Born Drug Free Montana 

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Healthcare Providers 

Physicians, Pharmacists, Nurses, Physician Asst, Nurse Practitioners, CNM 

Healthcare providers are encouraged to consult a local neonatologist for prenatal consult on any mothers using narcotics so that NAS can be discussed. 

For information on breastfeeding safety: LactMed https://www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm
If the mother is on a prescribed supervised medication program and HIV negative, the mother may continue to breastfeed as long as the medication is not above the maximum safe dosage.  Infants are at risk for respiratory depression, somnolence, and poor feeding.  Please ask breastfeeding mothers to update you when they start a medication, stop a medication, or change the dosage of a medication, as this may affect their baby. Drugs such as cocaine, heroin, methamphetamines are contraindicated in breastfeeding babies.


REGISTER and USE the Montana Physician Drug Registry Program! 


Follow the new CDC Guidelines for Opiate Prescribing 

Opioid Abuse in Pregnancy: Guidelines for Health Care Practitioners, Effects on Pregnancy and the Child
  • Chronic heroin abuse is associated with an increased risk of fetal growth restriction, abruptio placentae, fetal death, preterm labor, and intrauterine passage of meconium.  These effects may be related to the repeated exposure of the fetus to opioid withdrawal and the effects of withdrawal on placental function and may also occur in other types of opioid abuse.
  • First-trimester use of codeine has been associated with congenital heart defects in three of four case-control studies.  No association has been described between the use of other opioids during pregnancy and an increased rate of birth defects.
  • The lifestyle issues associated with illicit drug use put a pregnant woman at risk of engaging in activities such as prostitution, theft, or violence, to support herself and her addiction.  The consequences of these activities pose a host of risks to the fetus including STIs, Hepatitis.
  • Neonatal abstinence syndrome (NAS):
    • Occurs when newborns of opioid-abusing mothers are withdrawn from narcotic exposure.  NAS usually manifests within hours to weeks of birth, when the child is separated from opioids in the mother’s body, most commonly days 2-5. 
    • Symptoms of NAS include hyperactivity of the central and autonomic nervous systems.
  • Long-term data for children with in-utero narcotic exposure is limited, but studies have not found significant decreases in cognitive development with maternal opioid abuse.
Screening for Abuse 
  • Before pregnancy and in early pregnancy, all women should be routinely asked about their use of alcohol and drugs, including prescription drugs.  The patient should be informed that such questions are asked of all pregnant women to ensure they receive appropriate care and that all information will be kept confidential.  Maintaining a caring and nonjudgmental approach will yield the most inclusive disclosure. The goal is to HELP the woman and maintain a healthy pregnancy and stable, safe home environment. 
Validated screening tools for identifying prenatal substance abuse:
4P’s
  • Parents: Did any of your parents have a problem with alcohol or drug use?
  • Partner: Does your partner have a problem with alcohol or drug use?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
  • Present: In the past month, have you drunk any alcohol or used other drugs?

Any “yes” should trigger further assessment.

CRAFFT

(for women aged 26 and younger)

  • Car: Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
  • Relax: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
  • Alone: Do you ever use alcohol or drugs while you are by yourself or alone?
  • Forget: Do you ever forget things you did while using alcohol or drugs?
  • Family: Do your family or friends ever tell you that you should cut down on your drinking or drug use?
  • Trouble: Have you ever gotten in trouble while you were using alcohol or drugs?

Two or more “yes” answers should trigger further assessment.

Other questions to ask:
  • In the past six months, have you taken any medications to help you calm down, keep from getting nervous or upset, raise your spirits, or make you feel better?
  • Have you been taking any medication to help you sleep?  Have you been using alcohol for this purpose?
  • Have you ever taken a medication to help you with a drug or alcohol problem?
  • Have you ever taken a medication for a nervous stomach?
  • Have you ever taken a medication to give you more energy or to cut down on your appetite?
  • Have you ever taken over-the-counter cold preparations other than when you have had cold symptoms?  Do you take over-the-counter diet pills?
  • Positive answers to any of these questions warrant further investigation.
Treatment

Comprehensive prenatal care and monitoring, chemical dependency counseling, and other psychosocial services for women with opioid dependence should be a part of any treatment plan.

  • Methadone
    • The rationale for opioid-assisted therapy during pregnancy is to prevent complications of illicit opioid use and opioid withdrawal, encourage prenatal care and drug treatment, reduce criminal activity, and avoid risks to the patient of associating with a drug culture.  Comprehensive opioid-assisted therapy that includes prenatal care has been shown to reduce the risk of obstetric complications.
    • Perinatal methadone dosages are managed by addiction treatment specialists within registered methadone treatment programs.  A list of local treatment programs can be found at the federal Substance Abuse and Mental Health Services Administration.
    • The severity of NAS does not appear to differ based on the maternal dosage of methadone treatment.
  • Buprenorphine
    • Buprenorphine is the only opioid which may be legally prescribed for the treatment of opioid dependence in an office-based setting.  Physicians wishing to prescribe this medication must undergo specific credentialing.
    • Advantages over methadone include a lower risk of overdose, fewer drug interactions, the ability to be treated on an outpatient basis without the need for daily visits to a methadone clinic, and evidence of less severe NAS.
    • Disadvantages to buprenorphine include reports of hepatic dysfunction, lack of long-term data on infant and child effects, a clinically important patient dropout rate due to dissatisfaction with the drug, a more difficult induction with the potential risk of precipitated withdrawal, and an increased risk of diversion.
    • The drug is available as a single agent or combined with naloxone, but the single agent is recommended during pregnancy.  Although the single agent has a higher risk of abuse, it also has a reduced risk of exposing the fetus to naloxone which could lead to dangerous withdrawal symptoms. Naloxone should not be given to an infant whose mother was chronically using narcotics during pregnancy. 
  • Medically-supervised withdrawal
    • Not recommended because of its association with high relapse rates.
    • If this is to be undertaken, however, supervised withdrawal should ideally occur during the second trimester and with the aid of a perinatal addiction specialist.  If the only alternative to medically-supervised withdrawal is continued illicit drug use, the withdrawal should take place as soon as possible no matter the trimester.

Breastfeeding should be encouraged in both methadone and buprenorphine patients as minimal levels of these drugs are found in breast milk.


These guidelines are adapted from the American College of Obstetricians and Gynecologists’ Committee Opinion Number 524: Opioid Abuse, Dependence, and Addiction in Pregnancy and UpToDate’s Prescription Drug Abuse and Addiction: Prevention, Identification, and Management.