This lecture is on acute pain in pregnant and post-operative at-risk women. My name is Dr. Marla Kushner and I have one disclosure, I am a speaker for Alkermes. A little humor to start the talk, this cartoon says, Does it hurt? Can I get you a beer or something? And the caption is, Why no one uses mid-husbands. I speak about the disease of addiction to many different groups and feel privileged to be speaking to you. My job here is not to teach you how to prescribe pain medications or how to treat your patients. You're the expert on that. My job as I see it is to let you know about the concerns we're having today with access to opioids and to have you consider new guidelines and other ways including osteopathic manipulative medicine to help these patients. Our overview today, we're going to talk about substance use disorder, the definition, the opioid problem, different patient types, options for pain management and treatment, and some different cases. This is the new short definition by the American Society of Addiction Medicine on addiction. Addiction is a treatable chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. DSM-5 criteria for substance use disorder and opioid use disorder criteria are as follows. A minimum of two to three criteria is required for a mild substance use disorder diagnosis while four to five is moderate and six to seven is severe. Opioid use disorder is specified instead of substance use disorder if opioids are the drug of abuse. Taking the opioid in larger amounts and for longer than intended, wanting to cut down or quit but not being able to do it, spending a lot of time obtaining the opioids, craving or a strong desire to use opioids, repeatedly unable to carry out major obligations at work, school, or home due to opioid use, continued use despite persistent or recurring social or interpersonal problems caused or made worse by opioid use, stopping or reducing important social, occupational, or recreational activities due to opioid use, recurrent use of opioids in physically hazardous situations, consistent use of opioids despite acknowledgment of persistent or recurrent physical or psychological difficulties from using opioids. Tolerance is defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. This does not apply for diminished effect when used appropriately under medical supervision. And withdrawal manifesting as either characteristic syndrome or the substance use is used to avoid withdrawal. So it does not apply when used appropriately under medical supervision. This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision. What is the cause and why are we concerned? Some say it's the pharmaceutical companies that were not honest about the abuse potential over these drugs. Others say it's due to over-prescribing by physicians and a response to inadequately treating a patient for their pain in the past. Whatever the reason, we're finding ourselves in the midst of an opioid epidemic in this country. The latest statistics that I've seen include approximately 142 overdoses a day due to opioids, including pills and heroin. For someone like myself in primary care specializing in addiction medicine, I'm seeing this on a daily basis, whether it's a patient of mine or a friend or relative of a patient. There are a few different patient types that I want to cover during this talk. There's three groups. One is no known history of substance use disorder. The second is family history of substance use disorder. The third is that they are known to have the diagnosis of substance use disorder. I have another cartoon for you that says, I'm having a natural childbirth in that it's natural to take drugs that lessen excruciating pain. This also illustrates what's been happening over time. Really we need to work with patients, especially women who are in labor, on what is appropriate medication for during and after childbirth. Let's start with the patient who presents to us with no known history of substance abuse. It's important to screen this patient and all patients for substance use disorder, just like you would screen for depression or heart disease or any other family diseases. We then need to provide education and options as to what is out there for pain management. Continue to monitor for any abuse and adhere to the new guidelines that are available. I remember my personal experience with my first pregnancy. I went to my OB and said, I want barbaric anesthesia, knock me out and wake me up after the baby's born. My OB at the time then suggested that would probably do well with the Bradley method. I asked her if she didn't hear me correctly, and then she really encouraged me to find a good Bradley teacher. I was then able to have a natural delivery. Even as a physician, or maybe because I was a physician, I assumed pain medication would be the answer. Because of the way my OB presented this alternative option and her encouragement, I was able to try things differently and had a great outcome. The CAGE questionnaire is as follows. Have you ever felt you should cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover, an eye opener? The scoring, items responses on the CAGE are scored 0 or 1 with a higher score and indication of alcohol problems. A total score of 2 or greater is considered clinically significant and should be referred for further assessment. The opioid risk tool should be administered to patients upon an initial visit prior to beginning opioid therapy for pain management. A score of 3 or lower indicates low risk for future opioid abuse. A score of 4 to 7 indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse. You're going to mark the boxes whether or not the patient is female or male. Is there a family history of substance abuse, whether it's alcohol, illegal drugs, or prescription drugs? Is there a personal history of substance abuse, alcohol, illegal drugs, or prescription drugs? Is the age between 16 and 45 years? Is there a history of