Addiction in Pregnancy: Addiction Theory; Screening and Detection; Clinical Management; Brief Intervention

1. James J. Nocon, M.D., J.D.
© 2014
jnocon@me.com

2. 
Addiction Theory:





An approach to understanding addiction.
A review of addiction neurobiology.
Scope of addiction in pregnancy
Unique issues for women and pregnancy.
Clinical Management – Case Scenarios
 General principles.
 Focus on prescription drug abuse: Opioids.

Screening and Brief Interventions:
 Simple screening strategies.
 Effective brief intervention techniques.

3. 

Few Medical Schools Teach Addiction Medicine
“Not enough time in curriculum.”
 Addiction occurs in 1 in 10 patients, and
 Directly affects at least 25% of the population.


Minimal faculty with any training.
“Students resist learning,” (did med school deans actually
say this was a reason for not teaching addiction
medicine?).


Miller NS,Sheppard LM, Colenda CC, and Magen J. Why physicians are unprepared to
treat patients who have alcohol and drug-related disorders. Acad. Med. 2001;7:410–418.
What are the critical elements in treating addiction?

4. 
What are the critical elements in treating
addiction?
 Attitude (Compassion goes a long way)
 Attitude (Non-judgmental)
 Attitude (Roll with the Resistance)

Poor Attitudes lead to Shame Based treatment:
 52% of physicians agreed that drug use in pregnancy
constituted child abuse.
 60% of OB nurses hold punitive attitude to laboring addicts
even when patient is in recovery

5. 

Special shame reserved for addictive mothers.
Criminalized for using drugs while pregnant
 N.J. Div. of Youth & Family Servs. v. Y.N. (2013)
 This is a case in which a New Jersey Appellate Division
Court ruled that a woman who obtains medicallysupervised methadone treatment during pregnancy may
be found to have abused or neglected her child.

In contrast, when patients and providers have
a positive attitude, pregnancy enhances
recovery.
5

6. 
In a special clinic for “drug abuse in pregnancy”
renamed (with a positive attitude) the “Prenatal
Recovery Clinic:”
 2002 to 2012
 80% of opioid dependent patients in stable
maintenance program and free of other illicit or illegal
drugs.
 In contrast, in the same clinic in the years prior:
 85% of such patients tested positive for illicit or illegal
drugs (especially cocaine and marijuana)*
*Brown HL, Britton KA, Mahaffey D, Brizendine E, Hiett AK, Turnquest MA.
Methadone maintenance in pregnancy: a reappraisal. Am J Obstet Gynecol
1998;179:459-63.

7. 

Pregnancy enhances long-term recovery.
After one year of treatment:
 65.7% of women who entered treatment while
pregnant used no drugs, while
 Only 27.7% of non-pregnant women remained drug
free. (p<0.0005)


Peles E, Adelson M. Gender Differences and Pregnant Women in a Methadone
Maintenance Treatment (MMT) Clinic. J Addictive Diseases 2006; 25: 39-45.
A similar result in the Prenatal Recovery Clinic:
 65% of women were drug free at 6 months
postpartum.

8. 


Do we all feel good when
someone says something
nice about us?
Does that lead to a positive
attitude?
What does it take to make
you say,
 “That
made my day.”
There’s a simple way to do
this.
 It’s all about Affirmations.


9. 
You can affirm patients, friends, relatives, loved ones,
even strangers and especially your enemies.
Acknowledge their Appearance: (“Your tie is so
colorful”),
 Affirm their Character: (“I trust your compassionate
outlook”),
 Affirm the Effect they have on you: (“I am safe with
you”),
 Acknowledge their Skills: (You did a great job
presenting the lecture)

9

10. 


Enhances self worth and self esteem.
Something almost always absent in addicts.
When I affirm someone, I am also affirming
myself.
 An Affirmation is almost always about something
about myself that I see in the other person.

Affirmations to use with patients:


“I am proud of you for coming for care.”
“I am proud of you for staying clean.”

11. Affirm someone every day, especially those
close to you.
 Pay attention to their reaction.
 What effect did the affirmation have?
 What effect did it have on you?

Take a risk, affirm the first person you see
every day.
 Your life, as you know it, will never be the
same.

11

12. 12

13. 



Great question. Like obscenity, hard to define but, “I
know it when I see it.”
Lack of Moral Character – most prevalent theory.
Disease Model of Addiction – Neuro-science
Positive Reinforcement theory:
 Leads to the initial repetition of drug taking that becomes habitual
and eventually compulsive.
 Because it feels so good.

Negative Reinforcement theory:
 By the time the brain is hijacked by the addictive drugs or
behavior, the addict no longer uses the drug or behavior ONLY
for the “buzz.”
 They use the drug, or act out, just to feel “normal.”
 Otherwise, they get “sick.”

Wise RA and Koob GF. The Development and Maintenance of Drug Addiction.
.
Neuropsychopharmacology 39:254-262, 2014

14. 

As Voltaire is said to have replied when the
Marquis De Sade invited him to a second
orgy, since he enjoyed the first one so much:
“No Thanks,
 Once, a philosophy.
 Twice, a perversion.”

He might have added:
 “Three times, an addiction.”

15. Entitlement/Despair: I’m
entitled to feel good, or
things are horrible and I
need something to help
me feel good.
Despair: the effect
wears off
Preparation: obsessing
on how to feel good;
what to use or do.
Acting out: Using or
doing, or both.

16. 


“A primary, chronic disease of brain reward, motivation,
memory and related circuitry.”
ASAM describes five characteristics (the ABCDE) in its
definition:
 “Inability to consistently Abstain;
 Impairment in Behavioral control;
 Craving; or increased “hunger” for drugs or rewarding
experiences;
 Diminished recognition of significant problems with one’s
behaviors and interpersonal relationships; and
 A dysfunctional Emotional response”
American Society of Addiction Medicine. Public Policy Statement. The
Definition of Addiction (Long Version) Approved April 12, 2011.
http://www.asam.org/DefinitionofAddiction-LongVersion.html

17. 
Researchers have noted that
 Addiction is a chronic relapsing disease.
 Successful treatment is comparable to, or better than,
compliance with treatment plans for hypertension or diabetes.

And like diabetes and hypertension, addiction is an
interaction between:
 The substance: alcohol, tobacco and other drugs
 The host: genetics, vulnerabilities, co-morbid disorders
 The environment: family, culture

McLellen AT, Lewis DC, O‟Brien CP, Kleber HD. Drug dependence, a chronic medical
illness: implications for treatment, insurance and outcomes evaluation. JAMA
2000;284:1689-1695.

18. 
What drugs and behaviors have in common, which
results in “the buzz,” is the release of various
neurotransmitters in the nucleus accumbens in the
brain.

Dopamine gives you the “buzz.”

Addiction depletes dopamine and the altered brain
cannot manufacture sufficient dopamine to function
in a normal manner.

Antidepressants that are dopamine reuptake
inhibitors are effective in stabilizing dopamine levels

19. 

Ventral Tegmental Area
(VTA)
 Nucleus Accumbens –
dopamine rich center in
the limbic area
 Prefrontal Cortex – short
term memory
 Amygdala – moderates
emotional influences on
memory – fear response
 MFB: medial forebrain
bundle
These are the primary
centers involved in
pleasurable sensations.
19

20. 



Serotonin – sense of well
being.
Endorphins – euphoria.
GABA (gamma amino butyric
acid) – satiety and
somnolence (sleepy after a
big meal or sex).
Cannabinoids – the human
brain has more cannabinoid
receptors than any other drug.
Also receptors very high in the
CNS, ANS, the reproductive
and immune systems.
20

21. 



Tolerance: as repeated use of the drug or behavior
depletes the dopamine, more use or more drug, or
both, is required to get the same effect.
Dependence: Removal of the drug or behavior will
create withdrawal.
Withdrawal: physical and emotional symptoms,
often profound.
Addiction: There comes a point when the affected
person becomes an addict, as if a switch in the
brain is flipped, and the person no longer has the
ability to make free choices about the continued use
of the drug.
 Leshner AI. Addiction is a brain disease, and it matters. Science
1997;278:45-47

22. 





