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Opioid Dependence

Opioid Use Disorders A mong Mothers Dr. Surita Rao Chairman and Director, Behavioral Health Department St. Francis Care. Opioid Dependence. Mu opioid receptors : Responsible for analgesic [ pain control] effect , the euphoria associated with opioids, addictive properties.

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Opioid Dependence

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  1. Opioid Use Disorders Among MothersDr. Surita RaoChairman and Director, Behavioral Health DepartmentSt. Francis Care

  2. Opioid Dependence • Mu opioid receptors : Responsible for analgesic [ pain control] effect , the euphoria associated with opioids, addictive properties. • Tolerance and withdrawal • Dopamine: The Reward and re-inforcement neurotransmitter of the brain. Involved in addiction to any drug including alcohol or prescribed substances.

  3. Addiction : A brain disorder • The brain does not know the difference between a legal drug [ alcohol, nicotine], illegal drug, prescribed drug or a drug bought on the “street”. • There is nothing in science or nature that can re-create the effects of addictive substances on the brain!

  4. Addiction : A Brain Disorder • The mesolimbic pathway is the “ reward and reinforcement pathway of the brain. • It is a dopaminergic pathway. • It mediates drive behaviors [food and sex ]. • It is a phylo-genetically ancient pathway. You can also think of it as the “ lizard brain” • The reward and reinforcement pathway of the brain is “hijacked” in addictive illnesses to make the brain think the drug is more important than survival and survival of the next generation [ children]

  5. Women: Stress and hormones. • In general: Women process stress differently from men. • Several hormones play a part in the effects of stress on women . These include : • Cortisone : " stress" hormone of the body. Chronically Higher circulating levels can lead to lowered immune response, abdominal obesity • Epinephrine/norepinephrine [ also known as adrenalin and nor-adrenaline]: these are the “ flight or fight hormones of the body. In our prehistoric ancestors they flooded the body and brain when faced with a threat such as a tiger. The heart, rate, blood pressure and pulse go up. We are flooded with energy and an ability to run very fast. Today we are flooded with these with these hormones over and over with no real threat to life or limb. As a result women may develop hypertension, heart disease, anxiety disorders. • Oxytocin is the bonding hormone, it is associated with lactation and breastfeeding. In women oxytocin is released in response to stress at times to calm the body down. This can result in us trying to “ make things better” by taking care of people around us at the expense of our own emotional and physical needs.

  6. Women with substance use disorders Relationships • Abusive relationships [ physical, emotional, sexual, verbal] • The woman engages in sex for drugs or commercial sex to obtain money for her own drug use as well as that of her significant other. • Codependent Relationships • “Mutual” Abuse : verbal, physical fighting • Loss of relationship : BF or husband without any substance use disorder leaves and/or takes primary custody of the children. The mother is not able to see the children or has limited, supervised visit. • A large percentage of women have been introduced to the drug[s] for the first time by a boyfriend or husband. The relationship ends but they are left with the substance use disorder

  7. Women with substance use disorders: motherhood • Mothers with substance use disorder love their children but may not be able to get clean and sober in a timely manner to look after them and keep custody. • That is not a sign that they do not “ love their children enough”. • Addiction : The brain is “ hijacked” into thinking that the drug is the most important thing in life, more important than staying alive or looking after children[ the next generation] • Salience : a brain phenomenon in addiction.

  8. Ongoing heroin or oral opioid use exposes the mother and baby to risks of multiple bad outcomes • Experiencing the highs and the withdrawal everyday, sometimes multiple times within a 24 hour period • Drug using lifestyle: • commercial sex, exchange of sex for drugs, unprotected sex , sharing “ dirty “ needles and straws [ for intranasal heroin use] , both of which can cause the mother and baby to contract infectious diseases such as HIV , Hep C and B, herpes. • Using co-morbid drugs: alcohol, benzodiazepines, nicotine, cocaine, cannabis, hallucinogens, club drugs. • Poor nutrition • Lack of involvement or sporadic adherence with prenatal care

