March 24, 2025 • 31 mins
Join me, Dr. Casey Grover, as I provide a comprehensive guide to treating opioid use disorder during pregnancy, examining evidence-based approaches that protect both mother and baby through critical periods of care. The statistics are sobering - opioid use disorder in pregnancy has more than doubled in recent years, with overdoses now a leading cause of pregnancy-associated death.
• Two major medical societies (ACOG and ASAM) recommend treating with methadone or buprenorphine rather than attempting medication-free withdrawal
• Buprenorphine shows slight advantages over methadone for pregnancy outcomes, but the best choice is whichever medication keeps the mother sober
• Neonatal abstinence syndrome occurs when babies experience withdrawal after birth, but can often be managed with supportive care rather than medication
• Medication dosages often need adjustment during pregnancy as increased blood volume dilutes medication concentration
• Breastfeeding is compatible with both methadone and buprenorphine treatment
• The postpartum period brings unique challenges that increase relapse risk, requiring enhanced support for new mothers
• Two patient cases illustrate both successful treatment and the challenges of maintaining recovery while parenting a newborn
Visit centralcoastoverdoseprevention.org to learn more about preventing overdose deaths in your community.
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
This episode is going to be onthe topic of treating opioid use
(00:43):
disorder in pregnancy.
I gave this lecture a few weeksback as a part of my monthly
training for the drug andalcohol treatment program that I
work for, and I recorded thislecture to post on the podcast.
We've covered this topic opioiduse disorder in pregnancy once
before, with an episode thatcame out last summer.
This episode today is a muchmore holistic overview of opioid
(01:07):
use disorder and addiction inpregnancy, rather than a more
specific discussion ofpharmacology and the nuances of
medical decision making.
I hope you find it helpful.
My colleagues and I had a greatdiscussion after I gave this
lecture.
It's such an important topic.
Here we go.
Okay, so today we are going tobe talking about opioid use
(01:28):
disorder in pregnancy, and Iactually had a lot of fun
putting this lecture together,because there's a lot of funny
stuff on the internet about justhow awesome or not awesome
being pregnant is.
So many of you know my wife, drClose.
She's on the board for SunStreet and she's one of the
other addiction doctors and thiswas a meme I found about being
pregnant.
And the woman on the right is,I think, my wife's experience
(01:51):
with pregnancy.
So you can see the woman on theleft Pregnancy is amazing,
she's glowing, she's having agreat time, and the woman on the
right, the clothing is stained,she's been eating ice cream in
bed.
She's having trouble getting up.
My wife was done with pregnancyabout month seven.
She was like you know what?
I'm ready to have this thingover with.
So I just want to acknowledgethat pregnancy is a very unique
time and for many women it isvery challenging.
(02:14):
Anecdotally, some people reallyseem to enjoy it and have a
positive experience from it, andother people have a lot of
issues, whether it's nausea andvomiting, early pregnancy pains.
It can be a very difficult timeand a lot of stress on the
mother.
But in honor of my wife, Ithought this was funny.
Okay, so I think we all knowthat America has a major problem
with opioids and this is achart and I really just looked
(02:37):
online for the waves of theopioid epidemic and we all see
the trend where we see anincreasing number of deaths from
opioid use disorder over timeand, as you can imagine,
pregnant women aren't sparedfrom this.
In other words, as addiction toopioids increases across
America, it's also going toincrease in pregnant women
(02:57):
because they are part of ourpopulation and arguably, one can
say there's probably a similartrend globally.
But this is American data andwe know that the opioid epidemic
has risen very steadily untilabout last year, when it may
have gone down a little bit.
So here are some numbers.
So, as I said, opioid usedisorder affects pregnant women
too, and you can see some datahere on the screen.
(03:19):
In 2010, the prevalence ofopioid use disorder was 3.5
people per 1,000 deliveries andby 2017, that had risen to 8.2
per 1,000 deliveries.
And just to give you somecontext, at our hospital in
Monterey we do about 1,100deliveries a year.
So that's something that we'regetting.
(03:42):
Probably a pregnant woman withopioid addiction once a month,
twice a month, something likethat.
So not particularly common atour hospital, but certainly in
large hospitals with largerlabor and delivery units it's
going to be a bigger problem orin areas where opioid use
disorder is more common in thegeneral population.
That's going to be higher.
That's going to be higher.
(04:08):
And this next slide is reallysad, which is that as opioid use
disorder becomes more common,unfortunately so do opioid
overdoses, and I found some datalooking at the number of fatal
overdoses in pregnancy in thepostpartum period.
And, just for reference, thepostpartum period refers to the
time immediately after delivery,and so the rate of overdose
deaths in pregnant women andwomen immediately after delivery
, and so the rate of overdosedeaths in pregnant women and
women immediately after delivery, that rate doubled between 2007
(04:30):
and 2016.
And then after that, between2017 and 2020, that rate
increased again by 81%.
And one of the articles Ilooked at was from a reference
for doctors called UpToDate, andit pointed out that
opioid-related overdoses are nowa leading cause of death
associated with pregnancy in thepostpartum period, and you can
(04:53):
just think how sad that is right.
Not only does the mother die,if it's during pregnancy, the
fetus dies, and if it's in thepostpartum period, we now have a
neonate with no mother, andit's very, very devastating to
families and in terms of theabsolute size of this problem,
the rate of opioid overdosedeath per pregnancy is anywhere
(05:14):
as high as 16 per 100,000.
So we might see that maybe onceor twice a year here in
Monterey for context.
So not a big, big problem herein our area, but obviously very
devastating and when you bringthose numbers out to include all
of America, it's a significantissue.
So obviously treating opioiduse disorder and preventing
overdose in a pregnant woman orin the postpartum period is
(05:36):
extremely important.
Now it turns out there are someother issues as well.
As we enter the fentanyl eraand this is a picture from a
news story that talks about thatthere is now thought to be a
birth defect syndrome whenneonates are exposed to fentanyl
in utero, and I don't thinkit's been fully worked out yet,
(05:59):
but there appear to be somechanges in the facial structure
and in the hands, and this isstill emerging data.
But again, what we're seeing isthat in mothers who use
fentanyl during the pregnancy,their babies may be born with
birth defects.
This was a particular childthat was highlighted whose
mother used fentanyl throughoutthe pregnancy, and I'm just
(06:19):
going to point out in thispicture you can see there's a
little white thing under hisneck.
That's a breathing tube, sothere are some difficulties with
the airway, the leg is in acast, so there's likely some
skeletal abnormalities, but youcan see at least the baby seems
very happy, and this was a storyabout a family that adopted
this child with special needs.
So as we shift from theprevious eras to the fentanyl
(06:42):
era, the reason to help treatwomen with opioid addiction
during pregnancy becomes evengreater, and I'll talk about
withdrawal in newborns as we getfurther on.
Okay, so how do we treat opioiduse disorder in pregnancy?
In the world of medicine, everyspecialty usually has a
professional association.
