Opiates in pregnancy Flashcards
Why do we get addicted?
Neuroplasticity
addiction prodcues a change in brain structure and function (adaptation to the drug)
molecular and cellular changes in partciular neurons alter functional neural circuits
this leads to changes in behavior consistent with addicted states
addiction is therefore a form of drug induced neural plasticity
Natural rewards
food, water, sex, and nuturing are natural rewards
they allow organism to feel pleasure
they reinforce the behavior for repetition
these are required for survival
brain has pathway responsible for reward
Core criteria of substance dependence
tolerance
withdrawl
craving
imparied control/ compulsive use/ relapse
socio occupational dysfunction
persistent use despite psycho/physical harm
RIsk factors envioronmental
availability of drug
poverty
social change
peer culture
occupation
culutural norms/attitudes
policies on drugs: tobacco and alcohol
RIsk factors individual
genetic
child abuse
personality disorers
family disruption and dependnece problems
poor performance at school
social deprivation
depression and suicide
Drug Abuse during Pregnancy: Stats
Illegal substance exposure in childbearing women is approximately 11% nationwide
Incidence of prenatal substance abuse ranges from 375,000 – 625,000 infants exposed annually
Women who seek treatment
Single moms, little involvement or financial support from birth fathers
Lack employment skills and education
Live in unstable or unsafe environments (household where others may use drugs, homeless)
Lack of transportation
Lack of childcare / babysitting options
Experience special therapeutic needs (codependency, abuse, incest, relationship troubles)
Experience special medical needs
Concurrent Complications
Hepatitis C HIV/Hepatitis B Legal Abuse Psychiatric comorbidities
Addiction as a chronic disease
Chronic relapsing condition which untreated may lead to severe complications and death
Retention in treatment is key
Behavioral changes are needed
Adherence is around 30% (similar to asthma, hypertension and diabetes
Principles involved in treatment
Unique opportunity for intervention due to maternal concern for fetal well being
Non-judgmental, warm, caring environment
Telling the patient to “just stop” doesn’t work
Necessity for cooperation between perinatal services, rehabilitation services and methadone maintenance services
Management in Pregnancy
Avoid withdrawal
Can be life-threatening to fetus
Hypoxia, bradycardia, intrauterine demise
Increased fetal movement is indicator of fetal withdrawal
Maintenance program with dose adjusted to the patient’s symptoms
Detoxification
Consider desire to quit and outpatient social support
Slow taper of medication
Medication assisted treatment (MAT) for addiction during pregnancy
Relapse is main issue
Methadone maintenance is current treatment of choice for opiate addicted pregnant women
Methadone maintenance for opiate dependent pregnant patients
Improve perinatal outcome, decreases IUGR
Avoidance of IV drug use
Decreased risk of HIV, hepatitis, subacute
Minimization of “drug-seeking” behaviors Prostitution, STDs Scheduled administration Circumvents recurrent withdrawal Decreased fluctuations in opioid level
Initiating Methadone
For patients on illicit narcotics
Hospitalize
Start methadone at 20mg BID or equivalent to street drug use
Increase dose by 10-20mg/day until on stable once daily dose
Refer to methadone clinic – dosage needs will change as pregnancy progresses
For patients on methadone
Refer to methadone clinic
Anticipate changes in dosage with progression of pregnancy
Increased plasma volume, reduced protein binding, increased tissue binding, increased metabolism
If on dosage < 40mg daily and gestational age less than 20 weeks – consider detoxification
