Carl Christensen, MD, PhD
Principal, Christensen Recovery Services, Ann Arbor, MI.
Dr. Christensen has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: As both an addiction medicine physician and an obstetrician, you are in a unique position to advise other physicians about controlled substance use and pregnancy. What would you say are some of the most frequent questions you’re been asked by other physicians? Dr. Christensen: Typically, the most frequent problem that I’m referred is the pregnant patient who’s dependent on opioids. And this could be either someone who’s using illicit drugs, such as heroin, or is prescribed prescription opioids. I’ll get a call asking what to do. But sometimes, after learning that their patient is pregnant, some physicians will immediately discontinue the opioids and discharge the patient from their practice, without waiting for a consultation. This is one thing that I would absolutely recommend against. Unless there is a clear-cut diagnosis of opioid dependence, the meds should be maintained until the consultation is completed.
CATR: Let’s look at prescription opioids first. What should we do if we find that a pregnant patient is taking prescription opioids—not necessarily in an addictive fashion, but perhaps using them chronically—and might be physically dependent? Dr. Christensen: By stopping the opioids, you do put the patient in a very difficult situation of being physically ill, and this could result in the patient seeking out illicit drugs or becoming drug seeking in an emergency department. So, the recommendation, which also fits in with the new Centers for Disease Control and Prevention (CDC) guidelines, is that you seek referral to a maternal fetal medicine specialist or to an addiction specialist. (For a CDC fact sheet that you can provide to your patients, see http://bit.ly/2kTYI9M)
CATR: Is there a circumstance under which you would recommend that a pregnant patient be changed from prescription opioids to methadone or buprenorphine? Dr. Christensen: You would need an addiction evaluation with at least a strong suspicion of an opioid use disorder, and you typically see this when someone is taking opioids and benzodiazepines or opioids and amphetamines, or has the typical loss of control or the type of compulsive use that you see with an opioid use disorder. If there really is an opioid use disorder, buprenorphine is preferable to methadone because methadone can only be dosed once a day (Chou R et al, J Pain 2009;10(2):113–130). Buprenorphine can be adjusted any way that the prescriber and the patient want.
CATR: I know that prescribing buprenorphine would require a waiver if used to treat addiction, though it may not require a waiver if used to treat pain. So, would you still advise that a pregnant woman with a dual pain and addiction disorder, who requires buprenorphine, go to see a specialist who is buprenorphine certified? It can be hard for patients to find such practitioners. Dr. Christensen: I would recommend referral to a specialist who is buprenorphine certified. Your first comment about not requiring a DATA (Drug Addiction and Treatment Act of 2000) waiver is true. However, I’ve never encountered a primary care provider who’s willing to maintain someone on buprenorphine during pregnancy. Additionally, you should have a DATA waiver, and you should probably also have quite a bit of experience in managing buprenorphine. Among buprenorphine patients, this is an added complication that would require a physician who is experienced with buprenorphine at the minimum, and buprenorphine use in pregnancy more optimally.
CATR: Is there anything else we should consider when using either methadone or buprenorphine? Dr. Christensen: Yes. My main concern would be the use of methadone or buprenorphine with benzodiazepines added for an anxiety disorder. The use of benzodiazepines with any kind of opioid greatly magnifies the risk of that opioid. That leads to a risk of overdose, so in this case you should be very cautious and try to collaborate with the opioid prescriber.
CATR: Right. So, we now know about the risk of overdose when using benzodiazepines with other opioids. But can you tell us about additional risks to the baby? And what would you recommend to a mother who is taking benzos for therapeutic reasons? Dr. Christensen: During the first trimester, there is a very small chance of birth defects, which leads to a higher risk category (Ban L et al, PLOS ONE 2014;9(6):1–9). At birth, you may get what pediatricians call a floppy baby—that is, a baby that must be resuscitated or supported with ventilation. If a patient is prescribed benzodiazepines, and there is no sedative use disorder that you identify, my recommendation is that she remain on the benzos.
CATR: Let’s talk for a moment about stimulants. Say a pregnant patient is on methylphenidate or amphetamines for attention deficit disorder, or is using those substances for other reasons. What would you recommend here? Dr. Christensen: Considering their adverse effect on blood pressure, I would immediately try to discover why a pregnant patient is on any type of stimulant. If the patient tells me that it helps her focus, or says “I’m in school and it helps me pass exams,” that’s not a legitimate use, and I recommend discontinuation without any assisted therapy. If somebody has a history of medication for therapeutic reasons since childhood, then I recommend she continue using it.
