For Pregnant Women, Stigma Complicates Opioid Misuse Treatment

By Amarica Rafanelli 10/22/20

In Pennsylvania, one community health center is working with new and expectant moms to tackle opioid dependency.

Image: 
A mother holding a baby and looking at stuffed animals.
A new mom and her baby attend an event at the Wright Center for Community Health. The health center's Healthy MOMS program supports women addressing opioid dependency during pregnancy. Image via The Wright Center

New and expectant mothers face unique challenges when seeking treatment for an opioid use disorder. On top of preparing for motherhood, expectant mothers often face barriers to accessing treatment, which typically involves taking safer opioids to reduce dependency over time. The approach is called medication assisted therapy, or MAT, and is a key component in most opioid treatment programs.

But with pregnant women, providers can be hesitant to administer opiate-based drugs.

According to a study out of Vanderbilt University, pregnant women are 20% more likely to be denied medication assisted therapy than non-pregnant women.

“In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak of the Wright Center for Community Health in Scranton, Pennsylvania.

The health center serves low-income individuals who are underinsured or lack insurance altogether, many of whom struggle with opioid misuse.

“Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak, who is a board certified addiction medication specialist.

On this episode of the podcast, we speak with Dr. Hemak about whether medication assisted therapy is safe for new and expectant mothers and how the Wright Center is helping women overcome opioid dependency during pregnancy.

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Direct Relief granted $50,000 to The Wright Center for its extraordinary work to address the opioid crisis. The grant from Direct Relief is part of a larger initiative, funded by the AmerisourceBergen Foundation, to advance innovative approaches that address prevention, education, and treatment of opioid addiction in rural communities across the U.S. 

In addition to grant funding, Direct Relief is providing naloxone and related supplies. Since 2017, Direct Relief has distributed more than 1 million doses of Pfizer-donated naloxone and BD-donated needles and syringes to health centers, free and charitable clinics, and other treatment organizations.


Transcript:

When it comes to getting treatment for an opioid use disorder, pregnant women have an uphill battle.

Most patients undergoing opioid treatment are prescribed safer opioids that reduce dependency while limiting the risk of overdose and withdrawal.

This kind of treatment is called medication assisted therapy, or MAT.

But with pregnant women, providers can be hesitant to administer opioids.

According to a study out of Vanderbilt University, pregnant women are 20% less likely than non-pregnant women to be accepted for medication assisted therapy.

“In the beginning, I was so scared as a new provider to write my first prescription for medication assisted therapy to pregnant women,” said Dr. Linda Thomas-Hemak.

Hemak is a board-certified addiction medication specialist and CEO of the Wright Center in Scranton, Pennsylvania.

“Pennsylvania was hit particularly hard by the opiate epidemic that really has plagued, terrified and challenged America,” said Hemak who has been practicing in the state for several years.

In 2016, the health center launched a comprehensive opioid treatment program to address the growing crisis in their community. They quickly realized a number of patients were pregnant—and had specific needs, from prenatal care to job support. And so, a new program was born.

“The Healthy MOMS program is based on assisting mothers who are expecting babies or have recently had a child, up until the age of two,” explained Maria Kolcharno — the Wright Center’s director of addiction services and founder of the Healthy MOMS program.

“We have 144 moms, through the end of August, that we have served in the Healthy MOMS program and actively, we have enrolled 72.”

The program provides new and expectant moms with behavioral health services, housing assistance, educational support; providers have even been delivering groceries to moms’ homes during the pandemic.

But the crux of the program is medication assisted therapy.

Moms in the program are prescribed an opioid called buprenorphine—unlike heroin or oxycodone, the drug has a ceiling effect. If someone takes too much, it won’t suppress their breathing and cause an overdose.

Nonetheless, it’s chemically similar to heroin, which may raise eyebrows. But while some substances, like alcohol have been shown to harm a developing fetus, buprenorphine isn’t one of them.

“Clearly there are medications, like alcohol, that are teratogenic. And there’s medications like benzodiazepines that have strong evidence that they are probably teratogenic. When you look at the opioids that are used and even heroin, there is no teratogenic impacts of opiates on the developing fetus,” Dr. Hemak explained.

So, opioids like buprenorphine can be safe for pregnant women. What’s not safe is withdrawal.

If someone is abusing heroin, overdose is likely. In order to revive them, a reversal drug called Naloxone is used, which immediately sends the person into withdrawal.

But when a woman is pregnant and goes into withdrawal, it can cause distress to her baby, lead to premature birth, and even cause a miscarriage.

Which is also why these women can’t just stop taking opioids.

“Stopping cold a longstanding use of an opiate because you’re pregnant is a very bad idea and it is much safer for the baby and the moms to be transitioned from active opiate use to buprenorphine when pregnant,” explained Hemak.

Because buprenorphine has a ceiling effect and is released over a longer period of time, women are less likely to overdose on the drug.

Regardless, there’s still a risk their baby goes through withdrawal once they’re born. For newborns, withdrawal is called neonatal abstinence syndrome or NAS.

Babies may experience seizures, tremors, and trouble breastfeeding. Symptoms usually subside within a few weeks after birth.

Fortunately, the syndrome has been shown to be less severe in babies born from moms taking buprenorphine versus those using heroin or oxycodone.

That’s according to Kolcharno who has been comparing outcomes between her patients and those dependent on opioids, but not using medication assisted therapy.

“Babies born in the Healthy MOMS program, we’re finding, that are released from the hospital, have a better Apgar and Finnegan score, which is the measurement tool for NAS and correlates all the withdrawal symptoms to identify where this baby’s at,” said Kolcharno.

But NAS is not the only concern women have post-partum.

During and after delivery, doctors often prescribe women pain killers. For those with an opioid dependency, these drugs can trigger a relapse.

Dr. Thomas-Hemak says preventing this kind of scenario requires communication.

The Wright Center works with their local hospital to ensure OBGYNs are aware of patient’s substance use history.

“We want the doctor to know that this may be somebody that you’re really sensitive to when you’re offering postpartum pain management,” said Hemak.

That way, doctors know to tailor patients’ post-partum medication regimens. Instead of prescribing an opiate-based pain killer they can offer alternatives, like Ibuprofen or Advil.

Maintaining an open line of communication between addiction services and hospital providers also helps to reduce stigma.

Women with substance use disorders have long been subject to discriminatory practices by both providers and policy makers.

From denying them treatment to encouraging sterilization post-delivery, women struggling with opioid dependency can be hard-pressed to find patient-centered health care.

But Dr. Thomas-Hemak says, she’s learned to set her opinions aside.

“I think one of the magical transformations that happens when you do addiction medicine really well is, it’s never about telling patients what to do.”

It’s about allowing them to make informed choices, she says, and understanding it’s not always the choice you think is best.

This transcript has been edited for clarity and concision.

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Amarica Rafanelli is a multimedia journalist for Direct Relief, where she produces audio stories on humanitarian health issues. She has reported for several NPR member stations, including Los Angeles’ KCRW and San Luis Obispo’s KCBX covering politics, the environment, and international affairs. Her reporting on social issues has appeared in UC Irvine’s InSight Magazine and the Santa Barbara Independent. Amarica earned her B.A. in political science, with a minor in professional writing, from UC Santa Barbara.