(07:03):
So I used to work in theemergency department.
We had the American College ofEmergency Physicians.
Thousands of emergency doctorsacross the country participate
and as a professional societythey make recommendations on
best practices, in other words,what's the most evidence-based
medicine.
So for OBGYN, that's theAmerican College of Obstetrics
and Gynecology that's calledACOG, and then the American
(07:26):
Society of Addiction Medicine,that's the American College of
Obstetrics and Gynecology,that's called ACOG, and then the
American Society of AddictionMedicine that's often referred
to as ASAM.
Both of these professionalsocieties recommend treating
opioid use disorder in pregnancywith methadone or buprenorphine
, and we'll talk about thedifferences.
But just at the highest level,obgyns and addiction doctors
across America all agree thatthe treatment for opioid use
disorder in pregnancy should beeither methadone or
(07:48):
buprenorphine.
Additionally, these sameprofessional societies, again,
that's the American College ofObstetrics and Gynecology and
the American Society ofAddiction Medicine, recommend
against withdrawal management.
And again, just to clarify,withdrawal management is the
idea is that someone just wantsto wean off of opioids, deal
with the withdrawal and not beon any medications for addiction
(08:10):
treatment like buprenorphine ormethadone.
And the reason for that isbecause once they are off of
opioids and not on buprenorphineor methadone, their risk of
relapse is very high.
And that goes back to this ideathat we're really trying to
prevent fatal overdose inpregnant women.
Now I mentioned two of theFDA-approved treatments for
(08:31):
opioid use disorderbuprenorphine and methadone.
What about naltrexone?
Well, naltrexone is actuallynot used in pregnancy because we
don't know the safety data andI don't know the history behind
this, namely why we have data onbup and methadone and we don't
have data on naltrexone.
But that's just where we're at.
And, for context, we don't usenaltrexone for alcohol use
(08:54):
disorder in pregnancy either.
So, and again, to quote theup-to-date article up-to-date
being a reference that doctorsuse across America quote
information related to the useof naltrexone for the treatment
of opioid use disorder duringpregnancy is limited, end quote.
And you know, if it's a reallybad situation and the only thing
that can keep a woman soberwhile she's pregnant is
(09:14):
naltrexone, it becomes a veryindividualized decision of
weighing out the risks andbenefits of a birth defect from
fentanyl, an overdose, it's just.
It's gotta be a reallymultidisciplinary, everyone's
informed kind of decision.
If we're going to usenaltrexone in pregnancy,
(09:35):
no-transcript Okay.
Now we have to realize thatwhile pregnancy is a very unique
state, many of the things thatcontribute to addiction during a
time when a person is notpregnant are the same as when a
person is pregnant or not.
If they're unhoused, it's thesame If they have severe
post-traumatic stress disorder,which we talked about before, if
(10:06):
they're a victim of domesticviolence or they're in an unsafe
living circumstance, all of thesame factors that we try to
address when people are notpregnant are the same when a
person is pregnant.
So it's really again we've gotto think about the whole
person's circumstance and notjust focus on the pregnancy.
And I thought I was beingreally clever here when I made
the point that mutual supportmeetings like AA and NA and
therapy are safe in pregnancy,meaning that there's no
(10:29):
medication, there's no sideeffects, there's no impact on
the fetus.
You can do all the therapy andmeetings you want while you're
pregnant.
Okay, so the next questionbecomes how do you actually
start methadone and orbuprenorphine in pregnancy?
How is it different?
And the answer is it's not.
(10:50):
Starting methadone andbuprenorphine in pregnancy is
the same as starting methadoneand buprenorphine in people who
are not pregnant.
Who are not pregnant.
So, just how we start methadone, we start at a dose.
We titrate up until we managetheir cravings and withdrawal.
That's the dose, exactly as wedo it for someone who's not
pregnant, and the same forbuprenorphine.
If they need 8 milligrams,great.
(11:11):
If they need 16 milligrams,great.
Now, granted, we want to treatwith the lowest effective dose
possible, but that's, again, notany different for a person
who's not pregnant.
No one needs extra methadone orbuprenorphine just because
we're going to want to treatwith the lowest effective dose.
And again, how I dose it is youbasically go up on the dose of
(11:31):
methadone or buprenorphine untilyou find a dose where they're
not having cravings and they'renot having withdrawal.
Now there is some data comparingmethadone and buprenorphine
head-to-head in pregnancy, andthe effect size isn't huge.
But when people are onbuprenorphine there is a lower
(11:52):
risk of preterm birth ascompared to those on methadone.
There is less neonatalwithdrawal also known as
neonatal abstinence syndrome,which I'll talk about and that's
lower in people who are onbuprenorphine as compared to
methadone.
And there's actually a higherbirth weight in mothers who are
on buprenorphine for theirbabies as compared to methadone.
(12:12):
So you might be thinking, okay,well, there appears to be a
slight edge to buprenorphineover methadone.
Be a slight edge tobuprenorphine over methadone,
but when we think about what theultimate goal is, which is
sobriety, the real answer towhich is better, methadone or
(12:34):
buprenorphine in pregnancy iswhichever keeps the person sober
, meaning that if somebody'sdoing great on methadone, we
don't switch.
If somebody really wants tostart methadone, go with that.
In other words, again, the mainfocus of what we're trying to
do is to keep them sober duringtheir pregnancy because of the
reduced risk of overdose andthen the reduced risk of fetal
harm.
(12:55):
Now, one thing that comes upthat a lot of mothers talk to me
about, that I've treated and weprobably think about when we're
treating someone with opioiduse disorder in pregnancy, is is
the baby going to withdraw andthe medical term for that is
neonatal abstinence syndrome orNAS.
And essentially what happens iswhen a mother is on
(13:17):
buprenorphine or methadone orfentanyl or heroin or morphine
or any opioid, that opioid goesinto their bloodstream and it
passes through the placenta andthe baby is exposed to it.
The baby develops a toleranceto the opioid and dependence on
the opioid, just like the mother.
So when the baby is born andthey stop getting placental
(13:40):
blood, they don't get any opioidand they get withdrawal the way
an adult would.
And symptoms are a little bitdifferent in a newborn.
They usually don't sleep well,but that's not that different
from adults.
They often are shaky or jitterythat's actually not that
different from adults.
They get sweating, a runny noseand yawning again very similar
(14:03):
to adults.
The main issues are that theyhave frequent crying and their
cry sounds different.
Some neonatal ICU nurses willactually say that they can
detect a neonatal abstinencesyndrome cry, it's just
different.
And then they have troublefeeding and that's probably
similar to the GI symptoms thatwe get in opiate withdrawal in
adults, like nausea, diarrhea,stomach cramping, that sort of
(14:26):
stuff.
So yes, this is a real concernfor moms that are using illicit
opioids and moms that are onmethadone or buprenorphine.
And just to go back a couple ofslides, the risk of neonatal
abstinence syndrome is actuallylower in moms on bup as compared
to methadone.
