Buprenorphine Maintenance Therapy

The use of illegal opiate in this country has been on the increase especially among the women of childbearing age. While working as an investigator in the Department of Children of Families, I noticed more and more pregnant women who were opiate dependent. Most of these women were on Methadone or Buprenorphine maintenance. This group warrants special attention due to the fact that it is important that they get the best maternal and neonatal health and well being. Some of the factors that have both maternal and neonatal outcomes for pregnant substance abuse dependent women include relatively late discovery of pregnancy, poor nutrition and overall self neglect, poor living conditions as well as exposure to risky behaviors (prostitution, infectious diseases, suicide), poly-substance dependence and lack of interest in treatment (Fischer, 2005). The cumulative effects of these factors on the children born to substance-dependent women include low birth weight, premature delivery, poor nutritional status, developmental delays, and increased risk of sudden death syndrome (Fischer 2005). These concerns highlight the need for development of treatment strategies beginning in the early stages of the pregnancy.

In the studies carried out in the United States of America, it was found that the prevalence of opiate usage among pregnant women had rose from 2.5% in 2001 to 4% in 2007. This has also resulted into the subsequent increase in the cases of methadone maintenance usage or application among the pregnant women (Pani, 2008).

As numerous studies have noted, methadone maintenance has been the standard program of care for opioid-dependent pregnant women. It has helped to stabilize pregnant opioid-dependent women, thus allowing for better prenatal care and decreasing the prevalence of premature birth (Finnegan, 1992). Even though methadone treatment has proven beneficial, it is also known to cause Neonatal Abstinence Syndrome (NAS) in newborns. According to statistics, the rate of maternal opioid use increased almost five times between 2000 and 2009, and the diagnosis of NAS increased almost three times in the same period. NAS can be characterized by irritability, heightened muscle tone, tremors, feeding intolerance, seizures, and respiratory distress (Enos, 2012).

If caseworkers who are not much knowledgeable about buprenorphine treatment see a newborn that is suffering from the neonatal withdrawal syndrome, they may conclude that the baby’s mother has “exposed” him/her to a drug. In such a case, the caseworkers interpret that as a sign of neglect and threaten the mother telling her that she will lose her baby unless she stops the maintenance program. Unfortunately such behavior is very common in the child protective service field. According to Kandall and Doberczak (1999), “even though abstinence will always remain the primary goal for pregnant women, detoxification therapy during pregnancy should be conducted with great care, because withdrawal can cause fetal distress syndrome”. It can harm a fetus severely or even cause premature delivery (Kandall & Doberczak, 1999).

It has been shown that methadone and buprenorphine maintenance therapies lead to a positive pregnancy course through the controlled intake of an opioid and the patients’ increased medical and psychosocial contact with health-care professionals. Neurodevelopmental examinations at 6 and 12 months were normal and not different from children of mothers without a substance related disorder (Schindler, 2002).

The increased knowledge about the short and long term effects of buprenorphine maintenance on pregnant women will help child protective workers and clinical social workers look beyond the stigma attached to buprenorphine maintenance and proactively work with these mothers. This is important because medical doctors and not clinical social workers should be able to determine when buprenorphine maintenance is appropriate. Treatment professionals are concerned that the message to get pregnant women with opioid addiction into treatment will be lost, and instead, women will not tell their caregivers that they need treatment or will try to get off methadone or buprenorphine while pregnant (Enos, 2012). From my research and experience working for the Department of Children and Families, it is evident that there is a great stigma associated with methadone and buprenorphine maintenance. Hence, the main question is “What is the knowledge base of clinicians about buprenorphine and pregnancy?” This is important because child protective workers need to be educated about the impact of buprenorphine and look beyond the stigma attached to buprenorphine maintenance (Ohaeri, 2003).

It is important to know the extent to which the use of methadone and buprenorphine can serve as a way of suppressing the effect of drug addiction, which should be understood by the health workers that find themselves in the awkward position when they have to assist the pregnant mothers who are addicts of the drugs. Understanding this will improve the health status of the children in the sense that it will facilitate their understanding of the various challenges that exist in dealing with such children, which include the associated health risks and infections.

