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Deborah Howell (Host):   Welcome. Many women wonder is it okay to take any kind of drug while pregnant. Today we’ll talk about substance use during pregnancy with two experts. My guests today are Dr. Spencer Kuper, a maternal fetal medicine specialist at Tri-State Perinatology at the Women’s Hospital, and Dr. Ron Pyle, director of neonatal transport and athlete at the Women’s Hospital, assistant professor of Pediatrics IU School of Medicine, and chair of pediatrics. Great to have you both. Dr. Kuper, I’ll start with you. How is substance use in pregnancy treated?

Spencer Kuper, MD (Guest):   The very first thing we want to do is approach these women with an unbiased approach. The importance is getting them into care at a very early time in the first trimester and explain to them the optimal prenatal care for them. Then also to make sure they're established into a medication assisted treatment program.

Host:   Which is my next question. What is medicated assisted treatment?

Dr. Kuper:   Medicated assisted treatment is when we either use something called buprenorphine or the trade name or brand name for that is Subutex of Suboxone or methadone. The reason that we do that is several different reasons. It’s the safest thing for the pregnancy, but it also decreases the risk of adverse behaviors by the patient by using potentially IV drugs or by using other drugs. So it decreases the risk of overdose for the patients, but it also decreases the risk of infectious diseases such as HIV or hepatitis C or B.

Host:   Got it. Dr. Pyle, to you, how does the multidisciplinary clinic treat patients?

Ron Pyle, DO (Guest):   The name speaks for itself. It’s a great approach. It involves MFM, neonatology, our education director, lactation, social work. We like to sit down with families prior to even admission and moms who are in these MATs or otherwise. Again, I think it’s said very well. It’s unbiased. The goal is to have this multidisciplinary type approach talking about how we’re going to score, the modes of how we would treat, how we encourage breastfeeding, and when we can and cannot breastfeed. Again, this is not punitive or anything. This is really just to support them in how we can.

Host:   Got it. We’ll return to you Dr. Pyle to talk about NAS, but Dr. Kuper how would you recommend treating someone who is taking non-prescribed pain medications prior to pregnancy?

Dr. Kuper:   If they're using opioids, my absolute recommendation to them is that they either start Suboxone or Subutex or methadone. They continue those throughout the entirety of the pregnancy, including while they're here for their delivery, and then also after pregnancy.

Host:   People get alarmed when they heard methadone. Why should they not be alarmed?

Dr. Kuper:   It is the drug that has been proven to be safest for them. It does cross the placenta. Dr. Pyle will talk shortly about neonatal abstinence syndrome. That is certainly a risk, but long-term we feel like it and Subutex are both the safest options. It also decreases the risk of disease transition such as HIV or hepatitis C because it encourages compliance with the patient to take a prescribed medication.

Host:   Now in case you feel like you didn’t fully answer it, do you recommend taking Subutex or methadone during pregnancy?

Dr. Kuper:   I do. If a patient has a history of opioid use and if they're currently using opioids such as Percocet or Norco pills or injecting heroin, I absolutely do recommend those patients start methadone or Subutex during the pregnancy.

Host:   My follow up, should a patient discontinue Subutex or methadone when being induced?

Dr. Kuper:   No. We actually want the patients to continue that. It’s two fold. We want their pain to be controlled, but we also want to continue that medication so that they don’t have any lapse in the treatment.

Host:   Got it. How is a patient’s pain managed during labor?

Dr. Kuper: The most important thing is to continue that medication, but also so the patient gets an early epidural is a great way to manage the patient’s pain to decrease additional opioids that may be needed. Also to control their pain.

Host:   How is a patient’s pain managed after having a c-section?

Dr. Kuper:   So we recognize that these patients may need more pain medications because they're likely tolerant to opioids because of the methadone or the Subutex. So for a short period after their c-section, we definitely treat them with additional narcotics such as Norco or Percocet or oxycodone. Then they're generally sent home with a short supply of this medication if they're continuing to need that in the hospital, but we really try to use other modalities too to decrease the use of opioids such as the Percocet or the oxycodone’s. The reason is because we know that previously the patients had difficulty with those medications and misusing those medications. So it’s a team effort to work together to try to work with other modalities such as ibuprofen, ice packs, heat packs to decrease that amount of opioids that they may be sent home. They're also sent home with their Subutex or their methadone as well.

