Managing Opiate Addiction During Pregnancy

By Lisa Simpson

According to figures from the National Survey on Drug Use and Health, 5% of pregnant women in the US use illicit drugs, which rises to just over 20% in the under 18 age group. While heroin is used by only around 0.1% of women during pregnancy, a further 1% admit to using opiate based medications for purposes other than pain relief; prescribed opiates include codeine, fentanyl, hydrocodone, meperidine, morphine and oxycodone. Women are usually asked about their use of drugs early in their obstetric care to identify those who, along with their developing baby, are at risk from this habit. Displaying erratic behavior, signs of intoxication or withdrawal are easy to spot, but waiting till later in pregnancy to seek obstetric care, poor attendance at appointments and below expected weight gain are also indicators that a woman may be using opiates.

Risks from opiate use

Women who continue to use heroin during pregnancy risk reduced growth of their developing baby, fetal death, separation of the placenta from the uterus and premature labor. While birth defects have rarely been observed in babies born to women using opiates during pregnancy, a number of studies have demonstrated codeine use during the first trimester is linked to heart abnormalities; though this has not been seen with other prescribed opiates that have also been studied.

Methadone program during pregnancy

As well as treating pregnant women addicted to heroin with methadone, a similar maintenance plan is starting to be used with addiction to other opiates; there is also evidence that buprenorphine may be used as a safe alternative for management of opioid use, so this option may be presented to women. The dosage of methadone is determined by addiction specialists, who adjust the dose as required throughout pregnancy to avoid withdrawal; symptoms of this include cravings, anxiety, difficulty sleeping, feeling irritable and nauseous. Not only does this prevent these unpleasant symptoms for the mother, but protects her unborn baby; while withdrawal from opiates is rarely fatal for adults who are in good health, fetal death may occur in women who do not seek help with their addiction and try to withdraw on their own.

However, as with others who access help with opiate addiction, therapy goes beyond the prescription of methadone for pregnant women; she will also receive dependency counseling and have access to other medical and psychological interventions, as well as any other services deemed necessary. This ensures that by engaging in a program for therapy, women are more likely to receive prenatal care, which reduces the likelihood that complications will arise during their pregnancy. It is possible for most pregnant women to attend a methadone program on an outpatient basis, though in some cases it may be advisable to initiate methadone during a short stay at an opiate treatment center. While maintenance with methadone is preferred to withdrawal during pregnancy – even when medically supervised – due to the high risk of relapse, if participation within a methadone program is refused by a woman, the second trimester is the safest time for her to withdraw under the guidance of a specialist.

Neonatal Abstinence Syndrome

Although treatment with methadone is more likely to lead to a healthy pregnancy than if illicit opiate use was to continue, her newborn baby is at risk of developing a condition known as neonatal abstinence syndrome, which affects the nervous syndrome. As a result a baby’s sucking reflexes are uncoordinated, which interferes with feeding, and they are also more prone to be irritable. Babies who were exposed to methadone in the uterus usually develop withdrawal symptoms within their first three days after birth and while in some cases this may only last for a matter of days, in other infants they may remain for weeks. It is protocol for babies born to women who took opiates during pregnancy to be monitored for this syndrome so that treatment can be initiated as necessary; the obstetric and pediatric team work closely to ensure that the newborn receives optimal care to achieve normal feeding, weight gain and sleep patterns. As neonatal abstinence syndrome can be successfully managed and does not appear to have any lasting adverse consequences to physical or mental health, the advantages of initiating methadone in pregnancy far outweighs the risks.

Is opiate pain medication safe for addicts? Part I

A recent user question on VYou (see my response here) addressed the issue of prescribing addicts with opioid pain medication. Since prescription medication abuse and addiction is on the rise and getting more and more attention in the media every year, the question of whether addicts in recovery, or people who have dealt with substance abuse and addiction problems in the past, should be prescribed these medications is a very relevant one.

Chronic pain affects a substantial portion of the population worldwide (as many as 30%, see here). Opiate medications are one of the most commonly used approaches to treating such pain, which if untreated can cause serious disruptions to sufferers’ lives. Even when treated, chronic pain can be pretty debilitating. Some research (1) brings up good questions about the true effectiveness of opiate therapy for chronic pain, especially among long-term opiate users (like heroin and prescription pain medication addicts) but also among other drug using populations.

So how common is the practice? What sort of results do drug addicts usually get from these opiate therapies? And finally, how many of the addicts or drug abusers who receive these therapies end up abusing them and can we identify those people early so we can stop prescribing to them? In this three-part series of articles we’re going to cover these questions in-depth.