A clear understanding of the precautions that need to be taken during the child delivery and the care that should be given to the pregnant mothers, even if they are former drug addicts, is important since it will generally improve the health of the babies and reduce the potential life loss of careless mothers that fear being stigmatized and tend to commit suicide, especially when they feel that the world around them is not caring or is responding inappropriately.

Literature Review

Opioid addiction has been countered by use of several treatment methods that have been aimed at discouraging the continuation of the behaviors among the affected individuals. The methods that have been used on large scale include the methadone treatment, buprenorphine treatment, and the use of the placebo intervention. Each of these methods has its own side effects or resultant effects on either the patients that use them or the children they bear just in case the patient happen to be a pregnant woman. Two of these methods, that is the use of methadone and buprenorphine, are the most used when dealing with drug addiction among pregnant women. They have side effects on the pregnant mothers and also affect the children that are born. Most researchers direct their focus on the impact the two methods have on the children that are born and how their effects could be reduced (Ohaeri, 2003).

For over 5 decades, opioid addiction among pregnant women has been treated by the use of methadone through substitution therapy. When a parent that has been addicted to a drug for a very long time starts exercising withdrawal from the use of the drug, there is pressure that is usually placed on the unborn fetus that threatens its very survival. This withdrawal symptoms and effects are what the therapy aims at addressing. Prenatal substitution has been found to have several beneficial impacts in obstetrical maternal and neonatal perspectives. This is, however, dependent upon the manner in which the dosage is carried out. It was, for example, found out that the stress on the fetus can be reduced by the use of a stable dosage of the methadone. This approach was also found to reduce the habit of the drug addicts seeking for the drugs. This is the greatest achievement of the methadone dosage for it achieves the ultimate goal of stopping drug addiction, which is reducing the urge among the affected people to look for the drugs to satisfy their thirst. Engagement in commercial sex so as to access money to buy drugs is one of the most rampant methods that most drug addicts resort to when the urge to get drugs is overwhelming.

Accessibility of prenatal care to pregnant women is high when the women are enrolled in a program that focuses on substance treatment. This would result in children being born with a higher birth weight than those born by the addict pregnant women who despise going to such healthcare facilities. There, however, exist barriers that prevent successful treatment by the use of methadone. These factors include childcare needs, insurance, and a lack of assurance that the fetus would not be affected by the drugs. These combine to create fear among the participants about the potential legal consequence in case it was found that the care was given through contradicting the provisions in law. The legal consequences may include among others the loss of custody over certain children that may be identified by the health officials (Ohaeri, 2003).

Another maintenance method that is usually employed is the use of buprenorphine. Originally, this narcotic was used for treatment purposes in the prenatal stages of the patients. It majorly aimed at treating acute pain. Formulations were made for usage in the treatment of drug addiction and were then approved in late 2002. This approval was done by the FDA and was supposed to be used in combination with certain chemical elements (Krook, 2002).

Its working is unique because it involves cooperation with the mu and kappa receptors. The mu receptor acts as the agonist in a partial manner, whereas the kappa receptor, on the other hand, serves as the antagonist in the process. This orientation is believed to be the main reason that the drug succeeds in fighting with the addiction, thereby reducing the craving associated with addicts. The tendency of the drug to bind at the receptors displaces the opioid together with other addictive drugs, and this is what reduces the tendency of the person to get addicted to the drug. The binding, however, does not usually result in the full activation of the receptors and, thus, there is usually a limited physiologic and subjective agonist effect, which then renders it hard to abuse, as is the case with other maintenance therapies (Krook, 2002).

Buprenorphine has another characteristic: it produces a ceiling effect in addition to the other subjective effects. This is because the partial agonist activity causes less euphoria and, thus, cases of respiratory depression remain at a minimum level. The use of buprenorphine is, therefore, a safer approach as compared to other maintenance therapies such as methadone. Methadone becomes a less preferred drug in most cases because of the high cases of euphoria that then result in the abuse of the drug, which means that patients or pregnant mothers will have to take the drug in large qualities. In addition, higher dosage of methadone is known to cause serious withdrawal symptoms and increase chances of acquiring respiratory depression. In some worst cases, the over dosage may result in the death of the pregnant mother.