pre-adolescent sexual abuse? And then psychological diseases such as ADD, OCD, bipolar, schizophrenia, or depression. The next type of patient would be one who has a family history of substance use disorder. These risks do play a part in predisposition to substance use disorder. From a clinical perspective, when I ask my patients with the disease of addiction if they have a family history of the disease, in most cases they can identify someone. The same screening tools will apply. It's important that pain is managed or the patient will treat their own pain. You want to make sure there's plenty of education around pain management. And what is the usual and customary treatment for different procedures and childbirth? And you want to present the options to the patient. The third group of patients are the ones with a known diagnosis of substance use disorder. I tend to see these patients falling into one of two main groups. The first, those who under no circumstances want any pain medication due to fear of relapse. And the second, those who want to make sure that they will get adequate pain management and are fearful that pain will cause them to relapse. What is usual and customary for a patient that is not an addict? Acute pain management in the hospital versus pain medication to go home and prescribing medication as directed instead of as needed. It's also very important to monitor urine drug testing. Follow-up is key with these patients. The American Society of Addiction Medicine recognizes that this is a special population and has a public policy statement on substance use, misuse, and use disorders during and following pregnancy with an emphasis on opioids. Pregnancy complications can occur with exposure to a number of illicit and illicit substances, including but not limited to alcohol, nicotine, cocaine, amphetamines, opioids, and benzodiazepines. For example, alcohol-related neurodevelopmental disorders are the leading cause of preventable intellectual disability in the United States. Opioid-related overdose not only threatens the life of the mother, but also can lead to fetal demise. Opioid withdrawal may threaten the viability of the fetus through an increased potential for spontaneous abortion. Substance misuse and addiction are associated with behaviors that increase the risk of maternal and fetal acquisition of sexually transmitted infections, such as HIV and hepatitis C and B. Whereas 50% of pregnancies in the United States are unplanned, defined as women not attempting pregnancy at the time of conception, the rate may be as high as 80% among women with substance use disorder. Inadequately treated substance use disorders are associated with poor adherence to prenatal care, poor attention to maternal nutrition, and worsening of co-occurring psychiatric illness. Although co-occurring disorders are common among individuals with substance use disorders, pregnant women with substance use disorders are even more likely to have a co-occurring psychiatric illness, and postpartum depression is more common among women with substance use disorders compared to those without substance use disorders. The condition almost never arises de nouveau during pregnancy, but rather develop prior to conception. Often substance use disorder is first diagnosed during pregnancy. Pregnancy offers a window of opportunity for case finding, diagnosis, treatment entry, and initiation of recovery. The professional societies of clinicians involved in the care of women and children, including ACOG and ASAM, stress the importance of working with a pregnant woman to facilitate her quitting or at least reducing substance use during pregnancy, and engaging in addiction-related treatment if necessary. These professional societies oppose criminalizing and other punitive approaches to substance use during pregnancy as they turn women away from prenatal care, thus compromising maternal and fetal well-being. The American Society of Addiction Medicine recommends screening and prevention, treatment, education, and regulatory and law enforcement. The Center for Disease Control recently updated guidelines on how to treat chronic pain given the opioid crisis. They suggest to determine when to initiate or continue opioids for chronic pain, first you want to use non-pharmacologic therapy, and non-opioid therapy are preferred for chronic pain. Next, establish treatment goals prior to starting opioids, and three, discuss the risk and benefit. As far as opioid selection, dosage, duration, follow-up, and discontinuation, you want to prescribe immediate release opioids instead of extended release. You want to prescribe the lowest effective dosage, and for acute pain, prescribe three days or less. You want to evaluate benefits and harm within one to four weeks of starting therapy. Assessing risk and addressing harms of opioid use, you want to evaluate risk for opioid-related harms, use the state prescription drug monitoring program, use urine drug testing prior to starting, and then at least annually for chronic pain. Avoid prescribing benzodiazepines with opioids, and offer evidence-based treatment for patients with opioid use disorder. It's important to incorporate urine drug testing into your treatment plan. Remember that urine drug testing is not diagnostic. Patients with a positive urine drug test may not have substance use disorder, and patients with negative urine drug testing may have substance use disorder. The American Society of Addiction Medicine guidelines on urine drug testing in pregnant and postpartum women talk about consequences and confidentiality, screening, assessment, and monitoring, evaluating the patient-provider relationship, what are some considerations of the test, and what will happen with these test results. As an osteopathic physician, it's important to consider using osteopathic manipulative therapy in pregnancy. Some considerations would be for low back pain, heartburn, pelvic floor pain, and