PET/MRI has mapped the location in the brain where
drugs and behaviors have their effects.
The meso-limbic dopamine system is the primary site of
dysfunction - the “pleasure center.”
Addiction depletes dopamine and the altered brain
cannot manufacture sufficient dopamine to function in a
normal manner.
This process occurs in all addictive drugs and
behaviors.
Wise RA. Addictive drugs and brain stimulation reward. Ann Rev Neuroscience
1996;19:319-340.
McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricuarte GA. Positron emission
tomographic evidence of toxic effect of MDMA (“Ecstasy”) on brain serotonin
neurons in human beings. Lancet 1998;352:1433-1437.

24. Addiction is a “double whammy.”
1.
2.
Tolerance - The brain needs
more and more of the drug in
order to get the same effect.
And in this process, the brain
cells are actually altered.
Drugs reduce fear response
in Amygdala and Prefrontal
cortex – person uses more
drug with less fear of
consequences.
McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricaurte
GA. Positron emission tomographic evidence of
toxic effect of MDMA ("Ecstasy") on brain
serotonin neurons in human beings. Lancet 1998
Oct 31;352(9138):1433-7.
24

25. 
Three critical factors stimulate stem cells to
repair and rebuild neuro-circuitry
 Nutrition and exercise.
 Folic acid important (prevents CNS defects in fetus)
 Reading is critical to rebuilding new circuitry
It takes 8-12 months for stem cells to make
effective repairs.



Relapse in the first 3 months is high.
Relapse after 9 months is less than 10%.

26. 





Addiction is primarily a disease of the brain, which was
not taught to most of us.
Addiction fits the medical model.
Successful treatment of addiction is actually better than
compliance in hypertension and diabetes management.
A positive attitude is required.
Patients actually want to get better.
What is the scope of the problem and what are the
issues for addiction in pregnancy?

27. Treatment highly cost-effective
Reduction in preterm delivery accounts for huge
benefits for the children and huge savings for
the taxpayer.
 Sad to say: when physicians were required to
drug test and report drug use, Black women
were 10 times more likely to be reported to
authorities by M.D. than White women.



Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during
pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J
Med 1990;322:1202-6.

28. Approximately 89,000 deliveries.
At least 25% use tobacco
Estimates vary from a low of 10% to a high of
20% using alcohol, illegal or illicit drugs in
pregnancy.
 For purposes of this presentation, the estimate
is 15% (consistent with other US data)



 13,350 patients of which 90% go undetected, or
 12,015 untreated patients and newborns

29. 





About 89,000 deliveries in Indiana
51% funded by Medicaid – 45,390
15% substance use - 6,808
90% are undetected – 6,127
35% Preterm delivery – 2,144
Mean nursery cost per preterm $75,000

Total cost just for the nursery stay:
 $160,800,000.00

30. 






Estimated 6,800 Substance users
3400 detected (D) – 3400 undetected (U)
20% Preterm delivery D = 680
35% Preterm delivery U = 1190
Total is 1870 preterm deliveries
Difference from 90% U is 2144 - 1870 = 274
At $75,000 per “Premie” nursery cost, detection
of 50% saves Medicaid at least:
 $20,550,000.00 – that‟s 20 Million
dollars just for the nursery LOS.

31. 



Alcohol and tobacco,
often used in combination,
cause far more fetal
damage than all other
drugs combined.
Both Legal to use.
Women are not
“criminalized” for smoking
cigarettes during
pregnancy
Yet far less harmful drugs,
also legal, can lead to a
felony conviction in 25% of
the U.S.

32. 
Marijuana most common. Two surveys in
Indiana are consistent with U.S. data.
 29% tested positive for THC on the first
prenatal visit in a major Southwestern Indiana
Hospital (2006)
 40% positive for THC in a similar Indianapolis
survey (2005)

In both surveys, all patients were detected by
a urine drug screen at the first prenatal visit.

33. 
The number one preventable public health issue
in pregnancy. Two major subgroups:
1. Those who are dependent or addicted to any one of
the following Rx:
▪ Opioids: hydrocodone, oxycodone, methadone
▪ Benzodiazepines: Xanax, Klonopin, Valium
▪ Amphetamines: (ADHD Rx abuse)
▪ Antidepressants: (overprescribed for women)
2. Those dependent or addicted to any combination of
the above.
▪ Poly-substance use and abuse.

34. 
A 30 y/o woman, back pain from injuries in a
MVA, takes
 10 mg. hydrocodone/325 acetaminophen 4x, daily
 50 mg. amitriptylene at bedtime, daily.
 Stable relationship; 2 kids doing well.
 Good full-time job, enjoys life.


What percent of women dependent on
medications vs. what percent are addicted?
Does it matter?

35. 













Cocaine: all forms
Amphetamines – Increasing
abuse of ADHD prescriptions –
10-20 year olds
Methamphetamine
Ecstacy
Rohypnol
GHB
Ketamine
PCP
Salvia
LSD and other hallucinogens
Anabolic steroids
Inhalants
Nicotine, and
Alcohol.

36. 
2002-2007: 69/287 patients (24%) tested
positive for opioids
 43 patients in Methadone Maintenance
 4 patients on Buprenorphine Maintenance

2008-2010: 75% tested positive for opioids
 47 patients in Methadone Maintenance
 42 patients on Buprenorphine Maintenance

More pregnant patients in maintenance with
good outcomes, notwithstanding NAS.

38. 

Gender includes both physical and emotional components that differ
significantly.
 Less alcohol dehydrogenase in women’s stomachs
 More rapid uptake of alcohol into bloodstream: get drunk faster.
 Get high faster with cocaine.
The most significant emotional factor is the extraordinary high incidence
of physical and sexual abuse of women with addictions.
 If sexually abused as a child:
 6 times more likely to become drug addict
 4 times more likely to become an alcoholic
▪ Kendler KS, et al. Arch Gen Psychiatry. 2000;57:953-959.

PTSD (grossly under diagnosed): may be as high as 70-80% of addicted
women.

39. 
Opioids – women develop
dependence quicker than
men.


Ellinwood, et al. Narcotic
addictions in males and females:
a comparison. Int. J Addict
1966;1:33-45
Nicotine – women more
likely to use smoking for
weight control and reduce
stress
 Gritz, et al. Smoking
cessation and gender: the
influence of physiological,
psychological and behavioral
factors. J Am Med Women‟s
Assoc 1996;51:35-42.

40. 
Depression common – 45%
 Did the depression contribute to the addiction?
 Or vice-versa?

Substance Abuse - 19%
 Many chronic pain patients have been treated with a
benzodiazepine and easily become dependent: especially
Xanax; Klonopin



Anxiety disorders – 16% (Xanax very common)
PTSD (grossly under diagnosed) may be as high as
80%
Bipolar – often unrecognized; be aware of aripiprazole –
may cause significant HTN and Diabetes.

41. Need a Treatment Team
 Create a Recovery Plan with a drug use agreement.
 Follow with non stress tests, biophysical profiles and
ultrasounds for growth restriction.
 Encourage breast-feeding, especially in methadone patients
 Instruct methadone and buprenorphine patients to take their
maintenance dose on day of delivery or arrange for patient
to receive maintenance dose at appropriate time after
admission.
 For acute postoperative pain, methadone and
buprenorphine patients will gain relief with doses of opiates
70 to 100% over usual doses.


42. Effective treatment can occur with a
compassionate provider.
 Pregnant addicts are not necessarily high risk
but they can be “high maintenance.”
 Thus, a team spreads the workload.
 A basic team may include:





Provider (MD, OB Clinical Nurse, OB PA)
Addiction Counselor (access to Psych services)
Social worker
Dietician: very important person.

43. 




