Wean­ing preg­nant women off opi­oids not harm­ful to fe­tus, study finds

Modern Healthcare - - NEWS - By Har­ris Meyer

Dr. Craig Tow­ers’ preg­nant pa­tients who were addicted to opi­oids fre­quently asked him whether he could help them get off drugs so their ba­bies wouldn’t suf­fer ag­o­niz­ing with­drawal symp­toms af­ter birth. Tow­ers and his group, High Risk Ob­stet­ri­cal Con­sul­tants in Knoxville, Tenn., see 300 to 400 opi­ate-addicted preg­nant women a year.

Like most doc­tors across the coun­try, Tow­ers would tell them no, be­cause detox would risk pre­ma­ture la­bor or even fe­tal death. In­stead, he would rec­om­mend that they re­ceive drug main­te­nance ther­apy with method­one or buprenor­phine through their preg­nancy.

That’s the long-stand­ing opinion of the Amer­i­can Col­lege of Ob­ste­tri­cians and Gyne­col­o­gists, even though it means new­borns are likely to suf­fer neona­tal ab­sti­nence syn­drome, or NAS, and have to be hos­pi­tal­ized and slowly weaned off the opi­oid drug.

But, chal­lenged by his pa­tients, Tow­ers dug into the re­search lit­er­a­ture and found stud­ies sug­gest­ing that detox­i­fi­ca­tion dur­ing preg­nancy is not harm­ful. So he and his col­leagues launched a five-year ob­ser­va­tional study of 301 opi­ate-addicted preg­nant women who un­der­went four detox meth­ods. The re­sults were pub­lished re­cently in the Amer­i­can Jour­nal of Ob­stet­rics and Gy­ne­col­ogy.

They found no ad­verse fe­tal out­comes re­lated to detox­i­fi­ca­tion. In ad­di­tion, among women who went through detox with ac­com­pa­ny­ing in­ten­sive be­hav­ioral ther­apy, only about 17% of their new­borns suf­fered NAS, pri­mar­ily be­cause the mother had re­lapsed.

The find­ings may prompt more physi­cians to break with stan­dard clin­i­cal prac­tice and of­fer detox ther­apy dur­ing preg­nancy, which could sharply re­duce the num­ber of ba­bies with NAS.

“I’m not say­ing, ‘Change what you’re do­ing and start detox­ing ev­ery­one im­me­di­ately,’ ” said Tow­ers, a pro­fes­sor of ob­stet­rics and gy­ne­col­ogy at the Univer­sity of Ten­nessee Med­i­cal Cen­ter. “But for 40 years we’ve not been do­ing that be­cause we thought it was harm­ful. We’ve now shown that’s not true. This is doable, but we have to set up be­hav­ioral pro­grams be­cause oth­er­wise the re­lapse rate is too high.”

“I’m happy to see some­one has had the courage to pro­vide out­come data,” said Dr. Mark Hu­dak, a pe­di­atrics pro­fes­sor at the Univer­sity of Florida Col­lege of Medicine–Jack­sonville, who coau­thored a 2012 ar­ti­cle in the jour­nal Pe­di­atrics on treat­ing NAS ba­bies. “This opens the door to fur­ther re­fine­ment to do this in a safe way to achieve the best re­sults.”

Hu­dak said doc­tors who wanted to try detox with preg­nant women of­ten were blocked by hos­pi­tals, fear­ful of the li­a­bil­ity risk.

The num­ber of ba­bies born with NAS in the U.S. grew five-fold be­tween 2000 and 2012, with more than 21,000 in­fants suf­fer­ing from the syn­drome in 2012, ac­cord­ing to the Na­tional In­sti­tute on Drug Abuse.

Ba­bies born with NAS may suf­fer seizures, high fevers, vom­it­ing, di­ar­rhea and se­vere dis­tress. They re­quire weeks of in­pa­tient treat­ment with drips of mor­phine or methadone. The long-term ef­fects of this drug treat­ment are un­known. Hospital care typ­i­cally costs $50,000 to $60,000.

In Ten­nessee alone, treat­ment for NAS ba­bies cost the state Med­i­caid pro­gram more than $60 mil­lion last year, Tow­ers said. If detox could re­duce the num­ber of NAS cases, he said, the state could take those sav­ings and fund ad­dic­tion treat­ment pro­grams for preg­nant women. He’s cur­rently talk­ing with Med­i­caid of­fi­cials about de­vel­op­ing such pro­grams.

Tow­ers is also work­ing with Dr. Ge­ogy Thomas in the small east­ern Ten­nessee town of Jel­lico— where about 60 ba­bies with NAS were born last year— to launch an in­pa­tient detox pro­gram for preg­nant women. Thomas is try­ing to per­suade Med­i­caid man­aged-care plans to ad­e­quately pay for these ser­vices.

“The best thing is to get moms off drugs when they are preg­nant, when they’re con­cerned about their fe­tus, and we’ve got their at­ten­tion,” Thomas said.

In Tow­ers’ study, one group of pa­tients re­ceived slow out­pa­tient treat­ment with buprenor­phine com­bined with in­ten­sive be­hav­ioral health­care; the NAS rate for their ba­bies was 17.2%. Two groups re­ceived rapid in­pa­tient treat­ment with buprenor­phine. One of the in­pa­tient groups also re­ceived res­i­den­tial be­hav­ioral care; their NAS rate was 17.4%. The other in­pa­tient group did not re­ceive res­i­den­tial be­hav­ioral care and had an NAS rate of 70.1%. A fourth group was in­car­cer­ated and went through cold-tur­key with­drawal. Their ba­bies’ NAS rate was 18.5%.

Tow­ers said his addicted preg­nant pa­tients are mo­ti­vated to get off drugs “be­cause they have some­one else they are re­spon­si­ble for.”

“This is doable, but we have to set up be­hav­ioral pro­grams be­cause oth­er­wise the re­lapse rate is too high.”

DR. CRAIG TOW­ERS

High Risk Ob­stet­ri­cal Con­sul­tants

Knoxville, Tenn.

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