Prescription pain medication use in addict populations

Clinicians treating chronic back pain choose from a range of options, including opioid medications, exercise therapy, nonsteroidal anti-inflammatory medications, tricyclic antidepressants, acupuncture, and electrical stimulation. One study (1)  found wide variability in the percent of chronic pain patients prescribed opioids (from 3%-66%) although the studies varied widely in their size and population served – some even looks at general back pain and not chronic pain alone (they tended to have much lower opioid prescription percentages). Among chronic pain clinic patients, chronic opioid pain medication use was estimated at 19% (2).

Among addicted populations, concerns about tolerance, withdrawal, and abuse tend to cut prescription rates for opioid pain medications. However, past drug abuse can exacerbate pain issues, especially for people who abuse, or have abused, opiates in the past. For this reason, it can sometimes be difficult to properly manage pain in people with a history of addiction. One study (3) found that as many as 67% of patients in a Methadone Maintenance Program and 52% of patients in short term residential treatment programs were being prescribed opiates for pain. It’s important to note that these numbers are higher than those reported in other studies but that populations in treatment do generally show prescription rates higher than the general population. A study in Finland (a country that has great medical record data) found that opiate prescription rates in substance abuse populations were equivalent (not higher or lower) to those in the general population. The College of Problems on Drug Dependence itself had released an official statement noting that a balance must be reached between fear of opioid prescriptions for pain and the usefulness of opioid pain medication for chronic and severe pain (4).

Interestingly, it seems that of all opioid pain medication prescriptions, the largest increases in troubling use has been around oxycodone (Oxycontin), which gets mentioned as often in emergency departments (ED) around the country even though it is prescribed about one-third as often as hydrocodone (Vicodin). This is less surprising when you consider the fact that many addicts report using oxycontin in different ways including smoking, snorting, and injecting the stuff, which is stronger and does not have the same amount of fillers as most hydrocodone preparations. The fact that oxycodone is stronger also means it is more effective for pain relief through higher activation of the opioid system that is relevant for addiction.

In our next piece we are going to explore whether opiate pain medication is helpful in controlling pain among addicts and substance abusers, see you then!

Citations:

1. Martell, O’Connor, Kerns, Becker, Morales, Kosten, Fiellin. (2007). Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction. Annals of Internal Medicine, 146, 116-127.

2. Chabal, Erjavec, Jacobson, Mariano, Chaney (1997). Prescription Opiate Abuse in Chronic Pain Patients: Clinical Criteria, Incidence, and Predictors. Clinical Journal of Pain, 13, 150-155.

3. Rosenblum, Joseph, Fong, Kipnis, Cleland, and Portenoy (2003). Prevalence and characteristics of chronic pain among chemically dependent patients in methadone maintenance and residential treatment facilities. The Journal of the American Medical Association, 289, 2370-2378.

4. College on Problems of Drug Dependence taskforce on prescription opioid non-medical use and abuse: position statement.

Saving lives made easy – Treating opiate overdose with intranasal naloxone

oxycodone-addiction-big1Contributing co-author: Andrew Chen

Imagine that you and your friend have been using heroin (or another opiate). A few hours go by and you notice your friend is progressively becoming more and more unresponsive. You check on him and find that his breathing is shallow, his skin is cold, and his pupils are constricted. You recognize these as signs of opiate overdose and call for help. Now what?

Well… If you had some naloxone around, you might be able to treat the overdose and save your friend’s life before the paramedics even arrive.

Naloxone hydrochloride (naloxone) is the standard treatment for opioid overdose. Naloxone works by blocking opioid receptors, thereby removing opioid agonists, such as heroin or oxycodone, from those same receptors. As a result, the overdose is reversed and death is prevented.

What makes naloxone great is that it has no potential for abuse. In fact, it makes the user feel pretty crappy.

Naloxone is typically delivered through an injection, which makes it pretty much useless in many situations. However, it can also be delivered using an intranasal spray device. This intranasal form of naloxone is getting lots of attention recently because it is relatively easy to administer.

In 2006, The Boston Public Health Commission (BPHC) implemented an overdose prevention program, providing training and intranasal naloxone to 385 individuals deemed likely to witness an overdose. These individuals were often family members of opiate users or drug-using partners.

15 months later, the BPHC conducted a follow-up:

  • Contact was made with 278 of the original participants.
  • 222 reported witnessing no overdoses during the 15-month span.
  • 7 had their naloxone stolen, lost, or confiscated.
  • 50 reported witnessing at least one overdose during the 15-month span. Together, these 50 individuals reported a total of 74 successful overdose reversals using intranasal naloxone!

The BPHC program is not the only example of successful use of naloxone in opiate overdose prevention programs. Similar programs have popped up in Chicago, New York, San Francisco, Baltimore, and New Mexico.

Unlike injections, using a nasal spray isn’t rocket science. All of the participants in the BPHC program were trained by non-medical public health workers, which makes the idea relatively cheap. As the data shows, the participants were able to effectively recognize an opiate overdose and administer intranasal naloxone. By targeting at-risk populations and providing proper training, distribution of intranasal naloxone can help in saving lives.