Pre-conceptual Counseling
Prenatal Care
Labor and Delivery
Analgesia; Anesthesia
Post Partum Care

A more detailed description of obstetrical
guidelines in a “how to” format can be found:
 Toolkit: Treating Opioid Dependence in Pregnancy
 http://www.indianaperinatal.org

44. Especially helpful if you care for opioid dependent chronic
pain patients and methadone and buprenorphine patients.
 Will allow for a modification of opioid maintenance prior to
pregnancy.
 Evaluate existing medical problems, especially diabetes and
hypertension.
 Allows for a discussion of risks for the mother and fetus of
substance use.
 Especially helpful for the older mother to discuss genetic
risks.
 Allows for optimal diet and exercise counseling.
 Allows for consultation with mental health providers for
management of coexisting psychiatric co-morbidity.



45. 
Routine obstetrical care is modified for the substance user.





Perform all routine screening tests.
Generally, prenatal visits occur every two weeks until 36 weeks, then weekly.
Create a recovery plan with a drug use agreement. (drug contract)
Urine drug screen at every prenatal visit – enhances recovery.
Care coordination for psychiatric co-morbidity.
 Encourage other forms of support: therapy, AA, etc.
 Arrange to see social service consultant frequently.
 Dietician review at each visit.

Growth restriction is common, especially in methadone maintenance
patients.
 Follow with non stress tests, biophysical profiles and ultrasounds for growth
restriction.

Encourage breast-feeding, especially in methadone patients

Create a delivery plan.

46. 





Decision for delivery based on obstetrical reasons.
Stress of last few weeks of pregnancy places patient at risk
for relapse.
Induction of labor based on obstetrical reasons.
Early induction for IUGR in methadone patients.
Have detailed reports of drug use and maintenance
medications available for nursing staff and anesthesiologists.
Instruct methadone and buprenorphine patients to take their
maintenance dose on day of delivery or arrange for patient
to receive maintenance dose at appropriate time after
admission.

47. Epidural anesthesia for labor, delivery and cesarean delivery is the
standard.
 Spinal anesthesia for cesarean delivery.
 Intrathecal opioids very effective for acute pain relief.
 For acute postoperative pain, methadone and buprenorphine
patients will gain relief with doses of opiates 70 to 100% over usual
doses.

 The largest group of patients best tolerates morphine.
 Hydromorphone (Dilaudid) also well tolerated

Typically, postpartum analgesia is to:
 Start Ibuprofen 800 mg. every 8 hours
 Alternating with oxycodone 10 mg, every six hours.
 This regimen is effective for about 90% of patients.

In is imperative to inform the patient to continue her maintenance
dose on the day of admission and to restart maintenance as soon
as oral intake is tolerated.

48. 
Recommend at least three postpartum visits:
 Two weeks: stabilize all medications and
maintenance doses.
 Four weeks: Routine testing: Pap, STD, etc.
 Six weeks: Social service consultation with focus
on continued therapy, support and maintenance.



Urine drug screen at each visit.
Breast feeding support at each visit.
Family planning discussion at each visit.

49. 
There are no stupid
questions.

But I have occasionally
been known to give
stupid answers.

The goal: a happy
mother and healthy
baby.

50. 



The following section is
based on actual cases.
Similarity to anyone you
know is purely
coincidental and a
figment of your
imagination.
Names have been
changed to protect the
guilty.
In this realm, there are
no innocents.

51. Current Evidence
Overdose
Withdrawal
Detoxification
Maintenance
Analgesia/Anesthesia
for Labor and Delivery
 NAS
 Breastfeeding.







52. 

2002-2010
Four Groups: 212 Patients
1. Pain patients using only Opioids – 31
2. Pain patients Poly-substance Use – 45
3. Methadone Maintenance - 90
4. Buprenorphine Maintenance – 46
▪ Subutex – 12
▪ Suboxone - 34

53. 







Includes opioid/acetaminophen preparations.
N = 31
Preterm Labor: 4 (12.9%)
Positive Meconium (other than opiates): none
Mean newborn weight: 3085.9 grams
LOS (newborn): 3.3 days; range 2-21 days
NAS treated: 1
Intrapartum complications: 7
 No overdoses.

Nicotine use (> 0.5ppd): 21 (67.7%)

54. 







Opioids plus cocaine, or THC or benzodiazepines or all
three or more
N = 45
Preterm Delivery: 8 (17.7%)
Positive Meconium (other than opiates): 12 (26.6%)
Mean newborn weight: 2879 grams
LOS (newborn): 7.8 days; range 2-89 days
NAS treated: 5
Intrapartum complications: 7
 One antenatal overdose – mother and fetus survived
 One fatal postpartum overdose – “street methadone”

Nicotine Use (> 0.5ppd): 30 (66.6%)

55. Opioid (31)
Preterm Delivery:
LBW (<2500g):
Mean Birth Weight
Positive Meconium
NAS Treated
Mean Length of Stay
Failed to return PP
PP “negative”
Opioid + (45)
p
4 (12.9%)
3
3085 g
0
1
3.3
3
23 (74.2%)
8 (17.7%)
8
2879g
12 (26.6%)
5
7.8
13
25 (55.5%)
NS
NS
NS
0.001
NS
0.01
0.01
NS
Incidence of NAS treated in all opioid dependent patients in Prenatal
Recovery Clinic: 6/76 or 7.8%

56. Chronic pain patients managed with opioids in a
stable program are at low risk for NAS.
 In both groups doses ranged from:

 Hydrocodone: 40-80 mg./day
 Oxycodone: 40-80 mg./day
Even the polysubstance patients had reasonably
good outcomes.
 There is NO indication to shift these patients to
methadone.
 Doing so deviates from expected standards of care.


57. N = 90 (92 babies)
Mean daily dose:
Preterm Delivery:
Mean newborn weight:
LBW (< 2500g):
 Positive meconium:
 Mean LOS
 NAS treated:
 Intrapartum Comp:
 Nicotine:





90 mg.; range: 15-200 mg./day
28 (30%)
2718g
31/92 (33.7%)
9 (10.8%)
30.3 days
80 (86.9%)
15
51/90 (56.6%)

58. Subutex N = 12; Suboxone N = 34; Total N= 46
Mean dose 14 mg/day.; range 4-24 mg./day
 Preterm Delivery:
5 (10.9%)
 Mean newborn weight:
3079.5 g
 LBW (< 2500g):
5 (10.8%)
 Positive meconium:
3 (6.9%)
 Mean LOS (days):
6.78; range 2-49*
 NAS:
8
 NAS treated:
6
 Intrapartum Complications
8
 Nicotine Use:
29 (63%)


* 3 newborns with benzodiazepine withdrawal.

59. Bup. (46)
Preterm Delivery
LBW(<2500g)
Mean Birth Weight
NAS
NAS Treated
Mean Length of Stay
Failed to return PP
PP “negative”
Meth (90)
p
5 (10.9 %)
4
3079 g
8
6 (13%)
6.78 days
13 (28.8%)
29 (65.1%)
27 (30%)
26
2718g
89
80 (89%)
30.3 days
28 (31.1%)
59 (65.5%)
0.001
0.01
0.005
0.001
0.001
0.001
NS
NS
See also, Kakko J, Heilig M, Sarman I. Buprenorphine and methadone
treatment of opiate dependence during pregnancy: comparison of fetal
growth and neonatal outcomes in two consecutive case series. Drug
Alcohol Depend 2008 Jul 1;96(1-2):69-78.

60. 



Opioid dependent chronic pain patients in a
stable program can be managed by any OB
provider.
Opioid maintenance is far easier than
managing diabetes in pregnancy.
Even so-called “chronic pain” patients using
other drugs are relatively low risk for NAS.
Buprenorphine (Suboxone) is superior to
methadone in all respects.

61. 