Now how do we treat neonatalabstinence syndrome?
(14:48):
Most often we do not usemedication, and there was a
campaign that came out a fewyears ago called Eat Sleep
Console, which is we try to helpthe babies feed, we try to help
the babies get to sleep byswaddling, and then we console
them.
We try to shush them, rock them, whatever it's going to be, to
(15:09):
help them be soothed, and theneventually they just deal with
their withdrawal.
They go through the withdrawal,they begin to feel better,
their tolerance and dependencego away and then they start
feeding more normally.
In more severe circumstances,babies may actually be given
morphine or methadone to treattheir withdrawal and then
they're weaned off of that.
Now, if you did not know, youcan actually, depending on the
(15:34):
hospital, sign up as a volunteerto help cuddle babies with
neonatal abstinence syndrome.
In one particular area ofFlorida, where there was a very
high rate of opioid use disorder, there was actually such a rush
of support from the communitythat there was a waiting list to
be a baby cuddler to beactually to be able to cuddle
(15:56):
babies in the hospital and thisis an article published by the
hospital computer system Epicthat there was a hospital in
Denver that actually did a studythat showed that babies who
were swaddled and consoled, whowere in neonatal abstinence
syndrome, actually did betterand went home sooner.
So again, we really focus onbehavioral interventions with
(16:16):
babies whenever we can.
So I mentioned that for babieswho are born to moms on
buprenorphine the risk ofneonatal abstinence syndrome is
lower compared to moms onmethadone.
But this is not a reason at allto switch off of methadone.
Again, the whole goal is tokeep the mom sober and keep her
in recovery throughout thepregnancy.
(16:37):
So if the mom's doing great onmethadone, keep it.
If the mom's doing great onbuprenorphine, keep it.
We can manage the neonatalabstinence syndrome after
delivery.
Now, as the pregnancy grows, themother experiences some changes
in her body.
So you can imagine a woman hasa fixed amount of blood in her
(16:59):
body as the pregnancy grows, theplacenta grows, the uterus
grows and the baby grows and thewhole blood volume that is
required to nourish all of thoseorgans and the fetus increases.
So you can imagine a woman hasa large pregnant belly.
That's more organ tissue andthe fetus that is requiring
(17:23):
blood and the term for this isthe volume of distribution.
In other words, there's justmore blood in the mother
circulating.
So you can imagine if you're oneight milligrams of
buprenorphine a day and thewhole blood volume in the mother
is five liters.
As the pregnancy grows and let'ssay it grows to six liters,
it's going to dilute out thedose of buprenorphine or
(17:45):
methadone.
So what tends to happen overthe pregnancy is that some moms
will start to feel somewithdrawal in the second
trimester and we actually haveto increase the dose of
methadone or buprenorphine asthe pregnancy progresses.
And I'll actually share a caseof one of my patients where this
happens and that's totallynormal.
Again, if a mom says I justfeel like I'm craving a little
(18:07):
bit, can we go up on the dose?
The answer is yes.
We have to keep the mother intreatment with methadone or
buprenorphine to keep her insobriety throughout the
pregnancy.
Okay, so we get to thepregnancy.
The mom delivers, mom delivers.
Vaginal delivery can beuncomfortable.
It can be painful.
Sometimes women will tearvaginal tissue and require
(18:31):
stitches afterwards.
Or there's a cesarean section,which is a surgery, so there can
be pain after delivery.
The best way to manage the painis to continue buprenorphine or
methadone and then add in, aspossible, non-addictive
medications on top of it, likeacetaminophen, if tolerated,
anti-inflammatories.
We might even add in a few daysof a full agonist opioid like
(18:54):
oxycodone or hydrocodone, andthen, once the pain is better,
within like maybe three to fivedays of delivery, we really just
switch them back to methadoneand buprenorphine again and
we're looking for the dose thatmanages cravings and withdrawal
so they can stay sober.
So pretty simple there.
My daughter and I had a lot offun coming up with funny
(19:15):
pregnancy and breastfeedingmemes for this talk.
I love this.
A happy baby.
It might be the milk talking,but I love you man.
So, yes, let's talk about thepostpartum period and
breastfeeding.
You're going to see a themewhich is in breastfeeding.
We just continue medication foraddiction treatment.
(19:36):
It is absolutely okay tobreastfeed while taking
methadone.
Again, we want to preventrelapse.
And it is okay to breastfeedwhile taking buprenorphine.
We want to keep them on thedose that prevents relapse.
You can imagine if a motherdies from opioid overdose, that
neonate just lost a parent.
Now one little nuance here isbuprenorphine may be a little
(19:58):
better for breastfeeding womenbecause, if you think about it,
how do we take buprenorphine?
We take it sublingually.
If we take buprenorphine orally, it doesn't really get absorbed
.
So for the neonate that'snursing from a mother taking
buprenorphine, it actuallydoesn't get very well absorbed.
So it might be a little saferin the postpartum period to
(20:20):
breastfeed while onbuprenorphine, as compared to
methadone.
But once again, the whole focusis to keep the woman sober and
focusing on getting adjusted tobeing a new parent.
So really again, if they'redoing well on methadone, stay on
methadone.
If they're doing well on bupe,stay on bupe.
Okay, parenting a newborn Idon't know how many of you have
(20:43):
kids, but parenting a newborn isparticularly hard.
Here are a couple of funnythings that I found about
parenting.
This is a card I found at agrocery store.
Parenthood it's like a hangover, with less tequila and more
vomit in your hair, and then Ilove this picture of this little
baby with a kind of a connivinggrin.
(21:04):
How do I put this?
You will never sleep in again.
Yes, parenting, particularlythe neonatal period, is hard for
every human on planet Earth,and if they say it's easy,
they're probably lying.
I'm obviously being facetiousthere, but yes, transitioning to
parenthood is very challenging.
As I said here, parenting anewborn it's hard, like really
(21:27):
hard.
I mean really hard.
Maybe my wife and I just had avery difficult newborn, but that
was probably the hardest thingI've ever done is just adjusting
to the lack of sleep, having tochange your whole routine.
And many of you have heard thismnemonic H-A-L-T.
Hungry, angry, lonely, tired.
That's when a relapse is mostlikely to happen in a person
(21:50):
who's trying to stay sober.
I often joke that hungry, angry, lonely, tired, that's when I'm
a bad parent, in other words,my willpower is down because I'm
already in a stress state.
So for pregnant women that arebreastfeeding, they may be very
hungry.
When the baby's crying andwon't stop, you can be angry.
If you're a spouse at home withthe baby while your spouse is
(22:12):
at work, you might be lonely.
And then the silly newbornsnever seem to sleep on a regular
schedule.
So every new parent I've met istired.
In other words, the stress ofparenting a newborn in and of
itself, in my mind, is a riskfactor for relapse because it
puts an enormous stress on ourpsyche as we try to accommodate
the needs of these small littlehumans we have brought into the
(22:33):
world.
