Letter to the editor regarding 'When opiate abuse complicates pregnancy'

TO THE EDITOR:

I wish to congratulate Dr. Prasad and Contemporary OB/GYN for the timely and comprehensive article about substance abuse during pregnancy [“When opiate abuse complicates pregnancy,” February 2014]. I’d like to emphasize that the work of ob/gyns and MFMs to help pregnant women under these circumstances is fettered somewhat by 2 different sources.

First, we continue to battle with misinformed local and state agencies that by a) criminalizing opiate and other agent abuse during pregnancy, drive patients from care and interfere with utilization of well established and effective support/rehabilitation programs during pregnancy; and b) limiting funding for these programs and mental health professionals, increase the prospects of non-treatment and recidivism in this vulnerable transgenerational group. Sensible public health partnerships should and can be generated to resolve these roadblocks to care with our profession at the table.

Second, while the use of buprenorphine during pregnancy holds great promise for both mother and infant, the cadre of certified practitioners dispensing this medication are not required to abide by the regulatory backbone of methadone maintenance (MM) programs in many jurisdictions.

Consequently, patients are less often tested by them or referred to ancillary supportive services for social services and counseling. Communication with pregnancy care professionals is often spotty or nonexistent. Many such patients are left with the impression that they are no longer addicted and that they are no longer in an environment of risk.

The supportive success of MM programs provides a good working model that buprenorphine-dispensing professionals should draw from along with improved health professional communications to ensure optimal care of the patients we are both providing for.

Thanks for the opportunity to provide some personal insight.

John J. Botti, MD

Wilmington, North Carolina

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IN REPLY:

Thank you for your letter and for bringing to light the practical issues impeding our ability to care for opiate-dependent women. I came to this arena out of my interest in infectious disease, particularly HCV mother-to-child transmission, and was quickly educated regarding the lack of resources available to this population. It is no overstatement that, were it not for the cost of treating babies with NAS, the attention to opiate-dependent mothers would approach zero.

I agree with you that partnerships to optimize the health and rehabilitation of women while pregnant are urgently needed. I have always asserted that pregnancy is a pivotal time-point for women, and if we capitalize on that motivation and extend services to the year or 18 months postpartum, we may have the ability to change the lives of both mothers and babies. Even if one only considers the babies, maternal intervention has the potential to be primary prevention for NAS and other outcomes.

With regard to buprenorphine versus MM programs, I also agree that we have to mandate that providers prescribe buprenorphine in the setting of adequate comprehensive addiction care, counseling services, and frequent drug testing. The availability of those providers is limited, as you assert, which propelled me to become certified to prescribe buprenorphine for our pregnant population in Columbus, Ohio. This has allowed me and our clinic to be the backbone for care during pregnancy and feel confident that we are not just handing out pharmacotherapy in absence of those other services.

In order to move the needle regarding care for this population, we need data. We need data to more effectively describe the problem and to prove that this intervention is worth the investment. Only with those numbers will policy change, and I work daily to try to advocate for these women.

Thank you for your interest and support. Perhaps by combining our interests, we can use our collective voice more powerfully.

Mona R. Prasad, DO, MPH