TWO PATIENTS IN ONE
( continued from page 15 ) reactions during buprenorphine induction , even when the first dose is held until 12-24 hours after the patient ’ s last use of fentanyl . 2 Rapid quantitative testing for fentanyl and its metabolites could assist with pharmacological management , but these tests are not available for ASAP decision making .
Another challenge is the lack of case management and assistance for myriad social issues . Patient and societal goals go beyond merely ending the use of illicit drugs . SUD patients cannot be functional parents without safe housing , access to transportation , life skills training and employment . Postpartum women focused on immediate employment and securing housing while caring for a newborn , do not have sufficient “ therapeutic space .” Unfortunately , for those with limited means and family support , cognitive behavior health training , MAT visits or both are abandoned . Like all postpartum mothers , hormonal changes , sleep deprivation , depression and anxiety are likely in the first few weeks or months after birth . These conditions account for the high rate of relapse among postpartum SUD patients who are early in recovery . The rate of pregnancy associated mortality has increased significantly , especially in the last five to seven years . Drug overdose is the most common cause of mortality between two and 12 months postpartum . Drug-associated homicide and motor vehicle accidents are also major causes of deaths within one year of birth .
A large proportion of our MOST clients have family histories of SUD , trauma and high Adverse Childhood Experience ( ACE ) scores . Strong family history has traditionally been attributed to genetic factors , but recent evidence suggests that only 30-40 % of individuals with SUD have genetic markers associated with addiction . What of the fetal exposure to chronic opioids , illicit and therapeutic ? Emerging evidence suggest that such exposure is likely to result in epigenetic changes that may persist for multiple generations . Human and animal brain imaging studies have demonstrated morphological and functional changes well beyond birth . Randomized animal studies of in-uterus exposure to opioids vs . placebo have shown behavioral changes that persist , including a strong propensity to addiction when opioids are presented at maturity . Therefore , the epidemic of high-potency opioid use and the subsequent use of higher dose of MAT is a great cause of concern .
24 % were found to be functionally resilient , 65 % were abusing substances or dependent and 52 % had a criminal record .
Treatment for pregnant SUD patients should improve perinatal outcomes . Ideally , it should also be a catalyst for a plan of safe care , long-term parental recovery and the creation of a home environment that improves the long-term health and development of the children . Addiction has an early age of onset , and the incidence is related to genetics , prenatal drug exposure , environment ( including socioeconomic factors ) and ACE scores . If we are to break the “ cycle of addiction ” we need integrated care models within primary care , pediatric and obstetrical practices , to provide additional resources for family residential care during early recovery , and to empower children with education on the neurobiology of addiction .
Today , the primary medical approach to treating Opioid Use Disorder is essentially unchanged from the opiate agonist treatment proposed by Drs . Dole and Nyswander over 55 years ago . 4 Yet , the potency of abused opioids is hundredfold greater and neuronal dysregulation proportionally worse . I believe we urgently need to pursue other effective medical approaches . 5-7
References
1
SAMHSA . Highlights for the 2020 National Survey on Drug Use and Health . 2021 ; Available from : https :// www . samhsa . gov / data / sites / default / files / 2021-10 / 2020 _ NSDUH _ Highlights . pdf .
2
Wanar , A ., K . Saia , and T . A . Field , Delayed Norfentanyl Clearance During Pregnancy . Obstet Gynecol , 2020 . 136 ( 5 ): p . 905-907 .
3
Catalano , R . F ., et al ., An experimental intervention with families of substance abusers : one-year follow-up of the focus on families project . Addiction , 1999 . 94 ( 2 ): p . 241-254 .
4
Skinner , M . L ., et al ., Predicting functional resilience among young-adult children of opiate-dependent parents . J Adolesc Health , 2009 . 44 ( 3 ): p . 283-90 .
5
Towers , C . V ., et al ., Fetal Outcomes with Detoxification from Opioid Drugs during Pregnancy : A Systematic Review . Am J Perinatol , 2020 . 37 ( 7 ): p . 679-688 .
6
Weeks , D . and J . Weeks , Alternatives to Methadone for Opiate Addiction in Pregnancy . Journal of the Kentucky Medical Association , 2013 . 111 ( 10 ): p . 285-293 .
7
Towers , C . V ., et al ., Neonatal Head Circumference in Newborns With Neonatal Abstinence Syndrome . Pediatrics , 2019 . 143 ( 1 ).
Dr . Weeks is board certified in maternal-fetal medicine and addiction medicine . He is a member of the Norton Maternal-Fetal Medicine group , and he is Medical Director of the Norton MOST Program .
Over three decades ago , some Seattle methadone treatment centers incorporated a “ Focus on Families ” component to their treatment and counseling program . 3 Years later , they reported on the young-adult children of those opioid dependent parents . 4 The researchers sought to evaluate functional resilience in 151 young adults who were 18-23 years of age at follow up . Functional resilience was defined as being in school or employed , no criminal charges within the previous five years and no substance use disorder . Only
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