A couple of personal storiesfrom my wife and I trying to
adjust to having a newborn.
In the picture on the left thatis me swaddling my daughter at
about maybe five weeks it'sprobably about two in the
morning.
In that photo you can see I'mon a bouncy ball trying to
gently bounce her to sleep.
To my right is the dog formoral support and in front of me
(22:55):
is the cat for moral support,and you can see to my left are
several blankets that we'vetried to wrap the baby in just
to try to get her to stop cryingand go to sleep.
The picture on the right weheard from another parent that
if you find a machine that makesa whirring noise, it will
soothe the baby.
So we literally were so sleepdeprived that we went through
(23:16):
the house and grabbed everymajor appliance we could find to
see if it would make the babystop crying.
So we've got the blow dryer,we've got a blender base, we've
got a can opener, we've got theleaf blower, we've got the
coffee grinder, we've got theCuisinart, we've got the mixer,
we've got the vacuum.
We literally tried everythingto get the baby to go to sleep.
(23:37):
Ironically, it was the blenderbase, that little blender base
you can see in the center of thescreen.
We traveled everywhere withthat thing for like six months
because it was the only thingthat would make the baby stop
crying.
And, mind you, this is parentingby two physicians.
You'd think we'd know all thetricks.
It was very, very hard for ustoo.
So again, I just want to saythe stress of a newborn is an
(23:59):
independent risk factor in mymind for relapse, just because
it's so hard.
New parents all across theworld need lots of support.
New parents in recovery needextra, extra support.
Okay, let's do two cases andthen we'll stop and we'll do
some questions.
Okay, so case number one.
These are both my patients.
(24:23):
I've changed the details ofboth of them to make sure that
they're not recognizable.
Okay, so case number one.
This is a 38-year-old female andshe presented to me in recovery
from opioid use disorder.
Her original drug of choice wasprescription opioids use
disorder.
Her original drug of choice wasprescription opioids.
She did have a fairly abusivechildhood.
She got an ankle injury and theopioids were very euphoric for
her.
She was using prescriptionopioids.
(24:44):
Thank goodness someone put heron buprenorphine and her doctor
retired.
They needed her to see a newdoctor to take over her
buprenorphine, and so that wasme.
She was working, she wasmarried, doing very well.
She's about three years soberwhen I first saw her and she was
on eight milligrams of Subutexdaily my next appointment with
(25:05):
her.
She was very happily surprisedthat she was pregnant and I
actually.
She was my very first pregnantpatient and I told her I don't
really know what to do with this.
I'd only been done with mytraining and was a new addiction
doctor.
I'd only been done with mytraining for maybe like three or
four months and I was debatingweaning her off of her bupe
because I was worried aboutneonatal abstinence.
(25:26):
And so I checked in with her OBand I talked to some colleagues
and everybody was just no, no,no, no, keep her on her bupe,
keep her on her bupe.
And no, no, no, no, keep her onher bupe, keep her on her bupe.
And she had a lot of questionsabout neonatal abstinence.
She was worried about wantingto wean down.
Significant opioid withdrawal isa risk factor for premature
labor.
So I said you know what?
Let's just keep you on bupe,you're on a fairly low dose and
(25:46):
let's see how it goes.
So I saw her every month.
For the first six months of herpregnancy and maybe about month
five, month six, she started toget some cravings and she was
getting further along in herpregnancy.
I realized as her pregnancy wasgrowing the buprenorphine was
getting diluted.
So I upped her dose to 12milligrams in the second
(26:07):
trimester and all of hercravings went away.
I increased the frequency ofher visits at 34 weeks to every
other week.
So she did very well.
At 34 weeks I saw her every twoweeks.
She did very, very well.
No change in her bup dosing.
And then at 38 weeks I checkedin with her every week and she
delivered and did great.
The only issue is she had aprolonged labor but she was able
(26:30):
to deliver vaginally.
She delivered a healthy girland even though she was on 12
milligrams of bupe, she hadabsolutely no neonatal
withdrawal.
She was home with her daughterthree days later and I just saw
her in person maybe about twomonths ago.
Baby's doing great.
She's still on 12 milligrams,she's back to work, she is a
(26:51):
happy new mom.
She has a lot of support fromher family.
She has a lot of support fromher family.
She has a lot of support fromher husband and she works in
healthcare and is very satisfiedwith her work.
And the only issue that came upafter I saw her last week is
that she was having somecravings for alcohol.
And we went through her historyand I realized she had a lot of
(27:11):
post-traumatic stress disorder.
So we upped her bupe and addeda little bit of praisesin at
bedtime because she wasn'tbreastfeeding.
And she's doing great.
Her nightmares went away.
She's doing totally fine atabout 24 milligrams of bupe per
day and she's back to work, noissues.
And so yes, that's got frombefore pregnancy, through
pregnancy, delivery, postpartumand back to work, all right.
(27:33):
Case two is not so happy.
So a 39-year-old female came tome for opioid use disorder and
she and her husband were both inrecovery from opioids and they
were both on buprenorphine.
She was taking 16 milligrams ofbup a day.
She got sober during herpregnancy so she didn't have a
(27:54):
lot of prenatal care.
So it was really a lot ofcatch-up in the second trimester
and we got her treated withbupe in the second trimester.
So once she got on bupe wedidn't really need to make any
changes.
She got taken care of at ourhospital in Monterey.
She had a healthy delivery, noissues, no neonatal abstinence.
They were able to go homewithin about two, three days.
(28:16):
They monitored the baby for anextra day just to be sure there
wasn't any withdrawal and thebaby did totally fine and they
got home from the hospital.
They were staying with somefamily.
They were first-time parentsand they were really excited.
I checked in with them aboutevery two weeks after the
delivery.
They were both doing fairlywell and, unfortunately, even
(28:40):
with family support, the stressof being new parents led to a
relapse for both of them.
Fortunately, they called myclinic right away.
Her parents offered to helpwith childcare.
She ended up well.
Actually they both ended updoing fairly well.
They realized this was a, youknow, a major detriment to their
child.
They were really supportingeach other, getting a lot of
(29:00):
support from family, a lot ofsupport from the peer support
folks in my clinic.
And the mother enrolled in anIOP and got back on bupe at a
higher dose.
She's at 24 milligrams and soparents help with child care
while she's in the IOP.
Okay, so what are some take-homepoints around?
Opioid use disorder inpregnancy.
So treat opioid use disorder inpregnancy with methadone or
(29:24):
buprenorphine.
The best choice is whateverworks to keep the patient sober.
There's maybe some small effectsize in some of the studies
that buprenorphine has a littlebit better outcomes in pregnancy
, but not in any meaningful wayto ever change what you're doing
.
If someone's doing great onmethadone, keep them on
methadone.
If someone's doing great on bup, keep them on bup.
We're going to continuemethadone and buprenorphine
(29:47):
through the pregnancy, deliveryand the postpartum period.