CATR: I’d like to shift now to a more common—and in many states legal—recreational drug: marijuana. What’s your advice here for treating pregnant patients? Dr. Christensen: What I tell patients is that there is limited information about how marijuana in pregnancy is harmful, but there’s also no useful information about how it’s harmless. The bottom line is that it could result in a child protective services (CPS) investigation when the baby is born, which can be catastrophic for the mom and the family.
CATR: Let’s talk more about the risks of marijuana use during pregnancy. My take on the literature is that there are many studies describing severe risks, and then there are another group of studies that don’t show any potential harm. What is your take? Dr. Christensen: It’s very confusing, but what I focus on with patients is what we know. There are adolescent studies that show the possibility of schizophrenia and the decrease in IQ in heavy marijuana users. I point out that the fetal brain is even more sensitive than the adolescent brain to these medications, and there is simply no long-term benefit to using marijuana. Patients who tell me that they use it so they don’t throw up are probably suffering from marijuana withdrawal. This goes on during the entire pregnancy.
CATR: You mentioned earlier how women who are using substances during pregnancy risk a child protective services investigation. Is urine testing something that’s done routinely, or only in certain settings? Dr. Christensen: I can tell you that there’s a lot of controversy within the American Society of Addiction Medicine (ASAM), and within the American Congress of OB/GYN (ACOG), about urine testing. People argue that routine universal drug testing should not be done because it’s a violation of informed consent. Others, including myself, argue that it should be done because of the other tests that are already being done with pregnant patients. For example, we routinely test for sexually transmitted diseases, where a positive result can be personally catastrophic. We also tend to only focus on what would happen if somebody were identified as using an illicit drug during pregnancy rather than the other side of the coin, which is the opportunity to offer treatment and the opportunity to protect the fetus. In Michigan, I believe that most of the hospitals do not practice universal screening, and most medical practices do not, but this is something that I’m advocating for at the hospitals where I staff.
CATR: OK. Just to stay with this controversy for a little bit longer, do you think it’s true that, if the consequences of a positive test were more treatment oriented and less punitive, it would become less of an issue? Dr. Christensen: Yes, but the bottom line is that if a urine drug screen is positive, that baby is more likely to undergo meconium testing at birth, and if that test is positive, there is a higher chance of a CPS intervention. [Ed note: Meconium is the infant’s first stool, composed of materials—including drugs—ingested by the mother while the fetus was in utero.] However, on the other hand, if we use that as an opportunity to give treatment, and the patient becomes and remains abstinent, I feel the chance of an adverse finding by CPS is very small.
CATR: I’m guessing, though, that there is a lot of fear from women that their babies might be taken away because of drug use. Because of that, what are some of the behaviors you are seeing? Dr. Christensen: Rather than ask for help, patients will typically try and go “cold turkey” off opioids or benzos or alcohol, and that can frequently result in a disaster. Fear of intervention is a major problem for anybody with addiction, and it’s magnified in somebody who’s pregnant. There’s a chance the patient might not be honest with you about her substance use or abuse.
CATR: So, what do you recommend physicians do about this lack of honesty? Dr. Christensen: Start by doing universal screening. ACOG recommends universal HIV and STD screening. If there is a positive result on a urine test, you then ask additional questions and do some additional checking. For example, if the patient tests positive for hydrocodone but isn’t being forthcoming, you could then run a patient prescription search. As part of this, I would also recommend asking about tobacco and marijuana use.
CATR: What about substance use questionnaires? Dr. Christensen: In my opinion, the problem with interviews developed for substance use disorders is this: If patients know that the “wrong” answers can result in a bad outcome, they’re much less likely to tell you the truth. I think that’s only human nature. Also, sometimes just asking a pregnant patient to take a drug test can lead to an answer that you might not otherwise get, or defensiveness, which might tell you that there’s something being hidden. You need to look for those types of cues.
CATR: Finally, let’s talk a little about the postpartum issue of breastfeeding, and the use of medications and substances. While we would, of course, recommend abstinence from recreational use and for addiction, what are some general recommendations around these medications for therapeutic usage while breastfeeding? Dr. Christensen: So as far as medication-assisted therapy, the American Academy of Breastfeeding Medicine has said that women on stable doses of methadone and buprenorphine should continue to breastfeed (Reece-Stremtan S and Marinelli KA, Breastfeed Med 2015;20(11):135–141). Benzodiazepines are felt to be very low risk, and can be monitored through seeing if the baby becomes sedated. I know anti-epileptic drugs are typically not recommended for use with breastfeeding. For patients who are on other opioids for pain, I would also recommend that opioids not be used when breastfeeding.