Buprenorphine has specific properties that enable it to fully utilize the benefits associated with either antagonist of full opioid agonists. It, therefore, manifests the properties of both full agonists and antagonists; for instance, it reduces the constant desire that drives people to overuse drugs in a manner similar to methadone. On the other hand, it is similar to naltrexone for it has a higher affinity to get attached to the receptor, which is followed by slow dissociation. This, therefore, takes long for it to act on the receptors. A long period of action has the consequent beneficial effect of reducing the number of dosages that a person can be given in a day, and this results in reduced cases of abuse of the drug. It should also be noted that just like the drugs are important in facilitation of treatment, it is also known to efficiently result in the blocking of the potential effects of the illicit drug substances, thus preventing their abuse (Krook, 2002).

Prevalence of Drug Usage among Pregnant Mothers

Methadone and heroin are the most used opioids among pregnant mothers. In fact, it has been found that every year about 7000 births that are exposed to opiate occur. As a result of this phenomenon, there has been a record of 600% increase in obstetrical complications associated with the use of these opioids by pregnant mothers. The drugs used are usually in the range of 6 to 97% pure. When the opioids are overused by pregnant mothers, certain characteristic symptoms such as pinpoint pupils, coma, and circulatory collapse are shown by the women who are not pregnant. There is also an increase in the respiratory depression to risky levels. Withdrawal from the usage of opioid has symptoms that are similar to most respiratory infections, which sometimes make it difficult to ascertain what exactly causes the complication. Therefore, it becomes necessary for the tests to be carried out so as to identify the real causes of the symptoms so as to initiate the right care for the affected pregnant mothers.

The passage of the drug substance through the placenta to the unborn fetus is usually of high degree, and the withdrawal symptoms may also have an impact on the unborn fetus and may start within 6 to 48 hours. It has been shown that one such impact is the increase of a chemical compound called epinephrine in the amniotic fluid that usually surrounds the baby in the womb.

There is also a well known combination that might result from the usage of opioid by pregnant mothers, and this is known as the Neonatal Abstinence Syndrome (NAS), which is usually characterized by unstable body temperature, irritability, wakefulness of the child, and poor sucking mechanism. In some cases, there have been reports about the occurrence of seizures in the children. The paradox that exists with this syndrome is the manner in which it presents a dilemma in choices that have to be made: either to continue usage of the drugs or to withdraw the same by the pregnant mothers. This is so because of the worst outcomes on fetus that may occur if the mothers go ahead with the withdrawal from the drugs. The mechanism that could result into the demise of the fetus has not yet been understood, but many researchers attribute it to the possibility of meconium aspiration and hypoxia premature contractions, which may cause hyperactivity.

It is, therefore, important to note that drug addicted pregnant women and mothers who have given birth to their children require specialized care. They need different psychological approaches to be used while handling them at the healthcare centers, especially by the child care nursing personnel. This results in reduced cases of psychological breakdown among mothers, which would then have a disastrous impact on the lives of the children or unborn fetuses. In order to initiate a process that effectively addresses the stigma at the healthcare centers, it is imperative that one first of all understands the effects the drug would have on the user. This would also include understanding the cultural barriers that would play a role in the usage or stopping of the usage of that particular drug. There is also a need to have clear understanding of the differences in the impact of using methadone and buprenorphine by the pregnant mothers.

Research Design Issues

Research Design

The research will be aimed at ascertaining how the health care professionals deal with pregnant women just before delivery or those that have just delivered their children. In order to come up with the best findings, there will be a need to ascertain the clinicians’ knowledge of the prevalence of the problem of the drug usage among pregnant women. The clinicians will be also expected to show how they understand the various alternative maintenance therapies that could be used in the treatment of addict pregnant women. The study will also involve practical introduction of other maintenance methods to be used by several mothers so as to ascertain if indeed the use of buprenorphine can be replaced by a better maintenance drug. This will involve carrying out an experiment over a long period of time.

