Incidence of narcotic abuse during pregnancy in northwestern Ontario

DISCUSSION

The high rates of NAS experienced by neonates in our catchment area in 2010 was concerning, and our first clinical responsibility was to develop expertise in identifying and treating NAS.⁴ Subsequently, a prenatal narcotic maintenance and tapering program was initiated in 2012 to stabilize the large number of women using narcotics in pregnancy and lessen the neonatal burden of opioid withdrawal.

Maternal narcotic use has risen to 28.6% of all pregnancies (P < .001), including increases in both intravenous and daily use. Among infants born to narcotic users, the rate of NAS fell significantly from 29.5% in 2010 to 18.0% in 2013 after the January 2012 institution of our narcotic weaning program (P = .003).³ Traditional methadone and more recent buprenorphine maintenance therapies do not typically include dose weaning; infants born to participants have NAS rates of more than 50%, and rates are often quoted as being close to 90%.⁵ Our program has achieved stable, low rates of NAS in the face of increased overall daily intravenous narcotic use by our pregnant patients. More important, the number of neonates whose Finnegan scores mandated pharmacologic treatment (2 consecutive values ≥ 8) has fallen from 2.5% of all births to 1.5% (P = .403). In view of the dramatic increase in daily and intravenous use, we see these outcomes as promising.

In our study, narcotic-exposed and nonexposed pregnancies had similar neonatal outcomes as measured by general birth parameters. Birth weight was lower in the narcotic-exposed group but the difference was not clinically meaningful, with a mean (SD) birth weight of 3420.8 (538.6) g. Although the SLMHC provides intrapartum services for 63.0% of the region’s deliveries, all stillbirths in the region came to our centre in the 3-year study period as a function of air ambulance service routes. The 12 stillbirths are therefore measured against the regional live birth totals of 1899, for a rate of 6.3 per 1000 live births. The Ontario stillbirth rate in the study period was 8.4 per 1000. Of the 12 stillbirths, 3 were in the exposed group of 300 pregnancies and 9 were in the nonexposed group (P = 1.0).

The dramatic increase in intravenous use of illicit opioids is concerning for the risk of communicable diseases. Despite this development, hepatitis C infection was only seen in 3 cases and HIV infection was not seen. This finding might be secondary to the many well developed needle exchange programs in northern communities.

OxyContin (controlled-release oxycodone) manufacture ceased March 1, 2012, and its substitutes were no longer supported by federal or provincial drug subsidy programs (Non-Insured Health Benefits and the Ontario Drug Benefit Program).^6–8 Surprisingly, it continues to be a common drug of abuse in our region, lessening the likelihood that prescription drug abuse is an accurate description of this narcotic abuse problem.⁹

The 2012 Ontario NAS clinical practice guidelines recognized that while methadone maintenance therapy is generally recommended, our region, with limited resources over a vast geographic area, might need to explore alternative options, including other opioids or opioid tapering.^10,11 Our narcotic maintenance and tapering program uses more easily prescribed long-acting morphine preparations such as twice-daily MS Contin or daily Kadian. This approach seems to be effective in our population, with good birth outcomes and low rates of NAS. A recent Cochrane review also found that “oral slow-release morphine seemed superior to methadone for abstinence from heroin use during pregnancy ([relative risk] 2.40, 95% CI 1.00 to 5.77).”¹² A 1999 Finnish open randomized study of 48 opiate-addicted pregnant women found slow-release morphine to be equivalent to methadone in treatment and birth outcomes.¹³

Self-reporting seems reliable in our setting. Of 131 random drug screening tests done on self-reported non-users, all had negative results for oxycodone, while 1 patient had positive results for tetrahydrocannabinol, 1 had positive results for benzodiazepines, and 1 had positive results for opiates. It might be that the widespread nature of narcotic abuse in our region has lessened the stigma associated with self-reporting.¹ Advances in cross-cultural care at the SLMHC and a welcoming interdisciplinary prenatal program that commonly deals with narcotic use might also be factors.¹⁴

Also, rural populations might differ from urban ones. In a subanalysis¹⁵ of the MOTHER (Maternal Opioid Treatment: Human Experimental Research) study,¹⁶ Baewert et al noted regional disparities, with rural American newborns having shorter NAS treatment duration than European or urban American participants. They concluded the results “revealed significant intergroup differences with regard to sociodemographic and clinical/substance abuse characteristics,”¹⁵ suggesting that women in urban areas were more severely affected.

The SLMHC prenatal narcotic tapering clinics are managed by generalist rural family physicians working in a multidisciplinary team. These family physicians are capable of treating male partners, managing narcotic use, and delivering obstetric services and postnatal maternal and neonatal care. This is done in conjunction with nurses who have a broad scope of practice, a social worker, and a lactation consultant. Having a concentrated core of health care professionals who can move between critical functions is vital in a rural setting. Four family physicians are currently involved, 3 of whom provide cesarean sections when needed.

The psychological and cultural dimensions of drugs, withdrawal, and recovery are supported by outpatient and inpatient social and addictions workers in Sioux Lookout and the surrounding communities.¹⁷ In addition, community visits by addiction specialists have been useful in establishing remote community-based programs.¹⁸