A 32 year old presents to the labor suite at 32 weeks. She
complains of flu-like symptoms for three days associated with chills,
hot flashes and diarrhea. She is yawning frequently and appears
exhausted. A urine drug screen is negative.
The monitor tracing reveals mild short contractions every 2 minutes,
a fetal heart rate of 160, and she is 4 cm. dilated and 50% effaced.
Attempts to stop the contractions failed and she delivered a 1700gram pre-term male with Apgar scores of 7 and 9.
The baby appeared well for about 6 hours and then developed a
persistent irritable cry, tachypnea, restlessness and tremors.
An astute nurse ordered a drug screen which revealed opioids,
specifically oxycodone.
The newborn was treated for NAS while spending 62 days in the
NICU.

62. 



The mother was subsequently questioned about prior drug use and
revealed an “Oxy” (oxycodone) addiction of 90 mg per day.
She ran out of drugs 3-4 days prior to admission.
Note: Oxycodone and hydrocodone are more rapidly metabolized in
pregnancy and a patient in withdrawal may test negative 3-4 days
after last drug use.
In retrospect, she presented in acute opioid withdrawal, which has a
high incidence of:
Abruption – 12%
 Pre term Labor – 41%



She was started on buprenorphine/naloxone with a good response
and agreed to addiction treatment.
Six months later, she remained opioid free on
buprenorphine/naloxone maintenance and attends an addiction
treatment program.

63. 
Opioid metabolism increases in
pregnancy.
 Unless opioid use is adjusted, many patients will
go into withdrawal.

Withdrawal is more hazardous to
mother and fetus:
 Than NAS,
 Than all other obstetrical conditions.

64. 






Hydrocodone, oxycodone and methadone metabolism
Increases with each trimester.
Subtle in 2nd trimester and overt clinical withdrawal in
3rd.
Up to 50% of patients affected.
Doses may increase by 50% to prevent withdrawal.
Methadone patient may be in chronic withdrawal by
third trimester.
Higher dose methadone actually has better outcome.
McCarthy, J. J., M. H. Leamon, et al. (2005). "High-dose methadone
maintenance in pregnancy: maternal and neonatal outcomes." Am J Obstet
Gynecol 193(3 Pt 1): 606-610.

65. 







High rate of preterm labor - 41%
Increased abruption - 13%
Low Birth weight – 27%
Increased incidence HIV; Hep B; Hep C
Current recommendation is to avoid withdrawal during
pregnancy
This includes “detoxification” during pregnancy.
The risk of adverse events to the baby from withdrawal
is far greater than from the treatment of neonatal
abstinence.
Lam SK, To WK, Duthie SJ, Ma HK. Narcotic addiction in pregnancy with adverse maternal and
perinatal outcome. Aust N Z J Obstet Gynaecol 1992 Aug;32(3):216-21.

66. Prevention of withdrawal is paramount.
The risk of adverse events to the baby from
withdrawal is far greater than from the
treatment of neonatal abstinence.
 Treatment may include increasing the opioid
dose.




Efforts to wean off or “detox” opiates in pregnancy
carry an increased risk of harm to the fetus.
This represents a shift in the standard of care from
“lowest possible dose” to “appropriate” doses to
prevent withdrawal.

67. 




Michele B. is a 22 y/o
who presents to the
ED comatose barely
breathing.
She appears to be
pregnant at term.
Fetal heart rate is
180 BPM.
There is some froth
to her breath.
Diagnosis?

68. 



Characterized by
pinpoint pupils,
respiratory depression,
coma, and pulmonary
edema, then death.
Establish airway.
Inject Naloxone –
repeat if long acting
opiate present, e.g.,
methadone.
Naloxone will not harm
fetus.

69. 



Treatment will precipitate a severe withdrawal.
Will need to restart and modify an opioid dose
For maintenance, use methadone or buprenorphine
Methadone:
 Start at 20 mg BID and increase 5-10 mg per day until
stable.
 (Some suggest starting at 10 mg. BID)

Buprenorphine/naloxone:
 start at 2 – 4 mg;
 increase by 2-4 mg every 6 hours until withdrawal is
abated.

70. 



Sara P. is a 28 y/o who
presents for her first
prenatal visit at 20
weeks gestation by
dates.
US confirms dates.
She is using 180 mg of
“oxy” per day and her
last dose was 2 days
ago.
She is yawning
constantly, appears
sleepy and complains
of hot flashes.

71. Patient presents with abdominal pain, cramps and
diarrhea and may complain of contractions.
 Signs and symptoms often confused with “the flu.”
 Also has yawning, lacrimation, restlessness; may have
tachycardia.
 UDS may be negative for opiates! (many metabolites
cleared in urine during early withdrawal.
 A typical history reveals Rx for hydrocodone/acet. 5/500
for injuries in auto accident years ago

 Admits taking more than prescription allows – commonly up to 15
- 20 pills a day
 UDS positive for opiates; often find THC, Benzodiazepines,
cocaine.

72. 





CNS –hyperactivity in adults; tremors & seizures
in newborn
Metabolic – sweating; yawning
Vascular – hot flashes and chills
Respiratory – increased rate; respiratory
alkalosis
GI – cramps, nausea, vomiting, diarrhea
Drug specific effects – methadone has a
prolonged withdrawal: 10 – 20 days.

73. 
Short Acting (heroin;
morphine; vicodin):
 begins 6-24 hours;
 peak 1-3 days;
 lasts 5-7 days

Methadone:
 Begins 1-3 days;
 peaks 3-6 days;
 Lasts 2 weeks or more

74. 
She “ran out” of meds:
 Very common
 Most likely using more than prescribed because of
increased metabolism.
 And, pregnancy will increase pain, especially in lower
back as belly gets bigger.
 May need “early refill” and closer monitoring.

Or, did someone “steal” her meds.
 Is there an “agreement” in place.

75. 

Methadone vs. Buprenorphine maintenance
Buprenorphine: (key requirements)
 Must be motivated to use buprenorphine
 No more than one prior buprenorphine use
 No poly-substance use, especially benzodiazepines
 Psychiatric co-morbidity – other meds? Interactions?
 Needs to attend counseling, at least once per month
 UDS every prenatal visit.


Methadone by default.
Detoxification is NOT a good strategy.

76. 



Careful review of recent drug use.
Always have Naloxone immediately available.
Check acetaminophen levels in patients using
opiate/acetaminophen compounds.
Stabilizing withdrawal:




Oxycodone: may use oxycodone 10-20 mg q 4-6h for up to 72
hours to stabilize patient in withdrawal and then switch to
buprenorphine.
Buprenorphine: 2-4 mg. every 4-6 hours: most stable between 816 mg.
Methadone: 10-20 mg BID, increasing dose by 5-10 mg daily.
Buprenorphine most rapid and least risky for pregnant
patient.

77. May use during stabilization
with Buprenorphine or
Methadone or other Opioids

Phenergan 25 mg q 4-6 H for
withdrawal symptoms – best
for nausea, vomiting and GI
symptoms

Phenobarbital, 30 mg TID for
neurological withdrawal
symptoms.

Clonidine 0.1 mg TID –
vascular withdrawal
symptoms; hot flashes and
chills.

78. 
Liz C. is a 35 y/o G 4 P3003 at 31 weeks
long term methadone maintenance
currently at 120 mg/day.
 All UDS negative for any other substances
 Depressed but stopped taking her Sertraline due to
“suicidal” thoughts one week ago.
 Complains of electric shock like feelings in her brain.
 Also waking up about 3-4 AM with nausea, cramps,
muscle aches and sweating.

79. 
Methadone Withdrawal
 Methadone typically lasts 25-26 hours
 Methadone is more rapidly metabolized as the pregnancy progresses
 Characteristic of this process is that the patient wakes up in withdrawal
 Typically needs to increase dose of methadone 5-10 mg and assess:
eventually may need 50% increase

Sertraline Withdrawal
 “Brain Zaps” (not documented but often reported)
 Otherwise symptoms similar to methadone withdrawal
 May need to start an anti-depressant with a longer half life such as
fluoxetine or citalopram.