We want to keep them away fromhaving cravings and relapse.
And again, treating a patientwith opioid use disorder
involves thinking abouteverything housing, trauma,
mental health, whatever it'sgoing to be.
And then the last thing isparenting a newborn is hard.
Just period, new sentence.
(30:08):
Parenting a newborn is hard andin my mind I think of that as a
major risk factor for relapseand hopefully those two cases
were helpful.
I think that that is a majorrisk factor for relapse and
hopefully those two cases werehelpful.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction and ashout out to the nonprofit
(30:29):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(30:50):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Bye.
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
This episode is going to be onthe topic of treating opioid use
(00:43):
disorder in pregnancy.
I gave this lecture a few weeksback as a part of my monthly
training for the drug andalcohol treatment program that I
work for, and I recorded thislecture to post on the podcast.
We've covered this topic opioiduse disorder in pregnancy once
before, with an episode thatcame out last summer.
This episode today is a muchmore holistic overview of opioid
(01:07):
use disorder and addiction inpregnancy, rather than a more
specific discussion ofpharmacology and the nuances of
medical decision making.
I hope you find it helpful.
My colleagues and I had a greatdiscussion after I gave this
lecture.
It's such an important topic.
Here we go.
Okay, so today we are going tobe talking about opioid use
(01:28):
disorder in pregnancy, and Iactually had a lot of fun
putting this lecture together,because there's a lot of funny
stuff on the internet about justhow awesome or not awesome
being pregnant is.
So many of you know my wife, drClose.
She's on the board for SunStreet and she's one of the
other addiction doctors and thiswas a meme I found about being
pregnant.
And the woman on the right is,I think, my wife's experience
(01:51):
with pregnancy.
So you can see the woman on theleft Pregnancy is amazing,
she's glowing, she's having agreat time, and the woman on the
right, the clothing is stained,she's been eating ice cream in
bed.
She's having trouble getting up.
My wife was done with pregnancyabout month seven.
She was like you know what?
I'm ready to have this thingover with.
So I just want to acknowledgethat pregnancy is a very unique
time and for many women it isvery challenging.
(02:14):
Anecdotally, some people reallyseem to enjoy it and have a
positive experience from it, andother people have a lot of
issues, whether it's nausea andvomiting, early pregnancy pains.
It can be a very difficult timeand a lot of stress on the
mother.
But in honor of my wife, Ithought this was funny.
Okay, so I think we all knowthat America has a major problem
with opioids and this is achart and I really just looked
(02:37):
online for the waves of theopioid epidemic and we all see
the trend where we see anincreasing number of deaths from
opioid use disorder over timeand, as you can imagine,
pregnant women aren't sparedfrom this.
In other words, as addiction toopioids increases across
America, it's also going toincrease in pregnant women
(02:57):
because they are part of ourpopulation and arguably, one can
say there's probably a similartrend globally.
But this is American data andwe know that the opioid epidemic
has risen very steadily untilabout last year, when it may
have gone down a little bit.
So here are some numbers.
So, as I said, opioid usedisorder affects pregnant women
too, and you can see some datahere on the screen.
(03:19):
In 2010, the prevalence ofopioid use disorder was 3.5
people per 1,000 deliveries andby 2017, that had risen to 8.2
per 1,000 deliveries.
And just to give you somecontext, at our hospital in
Monterey we do about 1,100deliveries a year.
So that's something that we'regetting.
(03:42):
Probably a pregnant woman withopioid addiction once a month,
twice a month, something likethat.
So not particularly common atour hospital, but certainly in
large hospitals with largerlabor and delivery units it's
going to be a bigger problem orin areas where opioid use
disorder is more common in thegeneral population.
That's going to be higher.
That's going to be higher.
(04:08):
And this next slide is reallysad, which is that as opioid use
disorder becomes more common,unfortunately so do opioid
overdoses, and I found some datalooking at the number of fatal
overdoses in pregnancy in thepostpartum period.
And, just for reference, thepostpartum period refers to the
time immediately after delivery,and so the rate of overdose
deaths in pregnant women andwomen immediately after delivery
, and so the rate of overdosedeaths in pregnant women and
women immediately after delivery, that rate doubled between 2007
(04:30):
and 2016.
And then after that, between2017 and 2020, that rate
increased again by 81%.
And one of the articles Ilooked at was from a reference
for doctors called UpToDate, andit pointed out that
opioid-related overdoses are nowa leading cause of death
associated with pregnancy in thepostpartum period, and you can
(04:53):
just think how sad that is right.
Not only does the mother die,if it's during pregnancy, the
fetus dies, and if it's in thepostpartum period, we now have a
neonate with no mother, andit's very, very devastating to
families and in terms of theabsolute size of this problem,
the rate of opioid overdosedeath per pregnancy is anywhere
(05:14):
as high as 16 per 100,000.
So we might see that maybe onceor twice a year here in
Monterey for context.
So not a big, big problem herein our area, but obviously very
devastating and when you bringthose numbers out to include all
of America, it's a significantissue.
So obviously treating opioiduse disorder and preventing
overdose in a pregnant woman orin the postpartum period is
(05:36):
extremely important.
Now it turns out there are someother issues as well.
As we enter the fentanyl eraand this is a picture from a
news story that talks about thatthere is now thought to be a
birth defect syndrome whenneonates are exposed to fentanyl
in utero, and I don't thinkit's been fully worked out yet,
(05:59):
but there appear to be somechanges in the facial structure
and in the hands, and this isstill emerging data.
But again, what we're seeing isthat in mothers who use
fentanyl during the pregnancy,their babies may be born with
birth defects.
This was a particular childthat was highlighted whose
mother used fentanyl throughoutthe pregnancy, and I'm just
(06:19):
going to point out in thispicture you can see there's a
little white thing under hisneck.
That's a breathing tube, sothere are some difficulties with
the airway, the leg is in acast, so there's likely some
skeletal abnormalities, but youcan see at least the baby seems
very happy, and this was a storyabout a family that adopted
this child with special needs.
So as we shift from theprevious eras to the fentanyl
(06:42):
era, the reason to help treatwomen with opioid addiction
during pregnancy becomes evengreater, and I'll talk about
withdrawal in newborns as we getfurther on.
Okay, so how do we treat opioiduse disorder in pregnancy?
In the world of medicine, everyspecialty usually has a
professional association.
(07:03):
So I used to work in theemergency department.
We had the American College ofEmergency Physicians.
Thousands of emergency doctorsacross the country participate
and as a professional societythey make recommendations on
best practices, in other words,what's the most evidence-based
medicine.
So for OBGYN, that's theAmerican College of Obstetrics
and Gynecology that's calledACOG, and then the American
(07:26):
Society of Addiction Medicine,that's the American College of
Obstetrics and Gynecology,that's called ACOG, and then the
American Society of AddictionMedicine that's often referred
to as ASAM.
