Opiate Use and
Breastfeeding
Difficult conversations in the Neonatal
Period
Disclosures
• I have nothing to disclose and no conflicts
of interest
2
A Common Scenario…..
• You are called to do a prenatal consult
with a pregnant mom
• Mom is on methadone maintenance for a
previous heroin addiction
• You meet a well dressed young woman
who is obviously nervous about this
discussion
• Her main question: Can I breastfeed?
3
Objectives
• Provide an update on the prevalence and
patterns of opiate use in breastfeeding
women
• Describe the passage of opiate
medications into breast milk and the
effects on the newborn
• Discuss indications and contraindications
to breastfeeding in women using opiates
Illicit Substance Use
• 10.2% of Americans
older than 12 are
current illicit drug users
• Non-medical use of
prescription drugs is
second only to
Marijuana use
Past Year Heroin Initiates
among People Aged 12 or
Older, by Age Group (in
thousands): 2002-2014
(SAMSHA NSDUH 2014)
– Primarily opioid class
pain relievers
• Use of Heroin has more
than doubled since
2007
SAMSHA NSDUH 2014
5
Scope of the Problem:
• Among pregnant women:
– 5.9% report use of illicit drugs (Samsa-NSHUD 2013)
– 28% were prescribed at least one opioid pain
reliever during pregnancy (Patrick 2015)
• 96% were non-maintenance prescription opioids
– 20% of women experience mood or anxiety
disorders during pregnancy (Flynn 2006)
Substance Use Patterns
Prepared 3/3/2015 by Karina Atwell, MD
UW‐Madison Preventive Medicine Resident
7
Opioids in Pregnancy
• Opioids easily pass the placental and blood-brain
barrier.
• Fetus can develop physical addiction
– Opioids inhibit release of norepinephrine from nerves in
the brain
– Tolerance develops and more norepinephrine is produced
by the brain to overcome the inhibition
– If opioids are suddenly taken away large amounts of
norepinephrine are released and produce the physical
signs of withdrawal
• If the mother stops using opioids her fetus will
experience withdrawal and will be at increased risk for
distress and fetal loss
Neonatal Abstinence Syndrome (NAS)
9
Incidence of neonatal abstinence syndrome per
1000 hospital births in the United States, 2009 to
2012.
Patrick, J Perinatol 2015
10
NAS in Wisconsin
Prepared 3/3/2015 by Karina Atwell, MD UW‐Madison Preventive
Medicine Resident
11
Treatment of NAS
• Pharmacologic treatment with opiates
– Restart the infant on morphine
– Slowly wean
• Non-pharmacologic treatment
–
–
–
–
–
Tight swaddling
Holding and rocking
Quiet dark room
Limit number of visitors
Feeding on demand
• Small frequent feeds
– Have pacifier available
Length of Stay
Prepared 3/3/2015 by Karina Atwell, MD
UW‐Madison Preventive Medicine Resident
13
How do opiates work?
14
Passage of opiates into milk
15
What is baby getting?
• Depends on
– Size of molecule
– Degree of protein binding
– Lipid solubility
– Ionization
– Maternal factors
– Infant factors
16
Estimating Infant Dose
• Milk to Plasma Ratio
– Ratio between the concentration of medication in the
maternal plasma and milk at steady state
– Estimate of the relative amount of drug in milk
• Of limited value unless you know the maternal
serum concentration
– even if a medication has a milk to plasma ratio of
greater than 1, the concentration in the breast milk
may still be low if maternal plasma levels are low
17
Methadone
• Full opioid agonist
– Will interact with the brain in the same way
that morphine does.
• Very long half life (mean half life is 22
hours)
• Mothers must go to the methadone clinic
every day to get their dose
Transfer of Methadone into Breastmilk
• Variable but minimal transfer of
methadone into breastmilk
– Average amount transferred to infant 0.050.19 mg/day
• 1-3% of maternal weight adjusted dose
• Less than dosage used to treat NAS
19
Buprenorphine
• Subutex/Suboxone
• Semi-synthetic partial agonist
– Binds opioid receptors in the brain but is not very
active.
• Can be prescribed to women who can pick up
weeks worth of doses at one time
• Popular choice for women in rural or remote
areas.
