I was recently consulted on a 25-year-old female with a 3-year history of heroin dependence who has delivered her first child prematurely. She had been regularly attending her pre-natal appointments and has been compliant with treatment recommendations. She is HIV negative and is hepatitis C positive. At the time of the delivery she was receiving 40 mg of methadone 2 times daily. There were no complications during delivery. She was interested in breast-feeding her newborn and seeking my advice.
I would like to discuss the issues that are brought up by this case.
Among the substance use disorders in our community, which substance is most commonly associated with premature deliveries?
The most commonly abused substances associated with premature deliveries are opiates either in form of pain pills or heroin. This is then followed by alcohol, marijuana and cocaine. Recently there has been a spike in inhalant use as well as in use of synthetic substances which do not show up on regular drug screening and require specialized lab testing. Heroin tends to be disproportionately associated with premature deliveries.
How do you monitor compliance with treatment with patients with substance use disorders?
I will begin by outlining the Motivational interviewing stages. These are:
- Pre-contemplation: patient does not see a problem whereas others do. They may be aware of the cost of the problem but this is not seen as significant to them.
- Contemplation: Due to increasing knowledge of the problem, some people will develop concern about how their choices are affecting them and others in their immediate circle. They begin to weigh the pros and cons of their actions and inactions and at this stage, with increasing self-efficacy, may move into the next stage of determinism or preparation
- Preparation: here they may carry on as before or make a decision to change. They evaluate which behavioral changes they want to make and develop a plan for change. They begin to anticipate the benefits of change
- Action: At this stage, various activities that increase accountability for their choices and actions come into play. The success of the 12- step program which was begun to help address alcohol use disorders has been shown to be effective and members have accountability to each. The principles in this have been adapted to encompass other substance use disorders. Compliance in this case is measured by standards the pt. with regards to attending meetings, having clean urine random drug screens, attending the daily methadone clinics for their daily doses of methadone as well as the recommended individual therapy, compliance with antenatal visits.
- Maintenance: in this stage, the desired behaviors are maintained and many individuals in this stage for years whereas others may relapse and the whole cycle starts again. Substance use disorders are chronic relapsing and recurring conditions and individuals need to be supported through the various stages. The longer the longer the maintenance stage is maintained, this higher the likelihood of increased functioning but the relapse potential is a cloud constantly looming over these patients and they must be advised that their tolerance to substances is so low that a dose of an opiate that they could handle with ease in the past could be fatal after a period of abstinence.
Many people oscillate between these stages until the benefit of being off the substance becomes the overriding motive and then the maintenance stage needs to be continued by behaviors that will maintain the change. AA meetings and 12 step program have a proven to be of greater value in this stage. Becoming a sponsor is the greatest predictor of maintenance of sobriety and many people who have recovered from various addiction become sponsors or recovery specialists and this help them in their own journey. Individuals in treatment get weekly urine drug screens at the initiation of treatment and this frequency is tapered down as the patient maintains the benefits or is tapered up as the need arises.
What is the recommendation for methadone use in pregnancy?
Methadone should be continued in pregnancy and the dose may need to be increased. The patient may present with increase cravings or chills despite being on the methadone and these are the two indicators of the need to gradually increase the dose of methadone in pregnancy. Expectancy mothers are advised not to try tapering off the methadone in the first or third trimesters due to the degree of stress of the fetus and mother and the high likelihood of relapse into heroin use after discontinuing methadone. It is safest to continue the methadone throughout the pregnancy. The alternative agonist is subtext whose dose also needs to be tapered up in pregnancy.
Should social services be involved in this case?
If the mother is doing what she is supposed to be doing and is in a safe environment, social service involvement may not be warranted.
What is the recommendation for breastfeeding in patients in this category?
Since she is HIV negative, she is encouraged to breastfeed. Hepatitis C is not a contraindication to breastfeeding and the mother is advised to ensure that there are no cracks on her nipples. Breastfeeding a newborn continues to provide a low dose of the opiate to help reduce the neonatal abstinence syndrome and reduce the overall length of stay in the hospital.
What is the recommendation for analgesic use in patients on opiate maintenance treatment?
The dose of replacement opiate that the patient is using does not deliver analgesic effect and the patient will need the maintenance dose of the opiate and additional opiates to deliver the analgesic effect. This can be in immediate release preparations for a short time then return to the maintenance dose alone. Issues with respiratory suppression effect will need to be monitored and informed consent is always necessary so patients are aware of the risks they are in due to the perils of their preexisting condition.
What is the expected length of treatment for patients on opiate replacement therapy- either methadone or buprenorphine?
Methadone replacement has been known to be a long term treatment and there is data of patients in nursing homes who have been on this for years. When Office based buprenorphine treatment was started, there was a notion that the patients will be tapered off over 6-24 months and be completely off any opiate replacement. More recent data has been questioning this initial treatment expectation especially as the disease model approach to substance use disorders becomes more prominent. Now, the information we are providing patients is from a better understanding of the chronicity of the disease, the structural and chemical changes associated with the damage caused by the substances that have been abused, and the high chances of relapse after completion of therapy. In a recent training I attended addressing the substance use disorders; a slide was shown showing the PET scan images before abuse, during active abuse and 7 years after sobriety. The images showed that even after 7 years of sobriety, the anatomy was so far from the pre-abuse anatomy that there was minimal difference with the slide shown in active use state. The current approach to the expected length of treatment is the lowest dose that will manage the cravings, keep the patient as functional as possible in the community taking care of themselves and their families and contributing to the community and keep the patient off the substances that they were abusing.
I hear you asking-
“So are we substituting one addiction for another?”
You are not alone in asking this question. I had this question too.
This is the approach I now have adopted in keeping with the principles of managing patients with addiction and after attending additional training in this area:
When a patient is being treated for hypertension, diabetes or asthma, and they are on the lowest dose managing their chronic disease, are they addicted to their antihypertensive or other medication as the case may be? Do you consider them dependent on it? No. There is usually an attitude of supportive approval of maintain the patient on the dose of medication that is helping them become all that they were meant to be, functioning in the family and community and avoiding the complications of their untreated condition. The attitude is different when dealing with substance use disorders because the disease causes manifests in interpersonal and social disruption, legal issues, and complications include incarceration, disruption of family status, incarceration all of which have a very negative connotation that draws no sympathy to the person with the problem. The current thinking in this issue is similar to that of maintenance of treatment of other chronic condition which the patient has to deal with for the rest of their lives. Work with the patient to use the lowest effective dose, maintain outpatient group, 12- step programs and for those who are set on getting off the replacement treatment, they can be off the buprenorphine for a period of at least 2 weeks and then can be started on Naltrexone 50-100 mg to manage cravings until this is no longer an issue. The patients are advised that if they relapse the naltrexone reduced the level of euphoria they were getting before and the dose that they had been tolerant to before their sobriety could be lethal if restarted. This has been the unfortunate circumstances with several people even in recent media coverage. Better treat with the opiate replacement than not!