Both of these professionalsocieties recommend treating
opioid use disorder in pregnancywith methadone or buprenorphine
, and we'll talk about thedifferences.
But just at the highest level,obgyns and addiction doctors
across America all agree thatthe treatment for opioid use
disorder in pregnancy should beeither methadone or
(07:48):
buprenorphine.
Additionally, these sameprofessional societies, again,
that's the American College ofObstetrics and Gynecology and
the American Society ofAddiction Medicine, recommend
against withdrawal management.
And again, just to clarify,withdrawal management is the
idea is that someone just wantsto wean off of opioids, deal
with the withdrawal and not beon any medications for addiction
(08:10):
treatment like buprenorphine ormethadone.
And the reason for that isbecause once they are off of
opioids and not on buprenorphineor methadone, their risk of
relapse is very high.
And that goes back to this ideathat we're really trying to
prevent fatal overdose inpregnant women.
Now I mentioned two of theFDA-approved treatments for
(08:31):
opioid use disorderbuprenorphine and methadone.
What about naltrexone?
Well, naltrexone is actuallynot used in pregnancy because we
don't know the safety data andI don't know the history behind
this, namely why we have data onbup and methadone and we don't
have data on naltrexone.
But that's just where we're at.
And, for context, we don't usenaltrexone for alcohol use
(08:54):
disorder in pregnancy either.
So, and again, to quote theup-to-date article up-to-date
being a reference that doctorsuse across America quote
information related to the useof naltrexone for the treatment
of opioid use disorder duringpregnancy is limited, end quote.
And you know, if it's a reallybad situation and the only thing
that can keep a woman soberwhile she's pregnant is
(09:14):
naltrexone, it becomes a veryindividualized decision of
weighing out the risks andbenefits of a birth defect from
fentanyl, an overdose, it's just.
It's gotta be a reallymultidisciplinary, everyone's
informed kind of decision.
If we're going to usenaltrexone in pregnancy,
(09:35):
no-transcript Okay.
Now we have to realize thatwhile pregnancy is a very unique
state, many of the things thatcontribute to addiction during a
time when a person is notpregnant are the same as when a
person is pregnant or not.
If they're unhoused, it's thesame If they have severe
post-traumatic stress disorder,which we talked about before, if
(10:06):
they're a victim of domesticviolence or they're in an unsafe
living circumstance, all of thesame factors that we try to
address when people are notpregnant are the same when a
person is pregnant.
So it's really again we've gotto think about the whole
person's circumstance and notjust focus on the pregnancy.
And I thought I was beingreally clever here when I made
the point that mutual supportmeetings like AA and NA and
therapy are safe in pregnancy,meaning that there's no
(10:29):
medication, there's no sideeffects, there's no impact on
the fetus.
You can do all the therapy andmeetings you want while you're
pregnant.
Okay, so the next questionbecomes how do you actually
start methadone and orbuprenorphine in pregnancy?
How is it different?
And the answer is it's not.
(10:50):
Starting methadone andbuprenorphine in pregnancy is
the same as starting methadoneand buprenorphine in people who
are not pregnant.
Who are not pregnant.
So, just how we start methadone, we start at a dose.
We titrate up until we managetheir cravings and withdrawal.
That's the dose, exactly as wedo it for someone who's not
pregnant, and the same forbuprenorphine.
If they need 8 milligrams,great.
(11:11):
If they need 16 milligrams,great.
Now, granted, we want to treatwith the lowest effective dose
possible, but that's, again, notany different for a person
who's not pregnant.
No one needs extra methadone orbuprenorphine just because
we're going to want to treatwith the lowest effective dose.
And again, how I dose it is youbasically go up on the dose of
(11:31):
methadone or buprenorphine untilyou find a dose where they're
not having cravings and they'renot having withdrawal.
Now there is some data comparingmethadone and buprenorphine
head-to-head in pregnancy, andthe effect size isn't huge.
But when people are onbuprenorphine there is a lower
(11:52):
risk of preterm birth ascompared to those on methadone.
There is less neonatalwithdrawal also known as
neonatal abstinence syndrome,which I'll talk about and that's
lower in people who are onbuprenorphine as compared to
methadone.
And there's actually a higherbirth weight in mothers who are
on buprenorphine for theirbabies as compared to methadone.
(12:12):
So you might be thinking, okay,well, there appears to be a
slight edge to buprenorphineover methadone.
Be a slight edge tobuprenorphine over methadone,
but when we think about what theultimate goal is, which is
sobriety, the real answer towhich is better, methadone or
(12:34):
buprenorphine in pregnancy iswhichever keeps the person sober
, meaning that if somebody'sdoing great on methadone, we
don't switch.
If somebody really wants tostart methadone, go with that.
In other words, again, the mainfocus of what we're trying to
do is to keep them sober duringtheir pregnancy because of the
reduced risk of overdose andthen the reduced risk of fetal
harm.
(12:55):
Now, one thing that comes upthat a lot of mothers talk to me
about, that I've treated and weprobably think about when we're
treating someone with opioiduse disorder in pregnancy, is is
the baby going to withdraw andthe medical term for that is
neonatal abstinence syndrome orNAS.
And essentially what happens iswhen a mother is on
(13:17):
buprenorphine or methadone orfentanyl or heroin or morphine
or any opioid, that opioid goesinto their bloodstream and it
passes through the placenta andthe baby is exposed to it.
The baby develops a toleranceto the opioid and dependence on
the opioid, just like the mother.
So when the baby is born andthey stop getting placental
(13:40):
blood, they don't get any opioidand they get withdrawal the way
an adult would.
And symptoms are a little bitdifferent in a newborn.
They usually don't sleep well,but that's not that different
from adults.
They often are shaky or jitterythat's actually not that
different from adults.
They get sweating, a runny noseand yawning again very similar
(14:03):
to adults.
The main issues are that theyhave frequent crying and their
cry sounds different.
Some neonatal ICU nurses willactually say that they can
detect a neonatal abstinencesyndrome cry, it's just
different.
And then they have troublefeeding and that's probably
similar to the GI symptoms thatwe get in opiate withdrawal in
adults, like nausea, diarrhea,stomach cramping, that sort of
(14:26):
stuff.
So yes, this is a real concernfor moms that are using illicit
opioids and moms that are onmethadone or buprenorphine.
And just to go back a couple ofslides, the risk of neonatal
abstinence syndrome is actuallylower in moms on bup as compared
to methadone.
Now how do we treat neonatalabstinence syndrome?
(14:48):
Most often we do not usemedication, and there was a
campaign that came out a fewyears ago called Eat Sleep
Console, which is we try to helpthe babies feed, we try to help
the babies get to sleep byswaddling, and then we console
them.
We try to shush them, rock them, whatever it's going to be, to
(15:09):
help them be soothed, and theneventually they just deal with
their withdrawal.
They go through the withdrawal,they begin to feel better,
their tolerance and dependencego away and then they start
feeding more normally.