Buprenorphine and breastfeeding
• Buprenorphine has low oral bioavailability
(31%)
• Very low levels in breastmilk
– 0.38% of maternal buprenorphine dose
– 0.18% of maternal norbuprenorphine dose
• Assumed to be safe – more studies
needed
Ilett et al. Breastfeed Med 2012
21
Other Opiates
• Hydrocodone, oxycodone and fentanyl
– Usual doses for pain relief have minimal to no
effect on infant
– When used as a drug of abuse mothers
should be transitioned to maintenance opiate
– Caution with codeine
22
Polydrug Exposure
• NAS complicated by the interplay
between opioid withdrawal and
withdrawal from other substances
– SSRIs (7-8%) and Tobacco (85%) are
common co-exposures
– Symptoms are similar to NAS and may
exacerbate NAS
– Benzodiazepines, barbiturates and alcohol
are also known to cause withdrawal signs in
infants.
Polydrug Exposure
• Fetuses exposed to methadone +
polysubstances in utero had:
– Decreased fetal heart rate
– Decreased fetal movement
– Delivered 1 week earlier than fetuses
exposed to methadone only or no methadone
– Required treatment for NAS twice as often
Jannson, Drug and Alcohol
Dependence 2012
24
Breastfeeding and opiates
25
Breastfeeding and NAS
• Challenges
– Polydrug use
– Infectious disease risk
– Poor nutrition
– Comorbid psychiatric disorders
• Lack of evidence based guidelines
Jansson. Breastfeeding
Medicine 2009
26
Evidence Based Web Sites
• LactMed
– http://toxnet.nlm.nih.gov/newtoxnet/lactmed.ht
m
• E-Lactancia
– http://e-lactancia.org
– English and spanish
27
Screening for opiate use
• Based on risk?
• Universal screening?
– Universal Drug Testing in a High-Prevalence
Region for Opiate Abuse
• 2995 pregnant women, 96 + for opiates
• 77/96 had risk factors that would have triggered
screening
• 19/96 had no risk factors that would have triggered
screen
Wexelblatt et al. Journal of Pediatrics 2015
28
Breastfeeding Initiation Rates
• UK – 14% in women using opiates vs 50% in
general population (Goel 2011)
• Norway – 77% in women using opiates vs
98% in general population (Welle-Strand
2013)
• US - 187 women using opiate with no
contraindications to breastfeeding
– 66% did not initiate BF
– 24% did initiate BF: 40% still BF at time of
discharge (Wachman 2010)
29
Barriers to Breastfeeding
• Low SES
• High prevalence of mental health issues
• Lack of knowledge about specific benefits
of breastfeeding
• Prejudice
• Need for urine drug screening
30
Advantages of breastfeeding
• Breastfeeding is recommended for women
compliant with treatment and on
maintenance medications regardless of
dose
– Shorter length of hospital stay
– Lower Finnegan scores
– Less likely to require pharmacologic treatment
– If treatment is needed: lower doses of
medication and shorter duration of treatment
Abdel-Letiff, Pediatrics 2006
31
Breastfeeding and Incidence of NAS
Requiring Pharmacologic Treatment
Breastfed
Formula Fed
Welle-Strand
57% (n=58)
69% (n=20)
Wachman
50% (n=38)
77% (n=48)
Abdel-Latif
52.9% (n=85)
79% (n=105)
O’Connor
23.1%
30%
32
Breastfeeding and Length of Treatment
Breastfeeding
Formula Feeding
Abdel Latif
85 days (n=85)
108 days (n=105)
Welle-Strand
31 days (n=58)
49 days (n=20)
Wachman
15.8 days (n=38)
27.4 days (n=48)
33
Why?
• Dosage of opioids in breastmilk low
• Known benefits of breastfeeding:
– Skin to skin
– Holding and soothing
– Bonding
– Enhanced confidence
– Increased maternal participation in care of the
infant
34
Breastfeeding and SIDS
• Protective effect of
Breastfeeding against
SIDS (AAP 2005)
• Infants exposed to
opiates at higher risk
for SIDS (Burns et al
2010)
35
Encourage breastfeeding
•
•
•
•
•
•
Women in treatment
Consent for communication
No illicit substance use in last 90 days
Negative urine tox screens
Consistent prenatal care
No medical contraindications
Reece-Stremtan Breastfeeding Medicine 2015
36
Consider breastfeeding
• Relapse in 90-30 days before delivery but
not within 30 days of delivery
• Other prescription medications
• Prenatal care or substance abuse
treatment after the second trimester
• Custody or sobriety as motivators
• Lack of family and community support
systems
Reece-Stremtan Breastfeeding Medicine 2015
37
Counsel women not to breastfeed:
• Not in substance abuse treatment
• No prenatal care
• Relapse into illicit substance use within 30 days of
delivery
• Unwillingness to seek treatment or allow
communication
• Positive urine tox screen at delivery
• Women with active drug use
• Chronic alcohol use
• Other contraindication for breastfeeding
Reece-Stremtan Breastfeeding Medicine 2015
38
No easy answers…..
