Addiction,

Opioid Use Disorder,

and
Pregnancy

David H. Ryan MD FACOG

Assistant Professor
Division of
Addictions, Department of
Psychiatry
VCU Health System
david.ryan@vcuhealth.org
• OB/GYN
• Board certified OB/GYN
• UNC Chapel Hill 2007-2011
• Private Practice Greenville, NC 2011-2020

• Addiction Medicine Physician

• Board certified Addiction Medicine
• UNC Chapel Hill Fellowship 2020-2021
• VCU Division of Addictions

• Husband and Dad

Disclosures

No financial disclosures
Resources
Objectives

Ø Overview of substance use and addiction in general

Ø Overview of opioid use disorder in pregnancy
Ø Antepartum, intrapartum, postpartum
Ø Understand the need for compassionate, comprehensive care
 Overview of Substance Use Disorders
Ø Unhealthy use and addiction causes 23% of ALL DEATHS5
Ø Costs the United States 1.45 TRILLION
Ø~580B in economic loss, ~875B in economic harm

Ø 23 MILLION people need treatment for a SUD

Ø Less than 10% will receive treatment
Ø 85% of patients with diabetes will receive treatment

Ø PAST YEAR and LIFETIME prevalence rates of:

ØNon-alcohol drug use disorder: 3.9% and 9.9%
ØAlcohol use disorder: 13.9% and 29.1%
Ø Drug overdose is
Ø #1 cause of accidental death
Ø #3 cause of preventable death (tobacco, obesity)
The Opioid Epidemic in Waves
"The Fourth Wave"

SYNTHETIC OPIOIDS

COCAINE

PSYCHOSTIMULANTS
Overdose Deaths in COVID 19

21%
11%
4%
4%
32%
What is addiction?
 Definition of Addiction - ASAM

Ø CHRONIC, TREATABLE, MEDICAL DISEASE

Ø Involving complex interactions among
Continued
Ø brainuse DESPITE harmful consequences is a
circuits

SALIENT FEATURE
Ø genetics
Ø the environment
Ø an individual's life experience
Ø Prevention efforts and treatment approaches are generally AS
SUCCESSFUL as those for other chronic diseases
Ø People with addiction use substance or engage in behaviors that become
COMPULSIVE and often continue despite harmful consequences
 What is addiction?

Koob & Volkow

Lancet Psychiatry
It is NOT: 2016

Weak willpower
Bad character
Moral failing
 ACUTE AND CHRONIC SUBSTANCE USE: PATHWAY TO
ADDICTION
ACUTE
Euphoria
Withdrawal Normal

CHRONIC

Acute use Chronic use

Euphoria TREATMENT FOR SUBSTANCE USE DISORDER
People treated with medications for substance use
disorder feel NORMAL
Withdrawal Normal

Chronic use Maintenance

 Substance Use ≠ Substance USE DISORDER
National Survey on Drug Use and Health, 2020

Substance USE TOTAL % of people

DISORDER USE who use who
have a use
disorder
Marijuana 14.2 49.6 28%
Cocaine 1.3 5.2 25%
Methamphetamine 1.5 2.5 60%
Heroin 0.7 0.9 78%
 Why do some develop a use disorder?
• Family history • Substance-induced BRAIN
GENETICS • Dopamine receptor alleles dopamine surges
CIRCIUTS
• Metabolism • Age at exposure

ADDICTION
• Chronic stress • Adverse Childhood INDIVIDUAL LIFE
ENVIRONMENT • Current exposure Experiences (ACEs)
• Peer use EXPERIENCES
• Instability / abuse
 Adverse Childhood Experiences (ACEs)
1995-1997:
~14,000 patients in Kaiser Permanente
undergoing a physical exam answered a
confidential questionnaire
ACEs
ACEs
Trauma prevalence
 Co-occurring Mental Health Needs

Almost HALF of those with an SUD have

co-occurring mental health needs

About 1 out of every 3 people with

mental health needs
have a co-occurring SUD

NSDUH 2020, www.samhsa.gov

 Maternal outcomes with co-occurring
mental health needs

• 319 pregnant patients with OUD who were admitted from

2011 to 2018
• Self-reported those with and without psychiatric diagnosis,
and compared outcomes
 Return to Use / Relapse