Patients on multiple drugs may have complicated
withdrawals.

80. Encourage patient to remain on methadone during
pregnancy.
 Expect dose to increase up to 50% during pregnancy in
about 35% of patients.
 Doses typically range from 50-150 mg. per day.
 Higher doses not associated with severity of NAS but
improve maternal compliance with prenatal care.*
 Patient should be encouraged to breast feed.
 Note: Methadone was never FDA “approved” for
treatment for opiate dependence in pregnancy.


*McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone
maintenance in pregnancy: maternal and neonatal outcomes. Am J Obstet
Gynecol 2005;193:606-10.

81. 






Patient must be in opioid withdrawal to start
buprenorphine treatment.
Inpatient: some recommend initiating treatment with
buprenorphine, 2-4 mg sublingual by either tablet of film.
Increase dose by 2-4 mg every 6 hours to stop
withdrawal symptoms.
Convert to buprenorphine/naloxone for outpatient use.
Target doses range from 4 to 24 mg per day
Most pregnant patients are stable at 8-16 mg per day in
divided doses.
Withdrawal from buprenorphine is much milder than all
other opioids.

82. 



Epidural – labor/delivery/cesarean
Spinal
Can use intra-thecal opiates/caines
Post op pain management
 Use standard opiates – morphine, Dilaudid
 Use 70-100% more or double the dose for a
morphine or Dilaudid pump
 Ibuprofen; 800 mg q 8 h as soon as tolerated
 Lots of stool softener

83. Christine O. is A 32 y/o G3 P2002 at 16 weeks
on methadone maintenance at 95 mg/day. She
is a chronic pain patient (gunshot wound) and
stable at this dose.
 She chose to self detox by 5 mg a week.
 Apparently, the methadone clinic was
cooperative.
 She was made well aware of the risk of pre-term
labor, among other issues.


84. Must be closely controlled.
Benefits rarely outweigh risks. Studies indicate 56%
relapse within a month.
 Gradual reduction to minimize withdrawal
 Symptomatic treatment: Typical doses:
 Phenergan 25 mg q 4-6 H for withdrawal symptoms –
best for nausea, vomiting and gastrointestinal symptoms
 Phenobarbital, 30 mg TID for neurological withdrawal
symptoms.
 Clonidine 0.1 mg TID – vascular withdrawal symptoms.



85. She decreased her
dose to 5 mg. per day
 She went into preterm
labor at 33 weeks.
 The baby was
otherwise well but
spent about 60 days in
the NICU.
 A cautionary tale.


86. 

Hillary C. is a 34 y/o G3P2002, 2 prior C-sections, had a
back injury 6 years ago and multiple back surgeries.
She has chronic pain, attends physical therapy weekly.
She presents at 12 weeks for prenatal care.
Pain medication includes:
 Percocet 10/325; 2 q 6 h
 Fentanyl patch 0.75 mcg every 72 hours (10 per month)


She works full time as a truck dispatcher and wants to
continue working.
She states she has pain and it is tolerable but is most
concerned about not being to get to sleep. „If I can‟t
sleep, I always have a bad pain day.”

87. 



Patient did well during pregnancy.
Had a repeat C section and went home on day three
Baby was not observed to have withdrawal.
Adequate sleep is very important for chronic pain patients.
 Benadryl, up to 100 mg h.s., will work for many patients.

Tricyclic Anti-depressants appear to work well for sedation
and pain moderation
 Amytriptyline 50 mg h.s. is typical starting dose; can go to 150 mg.
 Fine PG, Miaskowski C, Paice JA. Meeting the challenges in cancer
pain. J Support Oncol. 2004;2(suppl4):5-22

Avoid benzodiazepine medications.

88. 
Maintain current opiate regimen – avoid
withdrawal (both legal to do and meets
standard of care)
 Hydrocodone 5/325 or 10/325 (up to 2 tabs q 6h)
 Oxycodone 5/325 or 10/325 (up to 2 tabs q 6h)
 Low rate of NAS noted with these doses


Requirement of opiate may increase
Pain moderators may be helpful
 Amytryptilene 50-100 mg h.s.
 Gabapentin 300 mg TID

Physical Therapy – maintain mobility.

89.  Concomitant use of two or more psychoactive
substances, in quantities and frequencies that cause
individually significant distress or impairment.
 In one study, 107/287 or 37.2% of pregnant women
presented for prenatal care with polysubstance use.
▪ Nocon JJ. Substance use disorders. In D.R. Mattison (Ed.), Clinical
Pharmacology During Pregnancy (pp. 217-256). Boston: Elsevier
(2013).
 Common conditions with polysubstance use:
▪
▪
▪
▪
Chronic pain conditions
Fibromyalgia
Bipolar
Anxiety disorders

90. 


Opioids and
Benzodiazepines.*
Opioids, THC, and
Cocaine.
Opioids plus:






Methamphetamines
Barbiturates*
Alcohol*
Nicotine
Too numerous to
mention
All of the above.
*Deadly combinations

91. 





Maintain or stabilize opioid component.
Prevent withdrawal
Reduce or eliminate benzodiazepines.
Eliminate illegal substances – cocaine;
THC
Smoking Reduction
Many require more intensive addiction
counseling.

92. 

Used in patients for musculoskeletal spasm and pain.
Most often used for anxiety/panic disorder.

Alprazolam and Clonazepam are Category D
 Abrupt cessation will cause withdrawal, often severe AND
prolonged.
 More prudent to prevent withdrawal.
 Gradual wean tolerated

NAS:
 Neonatal withdrawal will often occur and may be more severe
than opioid withdrawal.
 Benzodiazepines prolong NAS from opioids
 Best to avoid starting benzodiazepine in pregnancy.

93. 




Babies of mothers treated with therapeutic
doses of hydrocodone rarely have NAS
Morphine & Heroin – acute, severe NAS but
rapid – over in 72 hours
Methadone – prolonged – 14-28 days with 6-8
weeks not uncommon
Buprenorphine – mild and often not requiring
treatment
Breastfeeding assists NAS recovery

95. 
CNS signs:
 Irritability, excessive crying; voracious appetite
 Seizures in newborns (but not in adults)





GI signs: vomiting; diarrhea
Respiratory signs: tachypnia; hyperpnea
ANS signs: sneezing, yawning, tearing
Finnegan Scale: (or Lipsitz Scale)
Finnegan and Kaltenbach (1992) in Hoekelman (ed) Primary
Pediatric Care. St. Louis; CV Mosby 1367-1378.

96. 
Combination therapy
 Oral clonidine; phenobarbital (symptomatic)
 Dilute morphine drops



Increase morphine dose until signs of
withdrawal controlled
Maintain controlling dose for 2 days
Then wean morphine dose every 1-2 days.
AAP Committee on Drugs. Neonatal Drug Withdrawal. Pediatrics 1998;
101: 1079-1088.
 Clinical Report: Neonatal Drug Withdrawal. Pediatrics 2012;129:e540–
e560.


97. 
Data indicates buprenorphine safe and
effective in weaning newborn from
methadone with reduced length of stay
when compared to morphine.

Kraft WK, Gibson E, Dysart K, et al. Sublingual Buprenorphine for
Treatment of Neonatal Abstinence Syndrome: A Randomized Trial.
Pediatrics 2008;122:e601-607

98. Long half life
BUT, transfer to milk is minimal.
Maternal dose of 80 mg. per day (typical) yields
infant dose about 2.8% of maternal.
 Some studies indicate concentrations in breast
milk unrelated to maternal methadone dose.
 Appears to have mitigating effect on NAS –
shorter LOS of breast-fed infants.




Phillip BL, Merewood A, O‟Brien S. Methadone and breastfeeding;
new horizons. Pediatrics 2003;111:1429-1430.

99. 

