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Substance Use Disorder in Pregnancy

To begin this discussion, we need to understand Substance Use Disorder (SUD). SUD is a disease of the neurotransmitters and neuroreceptors of the brain. People can develop SUD in various ways. Some people have a predisposition for SUD due to genetics and others may have what is known as “risky substance use”. The genetics associated with “risky substance use” often leads to what is commonly known as addiction. Addiction by definition is, “a chronic dysfunction of the brain system that involves reward, motivation, and memory. It’s about the way your body craves a substance or behavior, especially if it causes a compulsive or obsessive pursuit of “reward” and lack of concern over consequences.”(Healthline) To help simplify this – when someone is actively using substances the neurobiology of addiction demonstrates a lack of control due to the bypass of the prefrontal cortex by the neurotransmitters. The prefrontal cortex controls the executive function part of the brain – the decision-making part of the brain. A person with active SUD is incapable of making choices – the brain has been highjacked and impulsivity takes over. This is the most important aspect of SUD – please feel free to read more about the Neurobiology of Addiction – there is an excellent article in The New England Journal of Medicine authored by Dr. Nora Volkow.


In addition, when a person is in active substance use disorder that person is often using substances to avoid withdrawal. Although they may still have the feeling of getting “high” most of the time the use is to stop the pain of withdrawal.


Now to move onto a woman who is pregnant. This is a very difficult situation for this woman. She has a SUD and wants to stop – most have a very strong desire to stop using substances. However, if this woman stops using and suffers withdrawal there is a high likelihood that she will lose the baby. Withdrawal is very difficult for the growing baby and often cannot survive the withdrawal from stopping substances. So, these women are required by healthcare to transition to either Buprenorphine or Methadone for the safety of the baby. I have had women crying in my office begging to be allowed to stop as they are afraid that the baby will be born dependent on either buprenorphine or methadone. It is not safe and the transition alone can be very difficult as they must be in a degree of withdrawal to begin the buprenorphine – which is also dangerous to the baby.


The women who take buprenorphine or methadone throughout their pregnancy deserve a great deal of credit as it is very challenging and they face a significant amount of bias throughout – from healthcare professionals (doctors, nurses, pharmacists, social workers, well - everyone) and the public due to a complete lack of understanding. They are not using buprenorphine or methadone to “get high” they are taking medically prescribed buprenorphine or methadone to help their baby stay safe. If at any point they stop taking the prescribed medicine – because it is withheld by a healthcare provider or a pharmacist - the two options for that mother are: 1. withdrawal with potential loss of baby or 2. use of illicit substances with possible overdose and loss of both mother and baby. Buprenorphine and Methadone should not be withheld from a pregnant woman who is dependent on that substance for any reason – unless there is fear of overdose due to current use of other sedating substance(s).


Then there are the women who do not seek prenatal care or Medication Assisted Treatment (MAT) for buprenorphine or methadone. These women have many reasons for this action. This may be fear based – they are afraid of what will happen and how they will be treated. Or they have a very severe SUD and the prefrontal cortex and innate maternal instincts are completely blocked by the substances. These women also deserve our compassion and care – attempting to develop rapport and earn their trust so as to save both mother and baby.


SUD is a disease of the brain – the neurotransmitters and neuroreceptors. It is not a moral flaw. Treating persons with SUD poorly is wrong – withholding medications to force them to be sober demonstrates a lack of understanding of the disease – it would be like telling someone with diabetes that they are not receiving their insulin until they stop eating sugar.


We as a society need to change the way we think and talk about Substance Use Disorder. These people have stories behind how they ended up with this disease. Their stories are amazing stories of resilience most of the time – many have suffered abuse, many have a genetic predisposition for addiction, and many have been prescribed risky amounts of opioids or benzodiazepines. If you take time to talk to someone with SUD they will tell you that they did not “choose” that life – and now they require our care and compassion to find the life that they are missing. Pregnant women are required to take medication to save their baby and deserve our care and compassion throughout their pregnancy and during the postpartum time as they strive to find their life and the life of their child.


Please educate yourself about substance use disorder – check judgment at the door – be willing to look at others with empathy.


References:

Volkow N, Koob G, McLellan T. Advances From the Brain Disease Model of Addiction. N Engl J Med 374;4 January 28, 2016.

Herron A, Brennan T. The ASAM Essentials of Addiction Medicine third edition. Page 329. 2020.

Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.


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