ØSUDS should be viewed through the lens of

a CHRONIC DISEASE MODEL
ØRelapse / Return to Use is NOT
CERTAIN, but also NOT UNEXPECTED

ØIT IS NOT A REASON

TO DISCONTINUE TREATMENT

JAMA, 284:1689-1695, 2000

 Substance use before and during
pregnancy
60
Pregnancy is a time when people
are
50
READY TO MAKE A CHANGE

40

30

20

10

0
Alcohol Cigarettes Illicit
Not Pregnant First Trimester Second Trimester Third Trimester
National Survey Drug Use and Health
2013/2014 Past Month Use Data
Creedon Health Aff (Millwood) 2016
Stigma is keeping our patients away
 “There is a stigma with suboxone & methadone.
Overcoming those stigmas is a pain in the butt.”
“I was still on suboxone. They have an issue with suboxone in general”
“…if you don’t look normal, if you are not stable, if you don’t say the right thing or if you don’t
look healthy or not ready they will shut you down and take your kid away…I told them I
haven’t done anything for 10 years and I was on suboxone...I even worry that I have to speak
to them today but she said it's just part of the process. Mainly it's just that you cannot say the
wrong thing.”
“And then they tell me and all the treatment I was doing here – like going to group, going to
therapy, going to a group, seeing the doctor every week. They said ‘No we don’t know that
place, so we want you to go to this place’…the court won’t recognize it”
“It's just like you take suboxone and methadone to keep you off the hard stuff, but they don’t
see it as a good thing. They just think you’re taking this drug to replace something else. They
told me I was replacing heroin with suboxone. They literally told the judge that I wasn’t sober
and I was still doing drugs because I just replaced one drug with another which is doctor
ordered…It’s a good thing that [suboxone/methadone is] keeping you away from doing what
you used to do but I guess they don’t see it that way.” Martin et al. Substance Abuse. 2021
The words we use matter...
§ To provider
§ To patients
§ To society
Screening for
Substance Use Disorders
In Pregnancy
Screening

ACOG specifically recommends15:

BRIEF screening QUESTIONAIRE to
ALL pregnant women that could trigger a
BRIEF BEHAVIORAL INTERVETION and REFERRAL (if warranted)
Screening

Ø Infectious disease
Ø HIV, Hep B, Hep C
Ø Other complications of injections
Ø Endocarditis, abscesses, cellulitis, osteomyelitis
Ø Intimate partner violence
Ø History of trauma / assault
Ø Comorbid mental health needs
Opioids in pregnancy

Ø Other things to consider

ØHigh-risk activities
ØCo-occurring mental health conditions
ØOther SUDs
ØNicotine use / withdrawal
So what can we do?
Medication treatment SAVES LIVES

Buprenorphine

Methadone
 ONLY TREATMENT WITH
BUPRENORPHINE OR METHADONE

JAMA Network Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622 (Reprinted) February 5, 2020

 Withdrawal management IS NOT treatment
Ø40-90% return to use after discharge from detoxification treatment ONLY
ØReview of 52 studies with 12,075 participants*
Ø MMT at appropriate doses is the most effective in retaining patients in treatment
and suppressing heroin
ØCochrane review 2014
Ø "High quality of evidence that buprenorphine was superior to placebo in retention
of participants in treatment at all doses examined."**

*Amato L, Davoli M, Perucci CA, Ferri M, Faggiano F, Mattick RP. An overview of systematic reviews of the effectiveness of opiate maintenance
therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat. 2005 Jun;28(4):321-9
**Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid
dependence. Cochrane Database Syst Rev. 2014 Feb 6;(2)
What patients say about MOUD...

"I don't feel high. I feel normal."

"I feel like a used
to before this all
happened."