Substantially reduced NAS.
Minimal to no effect on breastfeeding.
 Although some “lay” websites indicate breastfeeding
is contraindicated,
 All the evidence supports breastfeeding

If it is used to treat NAS in newborn and the
dose from breast milk is substantially lower, then
breastfeeding is not a problem.
 Kraft WK, et al. Sublingual buprenorphine for treatment of neonatal
abstinence syndrome: a randomized trial. Pediatrics; published online
August 11, 2008.

100. Hydrocodone, oxycodone and fentanyl.
Usual doses for pain relief appear to have
minimal to no effect on infant.
 However, many of these patients also use pain
moderators which may depress infant:


 Benzodiazapines: Xanax; Klonopin
 Gabapentin: Neurontin
 Amytryptilene: Elavil (generally safe)
 Cyclobenzaprine: Flexoril

High rate of tobacco use in these patients.

101. 


Documented High
dose in Breast
Milk,
Resulted in a
documented infant
death.
Breast feeding
contraindicated.

102. Does breastfeeding enhance or detract from
ongoing recovery in the postpartum patient?
 The most common cause of relapse is stress,
and it doesn‟t take much.
 If breastfeeding is not going well and the patient
is experiencing significant stress, she is ripe for
relapse.

 Plays into low self esteem - “I‟m a failure”
 Baby always crying – “I need some peace and quiet.”
 Despair – using drugs to “numb out.”

103. 




Pregnant addicts want to get better.
Addiction in pregnancy is treatable.
The average competent provider is expected
to be able to treat uncomplicated opioid
dependence in pregnancy.
Treating addicts saves money.
Putting them in jail costs 4-5 times more than
prenatal care.

104. And Now for Something Completely
Different…
Jennifer Nocon, Wolf in Fig Tree, 2010

105. Screening and Detection
Including Urine Drug Screens
A Brief Intervention Process:
FRAMES

106. First, An Important Digression:
• Alcohol and tobacco cause more fetal
damage,
• Than all the other drugs combined.

107. Strong Link Between Alcohol/Nicotine Use
and Use of Illicit Drugs
• Among Women using BOTH Alcohol and
Nicotine in the pregnancy
• 20.4% used Marijuana
• 9.5% used Cocaine
• Women NOT using Alcohol or Nicotine
• 0.2% used Marijuana
• 0.1% used Cocaine
Alcohol and Nicotine use is a “marker”
for other drug use.

108. Knowing That, If You Were to Ask
Only One Question to
Screen for Substance Use
Do you Smoke?
If yes, get a urine drug
screen.
If no, AND she did not use
alcohol in this pregnancy,
it’s unlikely she is using
illicit of illegal drugs.

109. Screening Strategies
 There is no “holy grail” for screening, that is, there is no
single or simple method that works across a range of
addictions.
 CAGE: alcohol in men.
 TACE: alcohol in women.
 TWEAK: alcohol in the current pregnancy
 Two Item Screen: broad screen for current use
 Four P’s Plus: broad screen for current pregnancy.
 CRAFFT: reveals drug behavior in adolescents

110. Screening and Detection
 A combination of screening tools will lead to an
increased level of detection.
 The more frequently the screening, the greater the
degree of detection.
 The evidence supports this premise.
 And also indicates that screening is, in itself, a
powerful form of intervention.
 But first, is there a duty to do any of this?
 And if so, why is there so much resistance?

111. Ethical Duty To Screen all Pregnant and
Postpartum Women for Substance Use
 The American College of Obstetricians and
Gynecologists (ACOG) Committee Opinion 422
addresses the ethical rationale for universal
screening for at-risk drinking and illicit drug use.
 American College of Obstetricians and Gynecologists. At-risk drinking and illicit
drug use: ethical issues in obstetric and gynecologic practice. ACOG
Committee Opinion No. 422, December 2008.
 The American Medical Association also endorses
universal screening.
 Blum LN, Nielson NH, Riggs, JA. Alcoholism and alcohol abuse among
women: report of the Counsel on Scientific Affairs. American Medical
Association. J Womens Health 1998;7:861-871
111

112. Universal Screening Means:
That every obstetrical patient is
asked about substance use.
 At the first prenatal or intake visit, and
 At least once per trimester thereafter.
Clear distinction between verbal
screening and drug screening
ACOG Committee Opinion No. 422, December 2008.
112

113. Why Universal Screening?
Early Detection Leads to Earlier Intervention
 Smoking cessation by 20 weeks:
 Many of the adverse effects of nicotine, cigarette
smoke and additives avoided, specifically:
20% of all low birth weight babies
8% of preterm babies
5% of all perinatal deaths
Did we mention that tobacco causes more fetal damage
than all the other drugs combined?
 Cocaine cessation by 24 weeks
Reduces prevalence of low birth weight and preterm labor
113

114. Screening Leads to Earlier Intervention:
Meconium Testing in 40 Term Newborns of
“Crack” Cocaine Positive Mothers Treated 2002-2007
 All 40 tested positive for cocaine at first prenatal visit.
 All used “crack cocaine.”
 27 (67.5%) negative at birth: mean newborn wt/gm:
3253.55; s.d. 473.99
 13 positive. mean newborn wt/gm: 2775.85: s.d. 466.68
p<0.01 (Author’s data base, Indiana University)
 It takes 10-14 weeks for the meconium to “clear” after
cessation of cocaine use - mechanism is unclear.
 Thus, for a term newborn to be negative, the mother had
to be drug free well before the third trimester.
 Early intervention clearly reduces the low birth weight
effects of cocaine use in pregnancy.
114

115. Universal Screening
Is Highly Cost Effective
 When identified and treated:





Rate of abstinence increases,
Maternal and fetal complications decrease.
Less Preterm labor
Less Growth restriction
Less abruption
 Reducing preterm labor and low birth weight
account for the largest savings.
 Hubbard RL, French MT. New perspectives on the benefit-cost and
cost-effectiveness of drug abuse treatment. NIDA Res Monogram
1991;113:94-113.
115

116. A Basic Screening Strategy
 Start with Two-Item Screen
 Follow with Four P’s Plus or CRAFFT
 Specificity about 75%
 Follow any “yes” answers with more specific evaluation.
 Follow any “yes” answers with UDS at that visit.

117. Initial Screening
Focus on Alcohol and Tobacco
 The Author recommends the following combinations
for their ease of use and high reliability.
 Two Item Screen and Modified Four P’s Plus
 Two Item Screen and CRAFFT
 The screening questions should be asked at the initial
history and physical and repeated at each trimester.
 Starting with questions about legal substances, alcohol
and tobacco, will be less threatening and patients are
more likely to acknowledge use of legal rather than illegal
substances.
117

118. Start with the Two-Item Screen
1. In the last year have
you ever smoked
cigarettes, drank
alcohol or used any
drugs more than you
meant to?
2. Have you felt you
wanted or needed to
cut down on your
smoking or drinking
or drug use in the last
year?
118

119. Two Item Screen
Validity Test

Two random samples of primary care patients
(434 and 702 participants) aged 18 to 59 had the
following results:

“No” to each question: 7.3% chance of a current
substance use disorder

1 yes answer: 36.5% chance

2 positive responses had a 72.4% chance

likelihood ratios were 0.27, 1.93, and 8.77
respectively

Brown RL, Leonard T, Saunders LA, Papasouliotis O. A two item conjoint screen for
alcohol and other drug problems. J Am Board Fam Prac 2001;14:95-106.
119

120. Negative Answers on
Two Item Screen
 If the patient states she does not use ATOD, she
is at low risk for substance use.
 Proceed to 4 P‟s Plus or CRAFFT
 Negative answers on either 4P‟s or CRAFFT
 Low risk of addiction – send for routine prenatal care.
 Urine screen only if all patients get initial urine screen.
 Any “yes”answer – order urine drug screen
 Drug screen positive – active using – intervention.
 Drug screen negative – needs more evaluation; repeat questions
and UDS at each prenatal visit.
120

121. Four P‟s (Plus) Screening
 Did any of your PARENTS have a problem with alcohol or
drugs?
 Do any of your PEERS have a problem with alcohol or drugs?
 Does your PARTNER have a problem with alcohol or drugs?
 Have you had a PROBLEM with alcohol or dugs in the past?
 (Plus) Have you smoked any cigarettes, used any alcohol or
any drug in this PREGNANCY?

