Psychoactive drugs cross the blood-brain barrier, also the placental blood barrier – so can affect a baby in utero. While pregnant women addicted to meth, crack and heroin have long been an issue, hospitals have recently seen a large increase in babies born addicted to opioids, and the profound consequences that follow. We discuss the issues, options for detox and treatment, also the use and misuse of methadone.
Transcript (edited):
Podcast #116
HOWARD: Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions, I am Howard La Mere. This week a couple of stories popped up – apparently NBC is doing a major story on pain killer addiction and pregnant woman. Weve talked through the years about pregnant women being addicted to heroin, meth and cocaine but this phenomenon of addiction to pain meds parallels our large and seemingly difficult to get a handle on problem with the abuse of prescription drugs, especially pain killers.
DARRYL: Yes, Howard, its nothing really that should surprise anybody, but I guess it has surprised a lot of people. Any drug that can cross the blood brain barrier is also going to cross the placental barrier and expose a fetus. Weve all seen and heard about women who are on methadone maintenance and how that impacts their pregnancy. Methadone is still the drug of choice for pregnant addicts to deal with their heroin addictions and it has been shown to be much safer than allowing a woman to continue her abuse of heroin. Many doctors are now treating pregnant patients with buprenorphine and Suboxone and they find it is easier and more acceptable to use a detox agent rather than a maintenance program, although some women are maintained throughout their pregnancy on Suboxone. Despite the denials of the pharmaceutical firms that there really isnt a major increase in prescription drug abuse and especially prescription opiate drugs, there really is. And were seeing evidence that there is an increase of women of childbearing age who are addicted to Oxycontin, Vicodin, even buprenorphine and other drugs.
HOWARD: And that drug is also being diverted and used because it it still has an opioid component, right?
DARRYL: Right. Suboxone has now become one of the more popular treatments for opiate addiction, primarily because it is more acceptable by the population becoming opiate addicts, but also because its the first opioid treatment available in a physician’s office. That means instead of having to register at a special clinic that treats addictions, your own family physician can prescribe it. Suboxone is used more frequently because its harder to abuse and maybe a little bit safer. But it is an opiate in and of itself and a powerful opiate so powerful that in places like India and Nepal its a major drug of abuse. Its actually more popular than heroin in those places. So, it can be a very addictive although its used very effectively in the treatment of addiction.
HOWARD: This is all about the dosage, right?
DARRYL: Well, its about dosage. Its about .
HOWARD: Whether its an antagonist or an agonist?
DARRYL: If you give small doses of buprenorphine, it is an agonist and will effectively take away withdrawal symptoms, take away pain effectively. But if you push the dose higher, it becomes an antagonist. So, then it does the opposite. It blocks all other opiates and precipitates withdrawal symptoms, which is one reason its used more and more as a treatment by personal physicians because if a patient wanted to abuse it to get high, when the dose is too high – tolerance causes it not to work anymore. Patients can’t overdose as easily as they can on methadone or Oxycontin or Vicodin. So, used in treatment it is an effective drug, but like any other substance that are capable of crossing the blood brain barrier, affecting mood and feeling and eliminating pain – it lends itself to abuse. We are seeing more people abusing and diverting prescription pain killers for abuse purposes. People get them from family or friends or buy them off the street. There aren’t too many people doctor shopping or getting them directly from several doctors. Pregnant women who use these pain killers expose their babies in their womb. The babies become addicted and after they are born they go through withdrawal. Infants are very sensitive to withdrawal and can actually die during the withdrawal process. These babies have a very, very high pitched cry and delivery room nurses and pediatric nurses tell me theyre able to recognize – without knowing anything about the baby just from the cry that theyre going through withdrawal. There are only a few places that really are adept at treating addicted babies and making sure their health is okay, they must be stabilized and safely detoxified. There are special hospitals in Washington and there are some pediatric and OB/GYN practices that are able to manage the detox – but if you dont know what youre looking for and you encounter the condition it can be a very, very scary thing. Because of the increase use – the projection I think is maybe 13,000 or more babies a year are born with withdrawal symptoms from opiates, prescription drug opiates like Oxycontin, Vicodin, that were taken during pregnancy. One of the nurses quoted in the story expects 20 times more babies that shes going to have to deal with every year.
HOWARD: Thats a lot. 20 times .
