Medication for addiction therapy in pregnancy
A solution to an increasing problem
By Debra Guinn, MD, maternal-fetal specialist, Montana Perinatal Center
Illicit drug and alcohol abuse are one of the greatest challenges I face on a daily basis as a medical professional that works in the field of high-risk pregnancies, also called perinatology. The abuse and misuse of these substances has reached epidemic levels − even in rural Montana. Every week, I meet pregnant women who are struggling with one or more of these intoxicants: alcohol, tobacco, cannabis (marijuana), stimulants, hallucinogens, and/or opioids.
Like the rest of the nation, our state is trying to get a handle on the treatment and support related to the opioid crisis. Fortunately, there is an optimistic silver lining for expectant mothers with opioid use disorder. In contrast to some other forms of substance abuse, opioid use disorder is actually treatable with medication for addiction treatment (MAT). The MAT approach is safe for use during pregnancy and an extremely important strategy to improve the lives of mothers, babies and families. Pregnancy gives us an opportunity to throw a safety net around families in need. Soon-to-be mothers are generally motivated to improve their lifestyles to protect their unborn babies and be good mothers and are more likely to go to the doctor to get the care they need for their unborn babies. This creates an opportunity for a medical professional to help identify the substance use disorders and provide treatment for women who might not otherwise seek help. It is imperative that women with substance use disorders understand that doctors, nurses and social workers are working on their behalf to help them. They should be welcomed into care and not scared away.
In the medical community, there is now a realization that “addiction is a chronic disease, like diabetes and hypertension, and must be treated over the long-term with a recovery-oriented system. Treating it more slowly and with improved understanding will lead to better long-term outcomes” (Krans and Patrick, 2016). Not everyone who uses drugs or opioids become “addicted.” People have different vulnerabilities to these disorders. More than 50 percent of people with substance use disorders have one or more family members with similar issues. Regardless of family history, it can take only one exposure to narcotics or other drugs for an addiction to take hold (see chart).
For those less familiar with substance use disorders, it is easy to believe that correcting harmful behaviors is as simple as “just saying no” − but it’s not. For example, suppose a diabetic person simply stopped taking their insulin or a person with chronic hypertension stop taking their blood pressure medication? Both could result in irreparable harm. These medications are critical to successful treatment in addition to making significant life style changes. Individuals with a substance use disorder experience similar difficulties. Change is very hard. Defying old habits can be insurmountable alone. In fact, very significant changes occur in the brain of a person with opioid use disorder that requires years or even a lifetime to re-set.
The mainstay of treatment of opioid use disorder is MAT, medication for addiction treatment. MAT provides the foundation to change behaviors and habits. While some may see this as “trading one addiction for another,” that is not the case. The medications used in MAT are legally prescribed and monitored very closely for abuse. They are essential to help people return to a “normal” life.
These people need more help and I want to be part of the solution. I equipped myself with the additional education to help with women with substance use disorders and obtained a special waiver to prescribe buprenorphine through the American Society of Addiction Medicine (ASAM) and the Drug Enforcement Agency (DEA). Buprenorphine is a partial opioid agonist that is used to treat opioid use disorder. In very simplistic terms, the medication binds tightly to the opioid receptors in the brain and blocks other opioids from the receptors so users can’t get “high.” The medication also helps to reduce withdrawal symptoms and control cravings. This allows patients an opportunity to learn healthy patterns of behavior through therapy, counseling and support.
Another medication commonly used to treat opioid use disorder is methadone. It is prescribed by addiction specialists and is only available in five sites in Montana. Both methadone and buprenorphine are safe to use in pregnancy and have the potential to reduce the growing demands on society as a whole. It is estimated that as many as 60 percent of child protective services (CPS) cases involve substance use disorders which can often be effectively treated. Participants who are successful with MAT are less likely to have their parental rights taken away or see involvement from CPS. MAT also reduces transmission of sexually transmitted infections including HIV. High-risk behaviors, emergency room visits and incarcerations are also decreased using the MAT approach. MAT is cost-effective and improves the overall health of our communities.
One of the hardest parts of working with persons with any substance use disorder and particularly opioid use disorder is the high risk of relapse despite effective therapies. Relapse rates measure about 40-60 percent. Interestingly enough, these figures are similar to chronic diseases like hypertension, asthma or Type 1 diabetes (NIDA 2018). When relapses occur, I am saddened, frustrated and sometimes angry. At Kalispell Regional Healthcare, we are lucky to have two perinatal social workers, Jessie Blanc, BSW, and Lisa Smith, MSW, who work with our moms and babies to help avoid relapse. We are also fortunate to work in partnership with Healthy Montana Families, a Flathead Valley-based state program that provides in-home case management to families in need that can bolster positive parenting practices. The goal is to set patients up for success with MAT so they can be able to become effective members of the community.
Substance abuse is a treatable disease and full recovery is attainable. It’s critical that we reach out to those in need instead of demonizing them. Remember that when helping pregnant mothers struggling with drug and/or alcohol abuse, you are saving at least two lives. Babies are not addicts and it serves no purpose to discourage treatment of any user. If you know of any pregnant woman with a substance use disorder, please encourage a visit to Montana Perinatal Center or read more about our services online at krh.org/MontanaPerinatalCenter.
First published in Montana Woman magazine, July 2018
Maternal-fetal medicine specialist Debra Guinn, MD, FACOG, practices at the Montana Perinatal Center where she cares for mothers with high-risk pregnancies and provides advanced imaging and diagnostic services to her patients. She works together with obstetrical providers, neonatologists, pediatricians, nurses and anesthesiologists to develop an optimal plan of care to promote the health and well-being of both mothers and unborn children.