Doctors differ on treatment methods for drug-dependent pregnant women

Zach Vance • Updated Jun 10, 2017 at 10:07 PM

Two local doctors who treat drug-dependent mothers strive for the same goal: reduce the chance a newborn has neonatal abstinence syndrome, or NAS.

But the methodologies of Dr. Martin Olsen and Dr. Vance Shaw couldn’t be more different.

The syndrome is an array of withdrawal symptoms experienced by a drug-exposed baby following birth and is highly prevalent in Northeast Tennessee.

Olsen, a professor of obstetrics and gynecology at Quillen ETSU Physicians, treats drug-dependent mothers by challenging several credible studies and a widely held belief in the medical community. He is the point person for the program at the ETSU Department of Obstetrics and Gynecology.

The Department of Obstetrics and Gynecology’s program encourages addicted mothers to wean themselves down to the lowest dose of buprenorphine a mother can tolerate. Buprenorphine is a medication used to treat opioid addiction, but also a contributor to NAS when given to pregnant women.

The near-unanimous opinion in the medical community is that drug-dependent mothers should not wean themselves off medication-assisted treatment, because detoxification could risk premature labor or even fetal death.

“When it comes to tapering women, especially force-tapering women off medication during pregnancy, every single professional organization without exception states that the standard of care is (drug) maintenance during pregnancy,” said Shaw, who operates High Point Clinic in Johnson City and also works with drug-dependent mothers.

The American Psychological Association, the American Society of Addiction Medicine and the American College of Obstetricians and Gynecologists all concur that mothers should stay on their same dosage during pregnancy.

“They even say if a woman comes to you and wants to be tapered, you’re supposed to try to talk her out of it,” Shaw said.

Although its not his preferred approach, Shaw said he’s not completely opposed to tapering expectant mothers, especially if they’re highly motivated.

“If a woman is really interested in trying to taper, we can work with her to see if she does well with the taper. A small percentage, about 10 percent of women, will be able to come off their medication,” Shaw said.

“But to really try to force them and intimidate them to come off their medication is really damaging to the patient and newborn child.”

Olsen has found that many narcotic-addicted patients want to come off these medications during pregnancy and are eager for medical assistance. He said his program is strictly voluntary for the mothers who participate.

His written agreement states, “Each patient must realize that weaning to lowest dose she can tolerate is planned. The ultimate goal is no buprenorphine in late pregnancy.”

The agreement also states that a patient is free to leave the program at any time and ETSU will continue to provide obstetric care while the patient receives her buprenorphine from another provider.

Shaw is skeptical of the voluntary agreement.

“That’s not true. We’ve had several patients come here from that practice who’ve told us they’re being force-tapered (and) that they must come off their medication,” Shaw said.

Olsen stands by his voluntary agreement and emphatically believes Shaw is repeating false information.

According to department chair Dr. William Block, "We are simply offering an option for patients that wish to wean during pregnancy and hopefully decrease the risk of neonatal abstinence syndrome. While providers that profit from MAT like to provide theories for continuation, there is universal agreement amongst prenatal providers that minimizing exposure to any medications, drugs, or alcohol during pregnancy is best for neonatal outcomes."

While it may seem logical that lowering the dosage of buprenorphine lowers the chance of NAS, some studies have shown that even babies born to completely detoxified mothers had longer admissions than the babies of women who had relapsed at delivery.

Other studies show that NAS induced by buprenorphine usage is less intense than NAS triggered by methadone usage.

A conflicting study completed by the University of Tennessee’s Dr. Craig V. Towers evaluated 301 drug-dependent mothers who underwent full detoxification during pregnancy. The study concluded that detoxification of opiate-addicted pregnant patients is not harmful, but the rate of neonatal abstinence syndrome is high primarily when no continued long-term follow-up occurs.

Shaw said a variety of factors, including the stress levels, depression and genetics of a drug-dependent mother, can also factor into a baby’s chance of being diagnosed with NAS.

“A large number of their babies are going to have neonatal abstinence syndrome,” Olsen said about the babies born to mothers who keep the dosage the same during pregnancy.

“The theory of our clinic is that we need to re-look at the recommendations of relevant organizations. For example, studies that report low success with weaning don’t report their dosages. So we think they probably haven’t weaned down to a low-enough dosage.’’

The second issue, Olsen said, is the difficulty of getting accurate dosage data from patients because of the high likelihood that some of the medication is being sold or diverted.

“In our community, the vast majority of patients are charged around $5,000 a year to see a for-profit buprenorphine provider,” he said. “Many people don’t have these dollars available, so they must sell some of their medication on the street in order to afford the next visit with a for-profit buprenorphine provider.’’

For example, if a patient is prescribed 16 milligrams of buprenorophine a day, perhaps she is taking 8 milligrams and selling 8 milligrams. Researchers therefore may be unable to record accurate dosages.

Olsen estimated that roughly one-third of babies born to mothers taking standard doses of buprenorphine still experience NAS. He wants to lower that percentage by weaning his patients down even further.

“Our theory is that if we get the mothers down to 4 milligrams (of buprenorphine) and off everything else by 28 to 32 weeks, their babies will have a lower rate of NAS,” Olsen said.

The ETSU obstetrics/gynecology prenatal buprenorphine clinic began in autumn 2016 under the vision of Dr. Selman Welt and the leadership of department chair Dr. William Block. Olsen began treating narcotic-addicted pregnant women in January, so it will take a while before any definite data is available, but he hopes preliminary data will be available by the end of the year.

The prenatal buprenorphine clinic is one of the few in the region that accepts insurance, but they cannot accept new patients at this time due to the 30-patient federal government limit for new prescribers.

Shaw treats a couple of hundred patients at his practice and offers various counseling programs for pre-and-post pregnant women.

Email Zach Vance at zvance@johnsoncitypress.com. Follow Zach Vance on Twitter at @ZachVanceJCP. Like him on Facebook at Facebook.com/ZachVanceJCP.

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