• Trauma informed care
• Family centered care
of the newborn
• Prenatal counseling
and education
39
References
•
CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States,
1999–2010. Morbidity & Mortality Weekly Report. 2013, July 5:62(26);537-542
•
Chisholm MS et al. Relationship between cigarette use and mood/anxiety disorders among pregnant and methadone
maintained patients. Am J of Addiction. 2009;18:422-429
•
Finnegan LP et al. Neonatal Abstinence Syndrome: Assessment and Management. Addictive Diseases. 1975;2(1):141158
•
Flynn HA, Blow FC, Marcus SM. Rates and predictors of depression treatment among pregnant women in hospitalaffiliated obstetrics practices. General Hospital Psychiatry, Vol, 28, No. 4, July-August 2006, pp 289-29.
•
Hudak ML et al. Neonatal Drug Withdrawal. Pediatrics. 2012;129(2):e540-e561
•
Jansson LM et al. The opioid exposed newborn: Assessment and pharmacologic management. Journal of Opioid
Management. 2009;5(1):47-55
•
Johnston A. Neonatal Abstinence Syndrome Scoring: Guidelines for treatment with methadone. Scoring Tool Training
MOTHER study 2006
•
Jones HE et al. Neonatal Abstinence Syndrome after methadone or buprenorphine exposure. NEJM.
2010;363(24):2320-2331
•
King JC. Substance Abuse in Pregnancy. A bigger problem than you think. Postgrad Medicine. 1997;102(3):149-150
•
Lambers DS and Clark KE. The maternal and fetal physiologic effects of nicotine. Semin Perinatol. 1996;20(2):115-26
•
Patrick SW et al. Prescription Opioid Epidemic and Infant Outcomes. Pediatrics 2015 135(5)
•
Patrick SW et al. Incidence and Geographic distribution of NAS: United States 2009 to 2012. J Perinatol 2015
•
Substance Abuse and Mental Health Services Administration. Results from the 2009 National Survey on Drug Use
and Health: Vol 1: Summary of National Findings 2010
References
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Reese-Stremtan S. ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Abuse or Substance
Use Disorder, Revised 2015 Breastfeeding Medicine 2015: 10(3)
Welle-Strand GK, Skurtveit S, Jansson LM, et al. Breast- feeding reduces the need for withdrawal treatment in
opioid- exposed infants. Acta Paediatr 2013;102:1060–1066.
Abdel-Latif ME, Pinner J, Clews S, et al. Effects of breast milk on the severity and outcome of NAS among infants
of drug-dependent mothers. Pediatrics 2006;117:1163–1169.
Jansson LM, Choo R, Velez ML, et al. Methadone main- tenance and breastfeeding in the neonatal period.
Pediatrics 2008;121:106–114.
Jansson LM, Choo R, Velez ML, et al. Methadone main- tenance and long-term lactation. Breastfeed Med 2008;3:
34–37.
Kocherlakota P. Neonatal abstinence syndrome. Pediatrics 2014;134:e547–e561.
Wachman EM, Byun J, Philipp BL. Breastfeeding rates among mothers of infants with neonatal abstinence syndrome. Breastfeed Med 2010;5:159–164.
D’Apolito K. Breastfeeding and substance abuse. Obstet
Clin Gynecol 2013;56:202–211.
Jannson et al. Pregnancies exposed to methadone, methadone and other illicit substances, and poly-drugs without
methadone: A comparison of fetal neurobehaviors and infant outcomes. Drug and Alcohol Dependence 2012
122(3): 213-219
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Questions
Elizabeth Goetz MD MPH
Department of Pediatrics
University of Wisconsin – Madison
Meriter Hospital