Host:   When you say short supply, what are we talking?

Dr. Kuper:   We’re talking two to three days’ worth.

Host:   Oh, very short. Okay. Dr. Pyle, speaking of team, let’s get back to you. What is neonatal abstinence syndrome?

Dr. Pyle:   It’s actually a term that’s used to incorporate a lot of different meds. I think it came out there and people thought it was more about narcotics and obviously our opiates. It’s really about the abstinence or the syndrome that’s related to a mom who’s taking meds. The meds are, it’s a long list. Any child who shows symptoms related to a maternal med and how we would approach that child and discuss with mom our approach and treatment plan.

Host:   How is NAS treated?

Dr. Pyle:   It varies, but the goal is I would prefer to do non-pharmacological. The goal is to eat, sleep, and console. Minimize stimuli and get the parents involved. It’s amazing what mom and dad’s touch and voice can do for a baby. It’s about not waking kids when they're sleeping, but it’s really just allowing them to eat and give them the nutrition they need but also giving the support not only to the family but to the parents. Obviously, some kids where non-pharmacological doesn’t work. There's just done enough. Then we’ll lean on—Our approach here is morphine. So we have a morphine type of protocol and a guideline that we follow to try to capture the baby. If you can imagine with any med—especially if you're talking about moms who are on, who I agree with Dr. Kuper about Subutex and methadone—is that those are meds that can still be in the breastmilk. So these are people that we would still allow breastfeed. The goal is just to capture them and try to wean them slowly off so they don’t need those meds and don't have those symptoms, which can persist up to six months or so.

Host:   Sure. Now let’s head into the NICU. What is the treatment approach in the NICU?

Dr. Pyle:   Well, it goes back to kind of what I said earlier. It’s really about eat, sleep, and console. It’s all non-pharmacological. It’s really, again, supporting. Getting the parents involved and teach them a lot of stuff, including massage, infant massage. Then obviously if our non-pharmacological doesn’t work, we would then lean on our medications. Which, again, our mainstay is morphine. There are places that use methadone, but we prefer morphine. Wean those kids accordingly based on their scores. There's a scoring system called Finnegan. It looks at fussiness, sleeping patterns, loose stools, jitteriness. It’s like a neurochemical process as well as they get GI symptoms, respiratory symptoms. So we look at all of those. We score them and then make an approach to how we’ll treat.

Host:   Now who can breastfeed and who can't?

Dr. Pyle:   I think with the MAT programs it’s awesome. So with Subutex, suboxone, methadone, if those moms are in treatment programs I really encourage breastmilk. Breastmilk is best for these babies. Plus it incorporates mom into the treatment. I mean she’s doing her part to help her baby. It really supports her and let’s her know that we’re behind her. Treatment programs, I would encourage breastfeeding. Marijuana’s out there and there's still some up in the air, but I think the benefit of breastmilk still outweighs the risk. Of course, we would encourage moms to kind of abstain if they can from using it.

Host:   Understood. Will a patient be judged?

Dr. Pyle:  No. That’s the key. You hear the word social work and people think you're going to call somebody or protective services or something. That’s not our goal. Our goal is to break the cycle. What I mean by that is what Dr. Kuper does with the MFM and the OBs is that they get these moms into treatment programs and they help them so that when I see the baby I can do that. Teach her the skills and hopefully as we work her out of the program, she will hopefully eventually abstain from meds altogether. Then I won't see the next child at all. So that’s the whole goal. They just need to know that we’re there for them. We’re there to support them and help them any way we can. It’s not for me to judge. It’s for me to help them to heal.

Host:   That is so refreshing to hear. I've got to say to both of you, your patients are in very, very good hands. Dr. Pyle and Dr. Kuper, thank you so, so much. It’s excellent information, could even save lives. I thank you for being with us today to talk about substance use and pregnancy. We learned so much.

Dr. Kuper:   Thank you.

Dr. Pyle:   Thanks for having us.

Host:   For more information, please visit deaconess.com/twh. That’s deaconess.com/twh. This is The Women’s Hospital, a place for all your life. I'm Deborah Howell. Thanks for listening and have yourself a great day.