  9. Ongoing heroin or oral opioid use exposes the mother and baby to risks of multiple bad outcomes • Spontaneous abortion, • Amnionitis, • Chorioamnionitis, • Intrauterine growth retardation, • Placental insufficiency • Premature labor • Premature rupture of membranes • Eclampsia • Toxemia • Septic Thrombophlebitis • Abruptio placentae • Intrauterine death Finnegan, L.P[Ed][1978]Drug Dependence in pregnancy. Clinical management of mother and child. A manual for medical professionals and paraprofessionals prepared for the National Institute on drug abuse. Services branch, Rockville, MD. Washington DC. U.S government Printing Office

  10. The pregnant woman with an opioid use disorder needs immediate referral to agonist maintenance treatment [ Methadone or Buprenorphine Maintenance] • Maintenance treatment helps the pregnant woman to get: • Regular prenatal care • Stop using illicit substances • Lead a more stable life • Improve her nutritional status • Receive parenting education during her pregnancy Rao, S . Schottenfeld ,R. “ methadone Maintenance”. Chapter 29. Sourcebook on substance Abuse [ Etiology, epidemiology, Assessment and Treatment]. Edited by Ott, P.J. Tarter, R.E. Ammerman, R.T. 1999

  11. Testing the mother and baby for the presence of drugs at delivery. • The mother being in methadone maintenance treatment by itself is not a reason to refer to DCF • These mothers often have complex psychosocial issues. The social worker from the hospital to mete with them to help with referrals and anything else they need. • Urine toxicology is done [ in 24 hours]. Mothers needs to give permission to get Urine Toxicology screen in CT now. • Sometimes the baby poops in the first 12 hours , sometime later. • Meconium toxicology results come I [ 5-7 days]. No permission needed for Meconium Toxicity.

  12. MOTHER Study • In this trial comparing methadone with buprenorphine in opioid-dependent pregnant women, neonates exposed to buprenorphine required less morphine to treat neonatal abstinence syndrome (NAS) and had a significantly shorter duration of hospitalization and of treatment for NAS. • There are significant public health and medical costs associated with the treatment of neonates exposed to opioids, which in 2009 was estimated at $70.6 million to $112.6 million in the United States alone. • Just as the use of methadone in non pregnant patients with opioid dependence improves patient outcomes, its use as part of a comprehensive approach to the care of pregnant women improves maternal and neonatal outcomes, as compared with no treatment and with medication-assisted withdrawal. • However, exposure to methadone in utero can result in a neonatal abstinence syndrome (NAS) characterized by hyperirritability of the central nervous system and dysfunction in the autonomic nervous system, gastrointestinal tract, and respiratory system. • When left untreated, NAS can result in serious illness (e.g., diarrhea, feeding difficulties, weight loss, and seizures) and death.1 Methadone-associated NAS often requires prolonged hospitalization, pharmacologic intervention, and monitoring. • Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. Hendrée E. Jones, Ph.D., Karol Kaltenbach, Ph.D., Sarah H. Heil, Ph.D., Susan M. Stine, M.D., Ph.D., Mara G. Coyle, M.D., Amelia M. Arria, Ph.D., Kevin E. O'Grady, Ph.D., Peter Selby, M.B., B.S., Peter R. Martin, M.D., and Gabriele Fischer, M.D. N Engl J Med 2010; 363:2320-2331December 9, 2010DOI: 10.1056/NEJMoa1005359

  13. MOTHER study Screening, Randomization, and Rate of Treatment Completion, According to Study Group Jones HE et al. N Engl J Med 2010;363:2320-2331

  14. Mean Neonatal Morphine Dose, Length of Neonatal Hospital Stay, and Duration of Treatment for Neonatal Abstinence Syndrome. Jones HE et al. N Engl J Med 2010;363:2320-2331.

  15. Opioid Treatment Programs Opioid Treatment Program (OTP) Survey: 2011 This report presents a census of all SAMHSA-certified OTPs in the United States, both public and private, and presents both highlights and tabular information from the 2011 OTP survey. The OTP survey was fielded in conjunction with SAMHSA’s 2011 National Survey of Substance Abuse Treatment Services (N-SSATS).

  16. The OTP survey was fielded in conjunction with SAMHSA’s 2011 National Survey of Substance Abuse Treatment Services (N-SSATS).