thoracolumbar junction and diaphragm dysfunction. Some of the techniques may need to be modified for sitting or lateral recumbent position. Some techniques that could be used, thoracic and lumbar soft tissue with the patient side lying, OA decompression, thoracic inlet myofascial release, myofascial release of the diaphragm, sacroiliac articulation with the patient side lying, and pubic symphysis decompression. Postpartum osteopathic manipulative techniques, considerations would be for pelvic pain, low back pain, and postpartum depression. For these techniques, be mindful of cesarean incisions. Techniques that may be used, cranial treatments, cervical thoracic lumbar spine soft tissue, myofascial release of the diaphragm, rib raising, pelvic diaphragm myofascial release, muscle energy for hip restriction, and sacral articulation for sacral rock. Here is a reference that you can go to for some of these techniques as well. Next I have a couple case studies that I would like to go over and if you have any questions feel free to email me and we can go over them in more detail. Case 1 is J.A. Subjectively, J.A. is a 36-year-old female who presented to the office in withdrawal after realizing that she was dependent on tramadol and other opiates. She was taking at least 3 pills a day of anything that she could get her hands on. Pill number 3, Vicodin, Norco, and Lorazepam, 0.5 to 1 mg a day when she was in withdrawal from narcotics. She was smoking 5 to 10 cigarettes daily, no alcohol, marijuana, cocaine, or methamphetamine. She abused Adderall in the past, but she was not currently taking it, denies heroin use, Patients state she only sleeps with Lorazepam, not without. Withdrawal symptoms that she has been experiencing are pain, tingling, nausea, diarrhea, and irritability. She began using opiates after having her first child. She had a bad recovery after her first childbirth and was given opiates. She states that they were being refilled and that she never stopped. She has two children. She did have an abstinent period for one year in between having her children. Patient has back pain, leg pain, shooting pains down her legs. She was also on sertraline and stopped one week ago. She was taking this for depression, 100 mg daily. She decided one day that she wanted to stop using. No one is pressuring her. Her husband is unaware of her relapse and her family does not know. She was taking Tramadol up to three daily and that seemed to be the worst withdrawal. She said it feels like brain zaps. Her last dose was two days ago. She has a very stressful high power job and is raising her two children. Objectively, Jay presented extremely agitated and anxious. She was pacing around the room, unable to sit still. Her urine drug screen was positive for benzodiazepines and opiates in the office. She presented with high blood pressure and a rapid pulse. Her assessment was opioid dependency and withdrawal, benzodiazepine abuse, and anxiety disorder. The plan was to start the patient on suboxone buprenorphine by induction and she was encouraged to go to 12-step meetings. She came in for her induction in withdrawal and by the time she left she felt better and has been maintained on a low dose of buprenorphine suboxone film. It took Jay about six months to go to her first AA meeting because she was afraid she would run into somebody she knew because of her position in the community that she lives. It also took her about six months to let her husband know what was going on. When she went to her first AA meeting, she did run into a neighbor and it ended up being a very wonderful thing and they have formed a good bond and relationship and go to meetings together and her husband has been very supportive of her. Five years later, she is still on low dose buprenorphine. She's doing very well. She's engaged in AA and is very successful with her work and as a mom. She stated that she wishes she were told more about what it would be like after the baby was born. She felt very comfortable and prepared about what was going to happen during pregnancy but not about what was going to happen afterwards. The second case, DS, is a 34-year-old female seen in the office for suboxone maintenance. She came to me on 16 milligrams of suboxone film a day. At the time, she was living in a sober living facility, going to 12-step meetings and had a sponsor. She started using opiates after her son was born 14 years ago. At that time, she did not have custody of her son. She found out recently that she was pregnant unexpectedly. The father of the baby is a young co-worker. He is not in recovery and feels that she can just tough it out and doesn't need to be part of a program. Immediately, she left sober living and moved in with him after finding out she was pregnant. She stopped going to 12-step meetings and connecting with her sponsor. Objectively, DS was extremely excited and happy about the pregnancy. Her urine drug screen was positive for buprenorphine, benzodiazepines, and THC. Her assessment was opiate dependency and remission, cannabis abuse, benzodiazepine abuse, anxiety, and pregnancy. The plan for DS, the patient was recommended to stay on suboxone and to meet with a high-risk OB as soon as possible to verify her medication and start her prenatal care. Instead, the patient went to a general OB at a local hospital. She did not share the extent of her addiction. She did share that she was on suboxone and had a release of information signed. The OB was not monitoring urine drug screens and was not familiar with the suboxone. The OB said that she did not do urine drug screens because the patient told her that they were being done at my office. The OB was concerned about anxiety and depression and wanted to refer to a social worker and possibly put the patient on an SSRI. Thank you. I'm happy to answer any questions by email that you have.

acute pain

pregnant women

post-operative women

opioids

pain management

substance use disorder