Morse B, Gehshan S, Hutchins E. Screening for substance abuse during pregnancy:
improving care, improving health. Washington, DC: National Center for Education in
Maternal and Child Health; 1977.
121

122. Four P‟s Plus Results
 A “yes” answer to any question was considered positive.
 The modified 4 P‟s Plus screen adds a question about
the current pregnancy and a positive answer identifies
34% of drug and alcohol users.
 With a positive answer about “partner,” 65% were found
to need drug treatment.
 Chasnoff IJ, Hung WC. The 4 P’s Plus. Chicago, IL: NTI
Publishing; 1999.
122

123. CRAFFT
 C - Have you ever ridden in a CAR driven by someone (including
yourself) who was high or had been using alcohol or drugs?
 R - Do you ever use alcohol or drugs to RELAX, feel better about
yourself or fit in?
 A - Do you ever use alcohol or drugs while you are by yourself or
ALONE?
 F - Do you ever FORGET things you did while using alcohol or
drugs?
 F - Do your FAMILY or friends ever tell you that you should cut
down on your drinking or drug use?
 T - Have you ever gotten in TROUBLE while you were using
alcohol or drugs?

124. CRAFFT continued
 The authors indicate two or
more positive answers to
CRAFFT indicate a need for
further evaluation.
Chang G, Orav EJ, Jones JA, et
al. Self-reported alcohol and drug
use in pregnant young women: a
pilot study of associated factors
and identification. J Addict Med
2011; 5:221.
 Consider that any positive
answer indicates the
necessity for a urine drug
screen and further
assessment.

125. Negative Answers
Two Item Screen and 4P‟s Plus or CRAFFT
 This is typical of about 85% of your patients and
you have just successfully accomplished
universal screening in about 90 seconds.
 These women will be at a very low risk for
addiction and should receive routine prenatal
care for the remainder of the pregnancy.
 But, repeat screen in each trimester.
125

126. When the Screen is Positive:
 Patient is at risk for substance use
 Does not mean she is using.
 Urine Drug screen indicated.
 Brief Intervention is indicated.
 Assess psychiatric co-morbidity, especially PTSD.
 Re-evaluate in two weeks.
 If no change in behavior, refer to specific treatment
program.

127. Strategies for Using Urine Drug
Screens (UDS) Effectively
 Can be used to determine prevalence in a
population:
 consent not required
 both legal and ethical.
 Necessary to monitor opioid dependent
patients.
 Many providers use UDS as a routine
prenatal test at the first visit; this is highly
recommended:
 Use “opt out” approach for informed consent.
127

128. OPT OUT Approach
to Urine Drug Screens
 Inform patient about routine prenatal care and frequency
of visits.
 Inform patient that a number of routine screening tests
are done in pregnancy, which include blood tests,
diabetes tests, genetic tests, tests for sexual infections,
ultrasound, and urine tests for protein, sugar, infection
and drugs.
 Inform patient that she may “opt out” of any test.
 If patient opts out of urine drug screen, inform her that
pediatricians may order drug screens after baby is born.
128

129. Opt Out Rationale
 State laws are very liberal about what constitutes child
abuse.
 A patient who opts out of a urine drug screen creates a
reasonable basis to suspect drug use.
 Thus, pediatricians may legally order urine and
meconium tests on the newborn without parental
consent.
 Patient must be informed of this if she opts out.
 When informed and treated in a respectful manner, our
experience has been that patients rarely drop out of care.
 Not one of the author‟s 500 substance use patients opted
out.
129

130. Urine Testing
 It is important to distinguish
urine testing as a screening
process from urine testing
as a treatment adjunct.
 Urine testing only captures
recent use.
 In contrast, it is well
established that urine
testing in the substance
user at every visit enhances
recovery and abstinence.
130

131. How Long is a Drug Detectable
in Urine After Use?
Alcohol
24 hrs
Amphetamines
48 hrs
Barbiturates
Short acting
48 hrs
Long acting
7 days
Benzodiazepines
72 hrs
Cocaine
72 hrs
Marijuana
30-40 days
Morphine/Heroin
72 hrs
Methadone
96 hrs
Codeine
Nicotine
72 hrs.
Chronic use
Opiates
Single use
Up to 10 days
3-5 days from last use
131

132. Strategy for Routine Urine Testing for
Substance Use in Pregnancy
 First visit even if late
prenatal care.
 If 1st visit before 16 weeks,
repeat urine screen at least
once at 20-24 weeks
 Rationale: many of the
adverse effects of nicotine
and cocaine can be
markedly diminished if
intervention occurs in first
half or pregnancy
132

133. What Should the Urine Test
Include?
 Depends on the drug use in the area – why a
meconium prevalence study is necessary
 Indianapolis: THC, cocaine, opiates,
benzodiazepines most common;
methamphetamine rarely found.
 Southwestern Indiana: methamphetamine more
common than cocaine
 Northwest Indiana: “street methadone,” ecstasy

134. Urine Drug Screens Indicated:
 At each prenatal visit for any
patient identified as a
substance user.
 Missing appointments.
 Any prior history of drug use.
 Late Prenatal Care.
 Admits to using alcohol and
tobacco in current pregnancy.
 Preterm Labor – may be
opioid withdrawal.
 Persistent requests for opioids
or benzodiazepines.
 Abruption, also may be
opioid withdrawal.
 Monitoring methadone or
buprenorphine .
 Monitoring the opioid
dependent chronic pain patient.
 Dental carries
 Growth restriction.
 Unexplained fetal
demise.

135. Intervention Strategies
That Actually Work and are Easy to Implement
 FRAMES – 3-4 minute intervention
 Developed for alcohol reduction.
 Also a good template for any drug
intervention.
 Two Intervention Tools to Make It
Work:
 Feedback
 What‟s at Risk?
135

136. 136
Feedback Tool
Four Points For Clear Communication:
And Clearing up Agreements and Expectations.
1.
2.
3.
4.
Data – Objective Agreement
Feeling – Connection
Judgment – Subjective Opinion
Wants – What you want the patient
to do.

137. Feedback: Clearing Up the Data
How it Works
 Always start with the data, an objective description of the
behavior.
 And be very specific and non-judgmental.
 When the listener and speaker agree about the data, the
resistance to feedback is decreased.
 Example: “The data is…Your urine drug screen was
positive for THC” (you may have to show her
lab results)
the
137

138. 138
Connecting Through Feeling
 This is about your feeling:
 Use the following four basic feelings:
 Fear (afraid), Sad (grief), Mad (angry) and Glad
(happy)
 By expressing how you feel, the patient
connects at a deeper level.
 Most of the time the feelings for the provider will
be fear or sadness.
 Example: “I am afraid that you may lose custody
of your baby”

139. 139
Judgment or Opinion
 This is your judgment or opinion and not necessarily
the truth.
 It‟s important to “own” the judgment:
 this separates it from the data and feeling, and
 makes it sound less like a condemnation
 “My opinion is that you can readily commit to
quitting...” (be specific about what she will do)
 Works for cigarette smoking

140. Feedback:
Ask For What You Want
 What do I want to have happen?
 Key is to be specific – ask for something the patient
can do with success.
 Sets up a “win-win” for the patient
 Be Specific
 “I want you to go to two NA meetings this week.”
 Then, get specific about where and when.
 You may ask, “How will I know you went to the meetings”
140

141. 141
Feedback Summary:
The Four Point Approach to Feedback
 Clarifies the issues
 The capacity to share
feelings enhances
empathy in the
relationship.
 Empowers the listener to
act.
 The listener is more likely
to act than resist.
 Empowers accountability
and responsibility.