  17. National Survey of Substance Abuse Treatment Services (N-SSATS) 2012

  18. Adolescent opioid use disorders : SAMHSA

  19. Among adolescent substance abuse treatment admissions reporting heroin abuse, almost half (48 percent) reported injection as the route of administration, and almost a third (32 percent) reported inhalation (Figure 1). Male adolescent heroin admissions were less likely than their female counterparts to report injection as the route of administration (43 vs. 56 percent), but were more likely than adolescent female admissions to report inhalation as the route of administration (36 vs. 27 percent).Figure 1. Route of Administration of Substance Abuse Treatment Admissions Aged 12 to 17 Reporting Any Heroin Abuse, by Gender: 2007

  20. Trauma issues • Childhood trauma [ verbal, emotional, physical, sexual , neglect] • Domestic violence • Trauma as a victim of sexual assault • Multigenerational trauma patterns in families

  21. Severe ongoing stressful , negative experiences • Exchanging sex for drugs which can leave the woman feeling exploited and coerced even if she entered into it “ willingly”. • Homelessness • In Childhood : Having to change neighborhoods, schools or mother changing boyfriends, husbands, significant others • Food insecurity • Lack of a stable income • Father of the baby being uninvolved or under involved • Father of the baby actively suing drugs or being in prison/jail • Lack of emotional support from family or friends

  22. Depression: Epidemiology • Depression: Women more than men • Depression: Lifetime prevalence of about 15% , maybe as high as 25% in women • Double Depression [ Dysthymia with superimposed MDD]: approx 20-25% of people with MDD • Dysthymic Disorder : approximately 6% • Bipolar Disorder I : 0.4-1.6% • Bipolar Disorder Type II: approx 0.5 % • Cyclothymia disorder : 0.4-1.0 %

  23. Depression in women • PMDD [ Premenstrual dysphoric disorder] • Post Partum depression • Menopause and perimenopause • Pregnancy • Take life issues and circumstances into consideration

  24. Depression in women • Women suffer from depression at higher rates than men. • Research has demonstrated the highest rate of depression is during the childbearing years. • Some women’s brains may be more vulnerable to the hormonal shifts and changes that occur throughout the reproductive years.

  25. “Baby blues” • Post partum Blues [ PPB]: “ Baby Blues” • Generally begin 2-3 days post partum and last 2 weeks or less. • Affect 50-85% of post partum women • Crying spells, anxiety, mood shifts , irritability, sadness.

  26. Post partum depression • The symptoms do not resolve within 2 weeks or impact the mother’s functioning. • 10-15% of post partum women suffer from it • DSM-IV criteria require the symptoms to begin within a 4 weeks period after birth of the baby.

  27. Post Partum Depression : Multi-factorial causes

  28. Doubts about parenting ability Feeling overwhelmed by caring for new baby Lack of emotional/childcare support Marital or financial difficulties Negative emotions about pregnancy Perceived loss of pre-child identity Body image issues after childbirth Fatigue after delivery Lack of sleep/disrupted sleep Stress due to lifestyle changes. Unrealistic expectations of being a "perfect mother.“ Substance abuse Tree.com Postpartum Risk Factors: Psychosocial/Environmental

  29. Post Partum Illnesses: Multi-factorial causes • Past history of mental illness • Family history of mental illness • Interpersonal problems, limited social support • Lack of good coping skills • Environmental problems. Massachusetts general hospital. Psychiatry update & board preparation. 2nd edition. Theodore A. Stern, John B . Herman. Chapter 28. Psychiatric disorders associated with the female reproductive cycle. Helen G. .Kim, Adele C. Viguera, Benita Dieperink

  30. Post Partum Psychosis • Very rare condition: 1-2 of every 1000 post partum women • Symptoms usually begins within 48-72 hours of delivery. • It is a medical emergency • Immediate hospitalization is needed

  31. Psychotherapy • Always make a referral to a therapist/ counselor specializing in dual diagnosis and substance use disorders. • The patient will get some psychosocial therapies at the methadone maintenance program or in the suboxone provider's office. Always find out the details , especially in the suboxone [ buprenorphine] provider’s office. Asses to see if the pregnant woman needs any additional level of care and make a referral. • Consider referring to a residential treatment program or an intensive outpatient program. • Parenting classes for the mother and the father or her family members or significant other. • Domestic violence issues. Does the woman need help with a safe place to live • Referral to prenatal care [ usually at a high risk Ob-Gyn clinic]. Monitoring and support to ensure optimal adherence to prenatal care appointments and recommendations. • Work with the patient to have appropriate release of information signed so that you can communicate with members of the extended treatment team.