"I don't have to constantly be thinking

about where to go, how to get (something)
to keep me from getting sick."
 Medications for OUD

Methadone Buprenorphine Naltrexone

Oral Sublingual / SQ IM

μ agonist / NMDA antagonist Partial μ agonist / κ antagonist Full opioid antagonist

CYP 3A4/2D6 CYP 3A4 *Non CYP enzyme

QTc prolongation -Paired with naloxone (misuse deterrent) -Has utility in AUD & OUD
Suboxone vs Subutex
-Ceiling effect

Suboxone is SAFE in pregnancy

MOTHER STUDY
-Published NEJM 2010
-Double- blinded RCT with 175 pregnant women with OUD
-Randomized to buprenorphine vs methadone

PRIMARY OUTCOME: Same incidence of NOWS

SECONDARY OUTCOME: In the buprenorphine group...
§ LESS medication for treatment of NOWS
§ SHORTER duration of treatment of NOWS
§ SHORTER duration of hospital stay
§ Women in methadone group were more likely to complete study (78% vs
67%)
 Medications for OUD and NOWS

DOSE
DOES NOT CORRELATE
TO NOWS / NAS SEVERITY
 Pain management
• CONTINUE MOUD at current dose
• Consider BID to TID split dosing
• Patients have complicated histories
• Trauma
• Fear
• Previous bad interactions with healthcare
• BELIEVE PATIENTS WHEN THEY TELL YOU THEY ARE IN
PAIN
• Utilize multi-modal pain management
• Leaving in epidural until the next morning
• Scheduled Toradol / Tylenol
• Opioid agonists ARE OK
• Repeat exposure to opioid agonists will lead to INCREASED dosing needs
• Consider higher affinity agonists like hydromorphone or fentanyl
 Other considerations

• Have the conversation BEFORE DELIVERY

• VCU: Routine OB anesthesia consult
• Nicotine replacement therapy / smoking cessation
• Close postpartum follow up
• Naloxone (Narcan) prescription and a conversation
Postpartum considerations
Schiff (Obstetrics & Gynecology) 2018
 190%

2/3!
CI 6.6–9.4) prenatal visits. Of the 46 women who therapies included: sleep aids, mo
had prenatal care and the opportunity to attend other classes of antidepressants. S
reuptake inhibitors were the dru
TIMING OF
monly discontinued during pregn
MATERNAL DEATHS
women who discontinued medica
ing a selective serotonin reuptake
POSTPARTUM
the 13 women who were docume
pedCOLORADO
the medications during
MMR DUE TO OVERDOSE = preg
atric medications on toxicology
5/100000
of (42% PRESCRIPTION OPIOIDS)
autopsy.
Social stressors were commo
the>50%
medicaldid records
not of women wh
attend
including unemployment
postpartum visit (n538 [
gle, divorced, or separated (n524
domestic violence (n511 [18.6%]);
uations such as homelessness (n5
rent domestic violence (n53 [5.1
Fig. 3. Temporal distribution of maternal deaths from self- Metz, Obstetrics & Gynecology 2016
medical record or coroner repor
harm by trimester of pregnancy and number of months
postpartum. Relatively few cases occurred during the child was noted to be involve
pregnancy. (n541 [69.5%]) of cases. Despite
Metz. Maternal Deaths From Self-Harm in Colorado. Obstet Gynecol social stress in the majority of w
VCU MOTIVATE clinic
• 501 N. 2nd St. off Jackson St.
• ASAM level 1 outpatient services
Addiction medicine
• Medicaid ‘preferred’ opioid-based
treatment program Access to VCU medical
services
Psychiatry consultation
• All providers offer to prescribe
buprenorphine (suboxone) for opioid VCU MOTIVATE
use disorder Referral to VCU violence
prevention & intervention
Group behavioral health
• Patients are offered full array of therapy

services, but not required to engage in

all (e.g., tailored to needs at the time) Individual behavioral
health therapy Social work
 VCU Women &
Addictions Program
VCU OB MOTIVATE
• Leadership: Caitlin E. Martin, MD MPH FACOG
• Marjorie O. Scheikl, MSN RN CNE

• Integrated care model:

• Substance use disorder treatment
• Reproductive/sexual health medical services
• Recovery support
• Wrap-around support services

• Trainee-based clinical service delivery: OBGYN

residents, Addiction Medicine Fellows, Clinical
Psychology PhD candidates, MSW interns, etc.

https://www.vcuhealth.org/services/womens
-health/our-services/ob-motivate-clinic
Summary – Key Take Aways

ØAddiction is a medical, chronic, and treatable disease

ØPatients deserve compassionate, empathic care without encountering
judgement or stigma
ØOutpatient follow up AND TREATMENT is key to recovery
References
1. https://www.commonwealthfund.org/blog/2021/drug-overdose-toll-2020-and-near-term-actions-addressing-it
2. www.cdc.gov
3. www.samhsa.gov
4. https://www.statista.com/chart/18744/the-number-of-drug-overdose-deaths-in-the-us/
5. ASAM Essentials of Addiction Medicine
6. https://www.drugabuse.gov/drug-topics/opioids/benzodiazepines-opioids
7. National Health Statistics Report, Jan 2020
8. Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013. Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Am J Public
Health. 2016;106:686–688
9. Centers for Disease Control and Prevention (CDC). Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI). Annual Average for United States 2011–2015
Alcohol-Attributable Deaths Due to Excessive Alcohol Use, All Ages. Available at: https://nccd.cdc.gov/DPH_ARDI/Default/Default.aspx
10. National Center for Statistics and Analysis, National Highway Traffic Safety Administration. Alcohol-impaired driving. In: Traffic Safety Facts: 2019 Data. Washington, D.C.:
U.S. Department of Transportation, 2019.
11. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the
leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58
12. Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicitdrug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N
Engl J Med 1990;322
13. Park-Lee E, Ren C, Sawdey MD, et al. Notes from the Field: E-Cigarette Use Among Middle and High School Students — National Youth Tobacco Survey, United States,
2021. MMWR Morb Mortal Wkly Rep 2021;70:1387–1389
14. Tobacco and Nicotine Cessation During Pregnancy, ACOG Committee Opinion, Number 807, May 2020
15. Heil SH, Melbostad HS, Rey CN. Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids. Prev Med.
2019 Nov;128:105794
16. Phillips, Lindsay A.; Shaw, Autherine (1 August 2013). "Substance use more stigmatized than smoking and obesity". Journal of Substance Use. 18 (4): 247–253
17. Cunningham, John A.; Sobell, Linda C.; Sobell, Mark B.; Agrawal, Sangeeta; Toneatto, Tony (1 May 1993). "Barriers to treatment: Why alcohol and drug abusers delay or
never seek treatment". Addictive Behaviors. 18 (3): 347–353
18. Marijuana Use During Pregnancy and Lactation, ACOG Committee Opinion, Number 722, Oct 2017
19. Willford JA, et al. Effects of prenatal tobacco, alcohol and marijuana exposure, Neurotoxicol Teratol 2010;32-580-8
20. Conner SN, Bedell V, Lipsey K, Macones GA, Cahill AG, Tuuli MG. Maternal marijuana use and adverse neonatal outcomes: a systematic review and meta-analysis. Obstet
Gynecol 2016;128:713–23
21. Chabarria KC, Racusin DA, Antony KM, Kahr M, Suter MA, Mastrobattista JM, et al. Marijuana use and its effects in pregnancy. Am J Obstet Gynecol 2016;215:506.e1–
22. Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA.
Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal
Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol. 2019 Jul;221(1):B5-B28.
23. Chen R, Pierce JP, Leas EC, et al Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017–2019 Tobacco Control Published
Online First: 07 February 2022. doi: 10.1136/tobaccocontrol-2021-056901
24. Exposure to Toxicants Associated With Use and Transitions Between Cigarettes, e-Cigarettes, and No Tobacco Hongying Dai, PhD et al. JAMA Network
Open. 2022;5(2):e2147891. doi:10.1001/jamanetworkopen.2021.47891
 Questions

david.ryan@vcuhealth.org
(c) 252-341-6820
(o) MOTIVATE 804-628-6777