In more severe circumstances,babies may actually be given
morphine or methadone to treattheir withdrawal and then
they're weaned off of that.
Now, if you did not know, youcan actually, depending on the
(15:34):
hospital, sign up as a volunteerto help cuddle babies with
neonatal abstinence syndrome.
In one particular area ofFlorida, where there was a very
high rate of opioid use disorder, there was actually such a rush
of support from the communitythat there was a waiting list to
be a baby cuddler to beactually to be able to cuddle
(15:56):
babies in the hospital and thisis an article published by the
hospital computer system Epicthat there was a hospital in
Denver that actually did a studythat showed that babies who
were swaddled and consoled, whowere in neonatal abstinence
syndrome, actually did betterand went home sooner.
So again, we really focus onbehavioral interventions with
(16:16):
babies whenever we can.
So I mentioned that for babieswho are born to moms on
buprenorphine the risk ofneonatal abstinence syndrome is
lower compared to moms onmethadone.
But this is not a reason at allto switch off of methadone.
Again, the whole goal is tokeep the mom sober and keep her
in recovery throughout thepregnancy.
(16:37):
So if the mom's doing great onmethadone, keep it.
If the mom's doing great onbuprenorphine, keep it.
We can manage the neonatalabstinence syndrome after
delivery.
Now, as the pregnancy grows, themother experiences some changes
in her body.
So you can imagine a woman hasa fixed amount of blood in her
(16:59):
body as the pregnancy grows, theplacenta grows, the uterus
grows and the baby grows and thewhole blood volume that is
required to nourish all of thoseorgans and the fetus increases.
So you can imagine a woman hasa large pregnant belly.
That's more organ tissue andthe fetus that is requiring
(17:23):
blood and the term for this isthe volume of distribution.
In other words, there's justmore blood in the mother
circulating.
So you can imagine if you're oneight milligrams of
buprenorphine a day and thewhole blood volume in the mother
is five liters.
As the pregnancy grows and let'ssay it grows to six liters,
it's going to dilute out thedose of buprenorphine or
(17:45):
methadone.
So what tends to happen overthe pregnancy is that some moms
will start to feel somewithdrawal in the second
trimester and we actually haveto increase the dose of
methadone or buprenorphine asthe pregnancy progresses.
And I'll actually share a caseof one of my patients where this
happens and that's totallynormal.
Again, if a mom says I justfeel like I'm craving a little
(18:07):
bit, can we go up on the dose?
The answer is yes.
We have to keep the mother intreatment with methadone or
buprenorphine to keep her insobriety throughout the
pregnancy.
Okay, so we get to thepregnancy.
The mom delivers, mom delivers.
Vaginal delivery can beuncomfortable.
It can be painful.
Sometimes women will tearvaginal tissue and require
(18:31):
stitches afterwards.
Or there's a cesarean section,which is a surgery, so there can
be pain after delivery.
The best way to manage the painis to continue buprenorphine or
methadone and then add in, aspossible, non-addictive
medications on top of it, likeacetaminophen, if tolerated,
anti-inflammatories.
We might even add in a few daysof a full agonist opioid like
(18:54):
oxycodone or hydrocodone, andthen, once the pain is better,
within like maybe three to fivedays of delivery, we really just
switch them back to methadoneand buprenorphine again and
we're looking for the dose thatmanages cravings and withdrawal
so they can stay sober.
So pretty simple there.
My daughter and I had a lot offun coming up with funny
(19:15):
pregnancy and breastfeedingmemes for this talk.
I love this.
A happy baby.
It might be the milk talking,but I love you man.
So, yes, let's talk about thepostpartum period and
breastfeeding.
You're going to see a themewhich is in breastfeeding.
We just continue medication foraddiction treatment.
(19:36):
It is absolutely okay tobreastfeed while taking
methadone.
Again, we want to preventrelapse.
And it is okay to breastfeedwhile taking buprenorphine.
We want to keep them on thedose that prevents relapse.
You can imagine if a motherdies from opioid overdose, that
neonate just lost a parent.
Now one little nuance here isbuprenorphine may be a little
(19:58):
better for breastfeeding womenbecause, if you think about it,
how do we take buprenorphine?
We take it sublingually.
If we take buprenorphine orally, it doesn't really get absorbed
.
So for the neonate that'snursing from a mother taking
buprenorphine, it actuallydoesn't get very well absorbed.
So it might be a little saferin the postpartum period to
(20:20):
breastfeed while onbuprenorphine, as compared to
methadone.
But once again, the whole focusis to keep the woman sober and
focusing on getting adjusted tobeing a new parent.
So really again, if they'redoing well on methadone, stay on
methadone.
If they're doing well on bupe,stay on bupe.
Okay, parenting a newborn Idon't know how many of you have
(20:43):
kids, but parenting a newborn isparticularly hard.
Here are a couple of funnythings that I found about
parenting.
This is a card I found at agrocery store.
Parenthood it's like a hangover, with less tequila and more
vomit in your hair, and then Ilove this picture of this little
baby with a kind of a connivinggrin.
(21:04):
How do I put this?
You will never sleep in again.
Yes, parenting, particularlythe neonatal period, is hard for
every human on planet Earth,and if they say it's easy,
they're probably lying.
I'm obviously being facetiousthere, but yes, transitioning to
parenthood is very challenging.
As I said here, parenting anewborn it's hard, like really
(21:27):
hard.
I mean really hard.
Maybe my wife and I just had avery difficult newborn, but that
was probably the hardest thingI've ever done is just adjusting
to the lack of sleep, having tochange your whole routine.
And many of you have heard thismnemonic H-A-L-T.
Hungry, angry, lonely, tired.
That's when a relapse is mostlikely to happen in a person
(21:50):
who's trying to stay sober.
I often joke that hungry, angry, lonely, tired, that's when I'm
a bad parent, in other words,my willpower is down because I'm
already in a stress state.
So for pregnant women that arebreastfeeding, they may be very
hungry.
When the baby's crying andwon't stop, you can be angry.
If you're a spouse at home withthe baby while your spouse is
(22:12):
at work, you might be lonely.
And then the silly newbornsnever seem to sleep on a regular
schedule.
So every new parent I've met istired.
In other words, the stress ofparenting a newborn in and of
itself, in my mind, is a riskfactor for relapse because it
puts an enormous stress on ourpsyche as we try to accommodate
the needs of these small littlehumans we have brought into the
(22:33):
world.
A couple of personal storiesfrom my wife and I trying to
adjust to having a newborn.
In the picture on the left thatis me swaddling my daughter at
about maybe five weeks it'sprobably about two in the
morning.
In that photo you can see I'mon a bouncy ball trying to
gently bounce her to sleep.
To my right is the dog formoral support and in front of me
(22:55):
is the cat for moral support,and you can see to my left are
several blankets that we'vetried to wrap the baby in just
to try to get her to stop cryingand go to sleep.
The picture on the right weheard from another parent that
if you find a machine that makesa whirring noise, it will
soothe the baby.