For more information, check out our post Addiction and the brain part IV – Opiates

Citation:

Doe-Simkins, M., Walley, A.Y., Epstein, A., & Moyer, P. (2009) Saved by the nose: Bystander-administered intranasal naloxone hydrochloride for opiod overdose. American Journal of Public Health. 99(5)

More money more problems? Rich teens and drugs

Teens raised in affluent homes display the highest rates of depression, anxiety, and drug abuse according to a recent article in Monitor on Psychology, the APA‘s monthly magazine.

One of our recent posts dealt with some of the issues unique to teens and drugs. In addition to the issues we’d already mentioned, the article named a number of reasons for the high prevalence of mental-health issues among affluent teens. Among them were an increasingly narcissistic society, overbearing parents, and an common attitude of perfectionism.

Each of these reasons are likely contributors to the prevalence of mental health and drug abuse issues among upper-middle-class (and above) teens. Still, as far as I’m concerned, the main take home message of the article is this:

Money truly doesn’t buy happiness – Rich teens and drug use.

While drug abuse research often focuses on the lower socioeconomic strata these recent findings indicate that being financially stable offers little in the way of protection from some of the most common psychological difficulties.

Thankfully, the researchers cited in the article gave some simple advice to parents:

  • Give children clear responsibilities to help around the house.
  • Take part in community service (to unite the family and reduce narcissism).
  • Reduce TV watching (especially of reality TV shows that glorify celebrity and excess).
  • Monitor internet use.
  • Stop obsessing about perfect grades and focus instead on the joy of learning for its own sake.

I couldn’t agree more with these recommendations. Having taught a number of classes myself, I have witnessed the ridiculous inflation in students’ expectations of top grades. I think it’s time we turned attention back to the family and reintroduce some of the basic skills that many addicts find themselves learning much too late… Often in recovery.

Addiction stories: Hellish Heroin – Bambi’s heroin addiction story

Opiate Addiction can be a horrible thing whether it's to heroin, hydrocodone, oxycontin, or any one of a number of available opiates. This is only the first in a series of addiction stories we will have on the site.Addiction stories seem to have an impact that objective research can never have. This is another in a series of addiction stories submitted by our readers. I hope that everyone will benefit from learning about others’ experiences. There’s no doubt that Bambi’s experience of escalation in use from what seemed initially innocent is a common one. If you, or someone you know, needs help with their opiate addiction, try our rehab-finder for the best way to get reliable, verified, rehab recommendations.

A harrowing tale of heroin addiction:

When most people hear the word heroin, some things come to mind. Those of you who have never even thought of doing a drug like heroin, would never understand. And for those of you who you know who you are, whether you have found your way out, or are slowly still slipping away… Believe me, if you know who you are, then you know how it is. Realizing you’re addicted to something doesn’t hit you, until you mentally find your way out by accepting what has happened and letting go with only one hell of a memory. Continue reading “Addiction stories: Hellish Heroin – Bambi’s heroin addiction story”

Is marijuana addictive? You can bet your heroin on that!

marijuanaThis is the ultimate question for many people. In fact, when discussing addiction, it is rare that the addiction potential for marijuana doesn’t come up.

Some basic points about marijuana:

The active ingredient in marijuana, THC, binds to cannabinoid receptors in the brain (CB1 and CB2). Since it is a partial agonist, it activates these receptors, though not to their full capacity. The fact that cannabinoid receptors modulate mood, sleep, and appetite to some extent is the reason behind many of marijuana’s effects.

But how is marijuana addictive? What’s the link to heroin?

What most people don’t know is that there is quite a bit of interaction between the cannabinoid receptor system (especially CB1 receptors) and the opioid receptor system in the brain. In fact, research has shown that without the activation of the µ opioid receptor, THC is no longer rewarding.

If the fact that marijuana activates the same receptor system as opiates (like heroin, morphine, oxycontin, etc.) surprises you, you should read on.

The opioid system in turn activates the dopamine reward pathway I’ve discussed in numerous other posts (look here for a start). This is the mechanisms that is assumed to underlie the rewarding, and many of the addictive, properties of essentially all drugs of abuse.

But we’re not done!

Without the activation of the CB1 receptors, it seems that opiates, alcohol, nicotine, and perhaps stimulants (like methamphetamine) lose their rewarding properties. This would mean that drug reward depends much more heavily on the cannabinoid receptor system than had been previously thought. Since this is the main target for THC, it stands to reason that the same would go for marijuana.

So what?! Why is marijuana addictive?

Since there’s a close connection between the targets of THC and the addictive properties of many other drugs, it seems to me that arguing against an addictive potential for marijuana is silly.