  32. Bipolar Disorder: Epidemiology • Lifetime prevalence of classic bipolar disorder is approximately 1% • Studies that carefully estimate milder forms of mood elevation and include cyclothymia and Bipolar Disorder NOS : 2-5% lifetime prevalence. • Only 1/3rd have been diagnosed by a physician • Only 27% have ever received treatment • This rate of under-treatment is one of the worst among any psychiatric illness Chapter 14. Bipolar Disorder. . Perlis, Roy H. Ghaemi, S. Nassir Massachusetts General Hospital. “Psychiatry, Update & Board Preparation” Second Edition. Editors: Stern, Theodore A. Herman, John B

  33. Medications for the treatment of substance use disorders • Alcohol: Acamprosate333 mg , 2 tabs , 3 times a day. Naltrexone 50 mg daily [ LFT’s should be within 3 times normal]. Topiramate. • Opioids:Naltrexone: blocking agent for opioids • Agonist maintenance agents: [ these are also used for detoxification from opioids] • Methadone • Buprenorphine [ Suboxone]: partial agonist. Acts as a blocker at higher dosages. In the united states Suboxone is mixed with naloxone , so it will induce opioid withdrawal if crushed and injected.

  34. DAWN Statistics • This publication presents national estimates of drug-related visits to hospital emergency departments (EDs) for the calendar year 2011, based on data from the Drug Abuse Warning Network (DAWN). • DAWN is a public health surveillance system that monitors drug-related ED visits for the Nation and for selected metropolitan areas. The Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), is the agency responsible for DAWN. SAMHSA is required to collect data on drug-related ED visits under Section 505 of the Public Health Service Act. • DAWN relies on a nationally representative sample of general, non-Federal hospitals operating 24-hour EDs, with oversampling of hospitals in selected metropolitan areas. In each participating hospital, ED medical records are reviewed retrospectively to find the ED visits that involved recent drug use. • All types of drugs—illegal drugs, prescription drugs, over-the-counter pharmaceuticals (e.g., dietary supplements, cough medicine), and substances inhaled for their psychoactive effects—are included. • Alcohol is considered an illicit drug when consumed by patients aged 20 or younger. For patients aged 21 or older, though, alcohol is reported only when it is used in conjunction with other drugs.

  35. DAWN : Non Medical Use of Pharmaceuticals • Nonmedical Use of Pharmaceuticals • DAWN estimates that over 1.2 million ED visits involved nonmedical use of prescription medicines, over-the-counter drugs, or other types of pharmaceuticals in 2011. • At 46 percent, pain relievers were the most common type of drugs involved in medical emergencies associated with nonmedical use of pharmaceuticals; narcotic pain relievers were involved in 29 percent. Some form of follow-up was observed for almost 40 percent of visits. • Overall, medical emergencies related to nonmedical use of pharmaceuticals increased 132 percent in the period from 2004 to 2011, with opiate/opioid involvement rising 183 percent. In the short term, between 2009 and 2011, overall pharmaceutical involvement increased just 15 percent, and opiate/opioid involvement saw no significant increase. • One category of drugs that has experienced both short- and long-term increases in involvement is central nervous system (CNS) stimulants (e.g., ADHD drugs). The short-term increase in involvement of CNS stimulants (85%) echoes a similar short-term rise observed for involvement of illicit stimulants (amphetamines/methamphetamine) (71%). Source: SAMHSA

  36. Drugs and Alcohol Taken TogetherEd Visits DAWN • In 2011, about a quarter of all ED visits associated with drug misuse or abuse also involved alcohol. • Among all visits involving alcohol, 58 percent involved illicit drugs and 56 percent involved pharmaceuticals. • Among all visits involving illicit drugs, about 30 percent also involved alcohol; higher levels of alcohol involvement were found for visits involving ketamine (72%). • Among all visits involving pharmaceuticals, 25 percent also involved alcohol. Alcohol was present in 38.6 percent of visits involving penicillin, 38 percent of visits involving CNS stimulants, and 31 percent of visits involving antidepressants. Just under half of the patients received follow-up care. Source: SAMHSA

  37. Adolescent drug use : NIDA

  38. Adolescent drug use : NIDA

  39. Adolescent drug use : NIDA

  40. Questions, comments and discussion

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