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Pregnant, addicted, withdrawal versus maintainence


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Too many specialties involved, so I am posting in the general professional area.

 

26 y/o wf, 20 weeks pregnant, addicted to both heroin and dilaudid, using up to 6 heroin injections (iv) and 20mg of dilaudid po a day.

 

Last dosing 24 hours ago.

 

OBGYN sends her to ED. For "withdrawal" protocol.

 

Classic withdrawal sx: nausea, intractable vomiting, tachycardic, tachypnic, diaphoretic, Etc.

 

All other considerations SBE, sepsis, PE, etc, are neg and ruled out.

 

No insurance.

 

Do not have addictionologist or inpatient pain management on staff. And none will see her in a methadone program without cash/ insurance ( they do not accept Medicaid)

 

In ED we put off the withdrawal for awhile by feeding the beast and giving IV Dilaudid to decrease adrenergic symptoms while we ferret out correct pathway.

 

OB does not want to handle her.. They insist hospitalist do "it".

 

Patient states she wants maintainence program, does not want to withdraw while pregnant, but states will want to come off opiates/narcs after delivery.

 

Trouble is, no one has authority to write for methadone as would be used in this case: addiction maintainence...

 

Loads of issues:

 

Whatever we do, the baby will be getting the same, including withdrawal.

 

We are not allowed to write for methadone suboxone etc unless specially designated by DEA.

 

can we force detoxification, under the principle of child endangerment?

 

Hospitalist's have NO experience with addiction issues beyond immediate care.

 

As I type, we are exploring transfer to a state facility which has the capacity to tx this issue, but patient has expressed that she has no interest in being transferred.

 

Every once in awhile, I forget " the patient is the one with the disease" and more than usual want to try and make it right...

 

But in this case I do not know the right thing to do...

 

Ideas?

 

Oh how I miss contrarian

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hospital legal/ethics committee input? I am not sure what pregnant women can be compelled to do in order to protect a fetus. Has psychiatry given a note? is she competent .... sounds like she is a danger to herself and others with her refusal to accept transfer and safer therapy and in the setting of substance abuse I am not sure how that influences consent. Very interesting case. Please update.

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Agree with danger to self and others. With those levels of opiates used (not to mention shooting up) she is a huge danger to herself; question competence. As regards baby, I'm of the opinion that it is a life that needs protecting including from mom in this situation. Get ethics committee ASAP; see if the hospitalists will admit her for a 24 hr obs/maintenance dosing until you can get a clear plan for how to make sure everyone gets out of this alive. The big concern I have is that if she leaves your ED, she's gone... In the wind, no follow-up as OBs don't want to take her and no family practice provider will either. So beg and plead the hospitalists to keep her until definitive care can be determined.

 

Godspeed and keep us posted.

 

Andrew

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Guest JMPA
Too many specialties involved, so I am posting in the general professional area.

 

26 y/o wf, 20 weeks pregnant, addicted to both heroin and dilaudid, using up to 6 heroin injections (iv) and 20mg of dilaudid po a day.

 

Last dosing 24 hours ago.

 

OBGYN sends her to ED. For "withdrawal" protocol.

 

Classic withdrawal sx: nausea, intractable vomiting, tachycardic, tachypnic, diaphoretic, Etc.

 

All other considerations SBE, sepsis, PE, etc, are neg and ruled out.

 

No insurance.

 

Do not have addictionologist or inpatient pain management on staff. And none will see her in a methadone program without cash/ insurance ( they do not accept Medicaid)

 

In ED we put off the withdrawal for awhile by feeding the beast and giving IV Dilaudid to decrease adrenergic symptoms while we ferret out correct pathway.

 

OB does not want to handle her.. They insist hospitalist do "it".

 

Patient states she wants maintainence program, does not want to withdraw while pregnant, but states will want to come off opiates/narcs after delivery.

 

Trouble is, no one has authority to write for methadone as would be used in this case: addiction maintainence...

 

Loads of issues:

 

Whatever we do, the baby will be getting the same, including withdrawal.

 

We are not allowed to write for methadone suboxone etc unless specially designated by DEA.

 

can we force detoxification, under the principle of child endangerment?

 

Hospitalist's have NO experience with addiction issues beyond immediate care.