Of course, some will read this as my saying that marijuana is always addictive and very dangerous. They would be wrong. My point is that marijuana can not be considered as having no potential for addiction.

As I’ve pointed out many times before, the proportion of drug users that become addicted, or dependent, on drugs is relatively small (10%-15%). This is true for almost all drugs – What I’m saying is that it is likely also true for marijuana (here is a discussion of physical versus psychological addiction and their bogus distinction).

Citation:

Ghozland, Matthes, Simonin, Filliol, L. Kieffer, and Maldonado (2002). Motivational Effects of Cannabinoids Are Mediated by μ-Opioid and κ-Opioid Receptors. Journal of Neuroscience, 22, 1146-1154.

Ray Charles – The movie, the legend, and the heroin addict

The movie Ray told the amazing story of an artist who struggled with heroin addiction and won.In 2004, only a few short months after Ray Charles passed away, Hollywood celebrated the life and legacy of the legendary R&B singer in a critically acclaimed biographical film. Anchored by a stunning performance by Jamie Foxx, “Ray” would go on to win two Academy Awards and introduce a younger generation to a giant of American song. But director Taylor Hackford’s most impressive feat may have been the film’s nuanced, evenhanded portrayal of Charles’ behind the scenes battle with serious heroin addiction.

In the attempt to portray his life in full, the film starts, appropriately, at the beginning, with a young Ray Charles Robinson growing up in the poverty of 1930’s Georgia. With his hard-working mother emphasizing the strength and resilience he would need to make it in an unforgiving world, a young Ray would find his fortitude tested immediately, when he witnessed his younger brother’s accidental drowning, a scene that would haunt him for the rest of his life. When he began to lose his vision shortly thereafter, his mother challenged him to overcome it, telling him that it was up to him to never let anyone or anything make him into a cripple.

In response, Ray was able to channel his energy into his earliest love: the piano. By 1948, he was performing at bars in and around the Seattle area. It was here that he was first introduced to drugs in the form of marijuana, which venue promoters would offer him in order to calm pre-performance nerves. As he signed a record deal and hit the road in support of his career, the stresses of life on tour began to sink in. With that came depression, and what that, drugs. Plagued by flashbacks of his brother’s death, he found two new ways to escape- women, and heroin.

Though marriage, children and skyrocketing career success could have all potentially acted as stabilizing factors for his life, Ray’s depression and guilt over the death of his brother had taken hold, and he was now as addicted to womanizing as he was to heroin. Neither would prove to be beneficial for his long-term stability, as his wife would discover both in short order. Heroin addiction, as Ray was to find out, is never something you can keep on the side.

Neither, it seems, were the women. By 1956, Ray Charles had brought one of his lovers- a backup singer named Margie- into his band, and his life. When an unexpected pregnancy pushed their relationship to the breaking point, he had inspiration for one of his most famous songs (“Hit The Road, Jack”), but it was to serve as yet another signpost along his road to personal ruin. Although the turmoil would inspire him to take a powerful stand for the burgeoning Civil Rights Movement by refusing to play at segregated clubs in the South, his demons were never far, as the film shows by dramatizing his arrest on tour for possession of heroin. Though supported by friends and family, he again finds himself unable to kick his powerful heroin habit.

The film goes on to portray what might be called the lowest period in the life of Ray Charles, where, despite great personal success, the singer is forced to deal with the death of his lover (and mother of his 3-year old son) Margie and a second arrest for heroin possession in Montreal while on tour. Sent this time to court-ordered rehab, the film pulls no punches as Foxx effectively channels the deep physical, mental and emotional torment of heroin withdrawal. Dope sick and hallucinating, Charles remembers his mothers words: stand on your own two feet. Don’t let anyone make you into a cripple.” It is then, and only then, that he realizes that he has allowed his heroin addiction to cripple him more than his blindness ever could. It is a powerful statement about the insidious strength of drug addiction.

After getting out of rehab, Ray Charles stayed clean for the remainder of his life. As one of the greatest American entertainers of all time, his songs, image and career were always going to survive the test of time. However, thanks to the film Ray, he will also be remembered for a success that readers of this site know is just as challenging and monumental- winning a brave battle with a deadly drug addiction to heroin.

If nothing else, the movie “Ray” teaches us that recovery from addiction is possible though it may not be easy and may not look pretty from the outside. Regardless of the depths of the “bottom” addicts dig themselves into, it’s possible to make the climb back to a healthy, full, life. Though celebrities often find recovery from drug addiction difficult due to the stresses of their job, the relatively low expectations of success, and the fact that they’re surrounded by “yes (wo)men” who sometimes act in ways that sabotage success in recovery, it’s still possible to quit drugs even under those conditions. Remember that recovery is possible, and with the right tools and program, even likely.