142. 142
Feedback from Friends
 A friend told me to always remember:
 What other people think of me is none of my
business.
 Another said, Perhaps a wee-bit more of the
scatological humor in this presentation
 And, it helps to keep in mind:
 When things become so serious and so sacred
that we can't laugh about them, it means that we
have elevated the profane to the realm of the
sacred and misplaced the sacred in the process.

143. What‟s At Risk
Is a Powerful Therapeutic Tool
 What’s at risk for you to stop smoking cigarettes?
 The patient may say there is no risk, obviously because she
knows quitting is beneficial. Well, there must be, otherwise
you would stop smoking.
 Then we “flip” the question, so to speak and ask, how does it
serve you to smoke or, what’s the payoff you have been
collecting all this time for keeping this pattern in your life?
 The Payoff is at risk if she quits smoking
 Helps to identify the choices made and the price they pay to get
whatever it is they want.
 They become aware of the cost of the pattern on their life.
 “What‟s at risk for you to stop smoking cigarettes?
143

144. What‟s At Risk?
The Benefits of the Behavior
 Whatever the answer, the question brings the patient into
an awareness of the problem and that the payoff, “feeling
good, relaxing”, etc., is the issue at risk, that is, she will
have to give that up if she stops smoking.
 Note that many women continue to smoke because they
have learned to use smoking to curb their appetite and
control their weight – that may be a very big payoff!
 And there may be much at risk (resistance) to quitting.
 Knowing this will allow for a more comprehensive
approach to the problem.
144

145. 145
What‟s At Risk?
Clinical Example
 At the first visit of a pregnant patient who tested
positive for cocaine.
 I ask, “name one way your life may be better by not
using cocaine (or smoking crack – I attempt to be
specific about dealing with how they use the drug).
 “I’ll be a better mother, or I’ll have more money for the
baby” are typical answers.
 So, what’s at risk for you to stop smoking crack and be
a better mother.
 The Risk is she will have to give up the very things she
fears the most.
 Often, it’s the friends with whom she smokes crack
 And, of course the drug reduces her fears.

146. 146
Follow Up What‟s at Risk
 Follow up quickly with a doable approach, that is, ask if
they are willing to cut down on their use of the drug
during in the next week?
 Again, ask what‟s at risk to do so – and when they
identify the payoff, ask if they will give some of that up for
one week.
 Most will agree to do so.
 Then get specific about what they will do to stop and how
will you know?
 Usually, they say they will have some extra cash. Keep
on asking the question, “how will you life be better if you
weren‟t using drugs?”
 In the author‟s clinical experience, 80% of patients will
substantially decrease or stop their substance use.

147. Now that you Have the Tools,
Let’s do a Brief Intervention
FRAMES INTERVENTION
 FRAMES was used in a World Health Organization study to
assess brief interventions. The study evaluated heavy male
drinkers from 12 countries with obvious cultural differences in
alcohol use.
 A brief intervention resulted in a decrease in alcohol use of
27%, compared to 7% among controls, still present 9 months
after the intervention.
 FRAMES also works well with other drug use.


World Health Organization Brief Intervention Study Group. A cross national trial of brief interventions
with heavy drinkers. Am J Public Health 1996;86:948-955.
Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993
Mar;88(3):315-35.

148. FRAMES:
Elements of a Brief Intervention
 F - Feedback about the adverse effects of drugs or
alcohol
 R - Responsibility for a change in behavior:
 A - Advise to reduce or stop use:
 M - Menu of options: treatment; medications
 E - Empathy is central to the intervention.
 S - Self-empowerment: You can change.

Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems; a review. Addiction
1993;88:315-335
148

149. Clinical Example: Patient Admits to Drug
Use, or Has a Positive UDS
 The patient answered “yes” to the 2nd question in the two
Item screen at her first prenatal visit:
 Have you felt you wanted or needed to cut down on your drinking,
smoking or drug use in the past year?
 She also answered “yes” to question 4 of the 4 P‟s Plus:
 Have you had a problem with alcohol or drugs in the past?
 AS a result a UDS was ordered with “opt out” consent and the
result was positive for cocaine.
 This is a good example of the value of point of service UDS.
 At the follow-up visit, it is important to show the patient a copy
of the positive drug test, in this case, cocaine. Such “proof” can
break through even the most hard-core denial.
149

150. First: Ask about Cocaine Use
 What type of cocaine do you use?
Crack
 How often do you smoke crack?
4-5 times per week
 How much does that cost you?
40 dollars a hit
 Does it get you high?
Don‟t wait for an answer - show her the test result.
 Start FRAMES intervention
150

151. FRAMES Intervention for Cocaine
Works for Alcohol, Tobacco and Other Drugs.
 Feedback
 About the adverse effects of Cocaine
 Specific feedback for specific drug
 Use Feedback Tool Formula: Data-FeelingOpinion-Want
 The data is your urine screen was positive for
cocaine
 I’m afraid that if you are positive at delivery,
CPS will investigate and may remove the baby
from your care.
 My opinion is that you can stop using
 I want you to stop using now
151

152. FRAMES Intervention
Responsibility
 Responsibility




For a change in behavior
Two simple statements:
“Only you can decide that you want to stop using.”
“Are you willing to stop using now?”
You may add, “I’m proud of you for choosing to
stop.”
152

153. FRAMES Intervention
Advise
 Advise to reduce or stop use:
 “Harm reduction” strategy works surprisingly
well.
 Medically, it’s a slow wean from the drug.
 "For the next week, will you cut down your use of
cocaine by 2 times per week. Can you make that
stretch?
 Set up a “win-win” for the patient, that is,
challenge her to do something she can do.
 “Since cocaine costs you 40 dollars a “hit,” that means you
will have 80 dollars more.”
 “I want you to buy something for yourself with the money.”
 “What will you buy?” (always reward success).
153

154. FRAMES Intervention
Menu of Options:
 Offer a MENU of Choices:
 "If you find that cutting back for the next week is
impossible, then we should consider other options.“
 Or, “You may need additional support for your
choice to stop using.”
 For example:
 Referral to counseling services/social services
 Adjunct medications;
 Support Groups: AA, NA, Smoking cessation
groups
154

155. FRAMES Intervention
Empathy and Self Empowerment
 Empathy is central to the intervention.
 “I realize this must be real hard to do.”
 “I am proud of you for considering a change.”
 “I am proud of you for being honest with me.”
 Self-empowerment:
 I am proud of you for agreeing to cut back.
 You will find that you can succeed.
 “I am glad that you continue to come for prenatal
care.”
155

156. FRAMES:
a Motivational Empowerment Approach
 Less emphasis on diagnostic label: “alcoholic;” “addict.”
 Reduces risk of “shaming”
 Motivation empowers patient to make choices and take
action – we call this “accountability.”
 Emphasizes personal accountability to change.
 Remember to order a UDS for each prenatal visit:
 Document the date of the negative test
 Tell her you are proud of her for getting clean
 This is very powerful reinforcement

157. The Motivating Questions
(to ask at every visit)
 “How will your life be better by not using (fill
in with substance)?”
 I‟ll be a better mother – of course you will.
 I‟ll have more money – how much more?
 I‟ll have a safer house – what do you need to be
safe?
 When she is clean ask, “How is your life
better now that you are not using
(substance)?”
 Record specific answers
 Say, “I‟m proud of you.”

158. Some Conclusions
 Addiction in pregnancy is treatable.
 We have a duty to screen and treat.
 Screening takes less that 5 minutes.
 Identifying the patient is more than half the
battle.
 Stay positive.
 Affirm someone else later today.
 Affirm someone every day.

159. The End, at least for now.
 Thank you for patiently persevering through
this lengthy presentation.
 This PowerPoint and others will be sent on
request: jnocon@me.com





Addiction Medicine in Pregnancy
Addiction and Breastfeeding
Effects on the Fetus
Motivational Tools for Brief Interventions.
Toolkit Opioid Dependence in Pregnancy