DARRYL: Its a lot. Its a real issue and its a real concern that with addiction per se, we are seeing a lot more unintended consequences suffered by babies who are born addicted. There is a misunderstanding among the general public and by women who are abusing drugs, that because it is a prescription and not street heroin, its safe and won’t cause the same problems that heroin does – only to find that they are giving birth to babies with the same problems as an infant born to a heroin addicted mother. Another concern I have involves a rare, very small percentage of women who can rapidly metabolize weaker drugs than morphine, like codeine and maybe even oxycodone. These rapid metabolizers of even common codeine, Tylenol with codeine, or any type of codeine/aspirin combinations commonly used for moderate pain by dentists, by doctors, by everybody else. They take the codeine and their bodies and livers metabolize it into morphine almost immediately and very efficiently, such that if they take 30 mg of codeine, it is changed to 30 mg of morphine, which is a lot higher dose of morphine than they would get in codeine. It has led to toxicities in breast milk when the mothers are given codeine postpartum or after delivery.
HOWARD: What percentage is that? Did you have any numbers?
DARRYL: No. I couldnt even guess except maybe in the 0.0012 or something like that. A very, very small percentage have this strange genetic anomaly that metabolizes codeine into morphine so quickly. Thats just one concern of many in dealing with the growing problem of prescription drug abuse and since 2009, weve seen an increase across the nation in abuse of illicit drugs. People turning to illicit drugs more often than they had in the 10 years previous to that. So, times have swung the pendulum has swung the other way and were moving again toward a very definite cycle of major drug abuse.
HOWARD: 2008, 2009 is when the economic bubble burst and… a lot more people are a more depressed probably and seeking to deal with that.
DARRYL: You know I think there were some studies done by Charles Beard, this Canadian economist and that look at drug cycles and especially the type of drugs, you know, what is becoming popular either an upper or downer as it correlated to economic
HOWARD: Yes in boom times it seemed like coke was the big deal.
DARRYL: so in down times when the market is a bear market, I guess it goes towards opiates and something to help you quell the pain of whats happening in the economic world.
HOWARD: Can we talk about methadone a little bit? Because it is now the number 2 cause of death from prescription drugs behind Oxycontin, I think. Its right up there at least. And I remember in the treatment context you had to go in once a day and the dosage was very strictly monitored, has this increased does it have to do more with methadone being prescribed for pain relief as opposed to treatment for heroin addiction?
DARRYL: Yes, methadone definitely I think right now it slipped to number three its the 3rd leading cause of all prescription drug deaths not just the opiates and pain killers and things like that, but of all prescription drug deaths. It was number 1, so there are indications that abuse has declined or stabilized. But, now that methadone is used for pain some patients are the ones who are able to divert it very easily and to get it on the market. When its used for addiction treatment, its usually or almost entirely given out already mixed in some sort of juice or some sort of liquid making it more difficult to market and to trade off on the street, although it has happened. And also, when its given for pain, there isnt a lot of respect given to the fact that methadone is a powerful opiate, a reinforcing drug that leads itself to abuse and also causes major overdose. Its that same phenomenon were seeing now with the general population believing that if its a prescription drug, its got to be much safer than buying something off the street.
HOWARD: Which we can pretty safely say is poor thinking not clear thinking.
DARRYL: well, Im sure prescription drugs can be safer because theyre more often reliable.
HOWARD: Well, theyre not made in the backroom bathtub, but still
DARRYL: There are counterfeits but still most of the time you see, you know, the icon and the markings on the tablet that indicate it is from a legitimate source. Those drugs are more reliable, they dont have the adulterance, they dont have the reactants and left over incomplete synthesis process that causes a lot of problems from the synthesized drugs street drugs. Still they affect the brain the same way that the street drugs affect the brain in terms of the addiction process and the toxic process. So, theyre not any safer in that realm.
HOWARD: And, I gather …in the context of opium, opioid addicted pregnant woman and her baby, she wants to quickly gets as clean as possible and apparently thats ill advised, both for the mother and for the child because of the potential consequences such as miscarriage if people abruptly stop.
DARRYL: Right. Methadone maintenance rather than detox is the preferred treatment for pregnant opiate addicts and the reason is that for a woman to go into withdrawal with a detoxification thats not well managed will cause irritation to the baby in her womb. There is also the potential for premature labor and stress to the fetus which can result in lots of problems. So, it is preferable for a woman to be on a monitored and managed opiate maintenance like methadone than to go cold turkey or use street drugs. But as I said, some doctors are beginning to look at using Suboxone and buprenorphine as a viable alternative to methadone.
HOWARD: Well, were going to have to keep our eyes on this issue since it is seemingly fairly new. Thats about all the time we have this time around. Thanks to you who have tuned in to listen. As ever, youre invited to make a comment, ask a question, or offer a suggestion, which you can do by going to the CNS website, cnsproductions.com. Thanks, Darryl.
DARRYL: Thank you, Howard.
HOWARD: Please check back soon for the next in the series and visit our website, www.cnsproductions.com