So we literally were so sleepdeprived that we went through
(23:16):
the house and grabbed everymajor appliance we could find to
see if it would make the babystop crying.
So we've got the blow dryer,we've got a blender base, we've
got a can opener, we've got theleaf blower, we've got the
coffee grinder, we've got theCuisinart, we've got the mixer,
we've got the vacuum.
We literally tried everythingto get the baby to go to sleep.
(23:37):
Ironically, it was the blenderbase, that little blender base
you can see in the center of thescreen.
We traveled everywhere withthat thing for like six months
because it was the only thingthat would make the baby stop
crying.
And, mind you, this is parentingby two physicians.
You'd think we'd know all thetricks.
It was very, very hard for ustoo.
So again, I just want to saythe stress of a newborn is an
(23:59):
independent risk factor in mymind for relapse, just because
it's so hard.
New parents all across theworld need lots of support.
New parents in recovery needextra, extra support.
Okay, let's do two cases andthen we'll stop and we'll do
some questions.
Okay, so case number one.
These are both my patients.
(24:23):
I've changed the details ofboth of them to make sure that
they're not recognizable.
Okay, so case number one.
This is a 38-year-old female andshe presented to me in recovery
from opioid use disorder.
Her original drug of choice wasprescription opioids use
disorder.
Her original drug of choice wasprescription opioids.
She did have a fairly abusivechildhood.
She got an ankle injury and theopioids were very euphoric for
her.
She was using prescriptionopioids.
(24:44):
Thank goodness someone put heron buprenorphine and her doctor
retired.
They needed her to see a newdoctor to take over her
buprenorphine, and so that wasme.
She was working, she wasmarried, doing very well.
She's about three years soberwhen I first saw her and she was
on eight milligrams of Subutexdaily my next appointment with
(25:05):
her.
She was very happily surprisedthat she was pregnant and I
actually.
She was my very first pregnantpatient and I told her I don't
really know what to do with this.
I'd only been done with mytraining and was a new addiction
doctor.
I'd only been done with mytraining for maybe like three or
four months and I was debatingweaning her off of her bupe
because I was worried aboutneonatal abstinence.
(25:26):
And so I checked in with her OBand I talked to some colleagues
and everybody was just no, no,no, no, keep her on her bupe,
keep her on her bupe.
And no, no, no, no, keep her onher bupe, keep her on her bupe.
And she had a lot of questionsabout neonatal abstinence.
She was worried about wantingto wean down.
Significant opioid withdrawal isa risk factor for premature
labor.
So I said you know what?
Let's just keep you on bupe,you're on a fairly low dose and
(25:46):
let's see how it goes.
So I saw her every month.
For the first six months of herpregnancy and maybe about month
five, month six, she started toget some cravings and she was
getting further along in herpregnancy.
I realized as her pregnancy wasgrowing the buprenorphine was
getting diluted.
So I upped her dose to 12milligrams in the second
(26:07):
trimester and all of hercravings went away.
I increased the frequency ofher visits at 34 weeks to every
other week.
So she did very well.
At 34 weeks I saw her every twoweeks.
She did very, very well.
No change in her bup dosing.
And then at 38 weeks I checkedin with her every week and she
delivered and did great.
The only issue is she had aprolonged labor but she was able
(26:30):
to deliver vaginally.
She delivered a healthy girland even though she was on 12
milligrams of bupe, she hadabsolutely no neonatal
withdrawal.
She was home with her daughterthree days later and I just saw
her in person maybe about twomonths ago.
Baby's doing great.
She's still on 12 milligrams,she's back to work, she is a
(26:51):
happy new mom.
She has a lot of support fromher family.
She has a lot of support fromher family.
She has a lot of support fromher husband and she works in
healthcare and is very satisfiedwith her work.
And the only issue that came upafter I saw her last week is
that she was having somecravings for alcohol.
And we went through her historyand I realized she had a lot of
(27:11):
post-traumatic stress disorder.
So we upped her bupe and addeda little bit of praisesin at
bedtime because she wasn'tbreastfeeding.
And she's doing great.
Her nightmares went away.
She's doing totally fine atabout 24 milligrams of bupe per
day and she's back to work, noissues.
And so yes, that's got frombefore pregnancy, through
pregnancy, delivery, postpartumand back to work, all right.
(27:33):
Case two is not so happy.
So a 39-year-old female came tome for opioid use disorder and
she and her husband were both inrecovery from opioids and they
were both on buprenorphine.
She was taking 16 milligrams ofbup a day.
She got sober during herpregnancy so she didn't have a
(27:54):
lot of prenatal care.
So it was really a lot ofcatch-up in the second trimester
and we got her treated withbupe in the second trimester.
So once she got on bupe wedidn't really need to make any
changes.
She got taken care of at ourhospital in Monterey.
She had a healthy delivery, noissues, no neonatal abstinence.
They were able to go homewithin about two, three days.
(28:16):
They monitored the baby for anextra day just to be sure there
wasn't any withdrawal and thebaby did totally fine and they
got home from the hospital.
They were staying with somefamily.
They were first-time parentsand they were really excited.
I checked in with them aboutevery two weeks after the
delivery.
They were both doing fairlywell and, unfortunately, even
(28:40):
with family support, the stressof being new parents led to a
relapse for both of them.
Fortunately, they called myclinic right away.
Her parents offered to helpwith childcare.
She ended up well.
Actually they both ended updoing fairly well.
They realized this was a, youknow, a major detriment to their
child.
They were really supportingeach other, getting a lot of
(29:00):
support from family, a lot ofsupport from the peer support
folks in my clinic.
And the mother enrolled in anIOP and got back on bupe at a
higher dose.
She's at 24 milligrams and soparents help with child care
while she's in the IOP.
Okay, so what are some take-homepoints around?
Opioid use disorder inpregnancy.
So treat opioid use disorder inpregnancy with methadone or
(29:24):
buprenorphine.
The best choice is whateverworks to keep the patient sober.
There's maybe some small effectsize in some of the studies
that buprenorphine has a littlebit better outcomes in pregnancy
, but not in any meaningful wayto ever change what you're doing
.
If someone's doing great onmethadone, keep them on
methadone.
If someone's doing great on bup, keep them on bup.
We're going to continuemethadone and buprenorphine
(29:47):
through the pregnancy, deliveryand the postpartum period.
We want to keep them away fromhaving cravings and relapse.
And again, treating a patientwith opioid use disorder
involves thinking abouteverything housing, trauma,
mental health, whatever it'sgoing to be.
And then the last thing isparenting a newborn is hard.
Just period, new sentence.
(30:08):
Parenting a newborn is hard andin my mind I think of that as a
major risk factor for relapseand hopefully those two cases
were helpful.
I think that that is a majorrisk factor for relapse and
hopefully those two cases werehelpful.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction and ashout out to the nonprofit
(30:29):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(30:50):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
Bye.
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