Opiate+Use+and+Substance+Use+Disorder+Management+in+Pregnancy

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** Prenatal Guideline ** Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

Prenatal guidelines for Opiate Dependency and Substance Use Disorders in Pregnancy
Substance use disorders:
 * **SCREEN:** Most important: ASK ALL PATIENTS about substance use history in a non-judgmental manner during first visit. **Do NOT rely on Healthy Start intake.**
 * Risk factors: positive history (current or past), family hx, ongoing legal issues, children not in custody, partners who are using, late to care/missed appointments
 * Continue to ask throughout pregnancy (“check-in” in a nonthreatening manner, to encourage patient trust and adherence).
 * Role of initial urine tox screen (utox):
 * Initial screening utox at first visit appropriate for all patients with risk
 * Consider screening utox for all other prenatal patients, case based
 * Role of ongoing urine tox screens:
 * Appropriate to do monthly utoxes for those with positive history
 * For active users: Helps guide management and determine risk to fetus as pregnancy continues
 * For those in recovery/remission: Helps build positive case for mom/baby with social work/CFS
 * **BRIEF INTERVENTION:** Give anticipatory guidance on how various drugs can affect pregnancy/neonate (see below); and assess readiness to change:
 * Opiates:
 * Antepartum: Preterm labor, pre-ecclampsia, placental abruption, low birth weight, non-reassuring fetal status, maternal overdose/death
 * Neonate: Neonatal abstinence syndrome (1-6 weeks in nursery). Also, increased risk of prematurity, neural tube defects, neurobehavioral deficits, SIDS
 * **DO NOT CUT PATIENT OFF** as withdrawal can be dangerous/fatal to fetus Rather, patient often needs increased dose as pregnancy progresses. If desire to quit, needs slow taper.
 * Safer option is opiate replacement therapy with methadone or Subutex (not suboxone). Continue subutex if already on; can be initiated in certain cases.
 * Subutex has less NAS, and mom can breastfeed
 * Stimulants (Meth/cocaine): preterm labor, placental abruption, IUGR. Needs intensive treatment program (i.e. Ujima)
 * Tobacco: SAB, low birth weight, abruption, PPROM, preterm delivery, previa, stillborn
 * Prefer abstinence alone, but nicotine replacement therapy: Nicoderm CQ = cat D, but consider if risk of continued high dose smoking (> risk of patch)
 * Alcohol: Fetal alcohol syndrome: Fetal alcohol syndrome, alcohol withdrawal
 * Treat withdrawal same as in non-pregnant, i.e. needs inpatient management
 * Marijuana: unclear; thought to include lower birth weight, increased risk of SIDS, increased childhood respiratory problems, childhood cognition problems
 * Benzos: **DO NOT CUT PATIENT OFF**: as withdrawal can be dangerous/fatal to fetus. Rather, patient often needs increased dose as pregnancy progresses. If desire to quit, needs slow taper.
 * **Antepartum testing:** All patients who have a history of using any substance during current pregnancy need to initiate testing at 32 weeks
 * **REFERRAL TO TREATMENT:** All patients that are actively using or were recently using benefit from treatment programs (i.e. Ujima). Refer to SBIR counselor and/or social worker.