel et al.,
    1982).
  • Protocols are available for scoring signs of
    opioid withdrawal to guide the appropriate use of
    medications to facilitate a safe and comfortable
    withdrawal of the passively addicted neonate
    (Finnegan, 1985).

39
Perinatal Addiction
  • Breast-feeding may be encouraged during MMT - if
    not otherwise contraindicated (Kaltenbach, 1992).
  • Multiple longitudinal studies find that
    methadone-exposed infants score well within the
    normal range of development (Kaltenbach, 1992).

40
Perinatal Addiction
  • Obstacles and barriers to MMT must be removed for
    the pregnant patients.
  • More research is needed on innovative models of
    treatment including medically supervised
    withdrawal during pregnancy with residential
    care, intensive relapse prevention and
    monitoring, high-risk prenatal care. When
    appropriate hospitals, clinics and individual
    obstetricians could provide methadone maintenance.

41
Withdrawal during Pregnancy
  • Rarely appropriate during pregnancy (ASAM 1990)
  • Same recidivism as non-pregnant opioid addicts
  • Slow withdrawal between 14 and 32 week
  • Patient lives in an area where MM is not
    available.
  • Patient refuses to be placed on MM.
  • Patient has been stable and requests withdrawal
    prior to delivery.

42
Withdrawal during Pregnancy
  • No harm reduction with OMT
  • Patient has been so disruptive to the treatment
    setting that the treatment of other patients is
    jeopardized, necessitating the removal of the
    patient from the program.

43
Pregnancy
  • Comprehensive OMT with adequate prenatal care
    can reduce the incidence of obstetrical and fetal
    complications, in utero growth retardation, and
    neonatal morbidity and mortality (Finnegan, 1991).

44
Model Perinatal Program
  • On-site prenatal care
  • On-site well-baby care
  • On-site child care
  • Educational groups
  • Pregnancy/medical issues
  • Methadone and pregnancy
  • Effects of drugs of abuse, including alcohol and
    nicotine, on fetus

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Model Perinatal Program
  • Educational groups--continued
  • Nutrition
  • Baby care
  • Parenting skills--include fathers
  • Contraception/Family Planning
  • Domestic Violence

54
Model Perinatal Program
  • Counseling on pregnancy termination and adoption
  • On-Site Psychiatric/Psychological evaluation and
    treatment

55
Use of Psychotropic Medication During Pregnancy
  • Weigh risks vs. benefits
  • Inform patient of drugs potential for
    teratogenic or other adverse effects (Category)
  • Consider consequences of untreated psychiatric
    illness
  • Use lowest effective dose

56
Antidepressants in Pregnancy
  • No increase in major malformations
  • ?cardiac defects with paroxetine
  • No increase in long term neurodevelopmental
    adverse outcomes
  • SSRIs in third trimester
  • may see withdrawal syndrome in neonate
  • increase in persistent pulmonary hypertension
  • no long term residual effects
  • Tricyclics relatively safe
  • MAI inhibitors contraindicated

57
Benzodiazepines During Pregnancy
  • Slight increase in oral clefts
  • Possible withdrawal syndrome
  • No long term neurodevelopmental adverse effects

58
Risks of Untreated Depression
  • Increase in miscarriage, hypertension and
    preeclampsia
  • Increase in likelihood of relapse to depression
    with stopping antidepressant medication
  • Global IQ negatively associated with duration of
    depression
  • Language development negatively correlated with
    number of postnatal depressive episodes

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63
Addressing Stigma
  • EDUCATE OURSELVES!
  • I dont believe in methadone!
  • ASAM addressing physician bias
  • Arizona study -- 96 refusal to treat or give
    pain meds
  • Example of physician opioid addict

64
Addressing Stigma
  • EDUCATE OURSELVES!--continued
  • Need to educate therapeutic communities,
    Minnesota model programs
  • Need to educate Twelve Step community
  • Methadone/buprenorphine as prescribed medications
    rather than drugs of abuse
  • Patients on OMT can work a program of recovery

65
Addressing Stigma
  • Educate service agencies and the general public
  • Arizona study -- 66 refused employment or lost
    job
  • Educate patients about the chronic disease
    concept
  • Methadone/buprenorphine as corrective, not
    curative
  • Educate family members

66
Addressing Stigma
  • Publicly funded programs should be mandated to
    accept patients on OMT
  • Private programs should be encouraged to accept
    patient on OMT
  • Great need for residential treatment/halfway
    houses for women (pregnant or non-pregnant) and
    their children

67
Addressing Stigma
  • Patients should be encouraged to get involved in
    advocacy
  • Patients need to risk divulging status to
    treatment providers with support from program
    staff

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