 

As I type, we are exploring transfer to a state facility which has the capacity to tx this issue, but patient has expressed that she has no interest in being transferred.

 

Every once in awhile, I forget " the patient is the one with the disease" and more than usual want to try and make it right...

 

But in this case I do not know the right thing to do...

 

Ideas?

 

Oh how I miss contrarian

she needs to be put on methadone immediately and withdrawal needs to be avoided at all costs. She may be using her pregnancy to fuel her addiction but providers cannot use that as a factor for legal reasons.

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Suggestions as to how to start on methadone?

No one but addictionologist or pain management folks can legally write for methadone as an opiate or narcotic substitute, and if we do that, the DEA would frown.

She cannot afford the drug nor the clinic. (seems heroin is cheaper or easier to buy/barter for than methadone)...

 

Which is worse for the baby? Narcosis or withdrawal???

 

Anyone have experience with Ibugaine? Is it avaialable? is it safe for pregnancy?

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Does she have any pain conditions? Methadone can be written prn for pain without any issues, at least in NC....

 

We could (and did) stretch it and claim that her diffuse pain warranted methadone, and ignored the fact that the diffuse pain came from her withdrawal.

 

Next problem.. Who will maintain her methadone use? And monitoring...

 

OB wants her detoxes and off Meds as a condition of following.

 

No local doc will accept her on methadone, and, as stated, pain clinics are a cash plus basis..

 

Ethics committed not involved.

 

Psych feels addiction does not constitute, on its face, non compos mentos. With withdrawal controlled, is fully rationale, but addicted, recognized right from wrong, adament that is her body, and welfare of baby is secondary to her desires until birth. Unclear about her desires for be baby after birth.

 

Discharge planning is trying to find somewhere for her to go for follow

 

She is medically stable, we have passed her off to hospitalist.. Too many roadblocks and "buts" in her responses.

 

Bottom line, I suspect, is that she is in throws of addiction and hasn't hit bottom. When she was withdrawing, she would agree to, or do anything to stop it.. Now that she is comfortable, I suspect she will bolt.

 

In her case, unless we desire to become a true nanny state, there is no right answer...

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I have contacted CSB in the past about harm to unborn child and per CSB, at least in my county, they can not do anything until birth if/when the child is born addicted to heroin/drugs. It is indeed a shame that the unborn child can't be protected.

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Guest JMPA
Suggestions as to how to start on methadone?

No one but addictionologist or pain management folks can legally write for methadone as an opiate or narcotic substitute, and if we do that, the DEA would frown.

She cannot afford the drug nor the clinic. (seems heroin is cheaper or easier to buy/barter for than methadone)...

 

Which is worse for the baby? Narcosis or withdrawal???

 

Anyone have experience with Ibugaine? Is it avaialable? is it safe for pregnancy?

Withdrawal is far worse leading to death. Methadone is usually started at higher doses in pregnant females than the general population. It is important to obtain a good history including how much, how often, and by what route she uses. Example you can ask how many bundles, or how much do you spend a day on use? Methadone is the treatment of choice. Do not fear addicting the baby, fear losing the baby do to withdrawal. Im assuming that you work in a hospital, if so than there should be protocols for this situation and if there are not than i would initiate action towards a protocol. Most people do not require greater that 80mg methadone for withdrawal prevention. In the pregnant female, depending on her usage history, it is usually best to divide the dose q6 for better control and earlier dosage adjustment.

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you can't do anything to compel her --- she is a free thinking adult....

 

 

having said that..... she needs enrollment into a methadone or subutex (this is becoming the standard med instead of methadone) ASAP - you need to get the address for some clinics that can write either of these and give them to her - patient autonomy dictates you can lead her to the watering trough, but not force her to drink.....

 

Methadone clinics are federally regulated and are responsible for getting transportation lined up for their patients

 

 

Many people can write subutex, (suboxone minus the narcan) but you need that X on you DEA number, and to write for pregnant patients you really need experience.

 

 

I hate to say it but she is beyond the scope of your center and needs to be transfered likely under that guise of fetal threat/demise......

 

Maybe at best to have a telephone intake with a clinic to get her started, and have to got give her enough narcotics to remove the chance of abuse or withdrawl as that is the real threat to the baby...

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