During the research, the clinicians will be expected to explain how they understand efficiency of using certain maintenance therapies to reduce cases of drug addiction among pregnant women. Under this topic, it will be important for the nurses to state several methods they use to ascertain whether a mother is addicted to substance use or is just going through instantaneous drug use. The various legal provisions or procedures should be considered in order to successfully address the limitations that exist in the system of delivering healthcare. The research will seek to find the major causes of the biased attitude towards addict mothers developed by the clinicians. When these factors are identified early enough, it will be easier to draft the various measures or procedures that could be used in the whole process of alleviating the associated challenges.

The challenges the nurses face during their work will be also analyzed so as to come up with relevant solutions to the problem of stigmatization. The nurses will be given a chance to state the problems they face and asked to propose potential solutions to the problems. In this way, it will be easier to come up with specific solutions that would address the challenges in a specific healthcare facility.

The research will also be aimed at ascertaining which social events should be introduced at the work place so as to increase the chances of preoccupying the pregnant mothers as a way of reducing their attention towards the drugs. In addition, it will seek to understand the various procedures that the clinicians use when they want to report a birth that may have taken place in their premises but which involves a mother that is addicted to opiate. Legal provisions in this case include the process that has to be undertaken before the mother of the child is given full custodial rights to have her baby. Before the mother is given back the child, the various drug rehabilitation processes she goes through should be discussed and analyzed fully.

Finally, the research will seek to understand the various prosecutions that have taken place as a result of perceived risk the child is exposed to. Having taken this into account in the research, it will be easier to understand the exact environment that surrounds the clinicians and how this environment affects the decisions they make at the time they serve the pregnant mothers, which includes the attitude they develop towards them.

Sampling Plan

Participants in this research will be selected randomly from several facilities that are involved in providing child care for mothers that are addicts of drugs such as opiate. The interviewees will include a variety of people who are usually affected by the problem of drug addiction among mothers. The selection will depend on several factors such as the willingness of the mothers to cooperate and give accurate or honest answers. This, therefore, means that the state of the interviewees will be taken into consideration before he/she is given a chance to give his/her side of the story.

Measurement and Instrumentation

The interviewees will include the victims of drug addiction, who will be also the mothers of the young children born. These will also include the pregnant mothers that are yet to have their children but are serious drug addicts or are recovering from the same. The mothers will be expected to give an account of the treatment they receive at the healthcare facilities and state whether or not they get fair treatment from the clinicians. The research at this stage will also aim at ascertaining whether pregnant mothers understand and appreciate the effects of the use of drugs such as buprenorphine on their pregnancy.

The second category of interviewees will include the clinical officers that have first hand interaction with the pregnant mothers in the child care facilities. These will be expected to give a firsthand experience on the challenges the nursing fraternity in such facilities face. It is also at this point that the research will try to find out if the nurses understand the impact of buprenorphine on the pregnancy.

Another group of interviewees will include professionals that are well acquainted with the provisions in the law, especially those that deal with the custodial laws of children born in such circumstances. These professionals will be also expected to give their own account on how the pregnant women should be treated by the nurses at the childcare facilities. This will give insights into how nurses or medical practitioners may have been wrongfully mishandling the pregnant women.

Data Collection Methods

The main method that will be used in collecting information will be the use of questionnaires. This will be achieved by the use of both closed and open ended questionnaires. Closed ended questionnaires will be important for the purposes of getting definite answers, especially those that will just require a yes or no answer. The open ended questionnaire, on the other hand, will be used for the instances in which the interviewee may be required to give more information than that which is targeted or in which the answer is not direct or definite.

The questions will be structured in a manner that addresses specific issues involved. Since the participants in the research are people who differ greatly in the roles they play in this research, it will be important for the questionnaires directed toward a specific group of interviewees to be structured differently from the rest. This is logically sound since the issues that the three groups of interviewees will be expected to handle are different by default.

The procedure of the research will include, first of all, seeking permission of the relevant authorities, especially in areas where such interviews are restricted or have to be done in a scheduled manner. This will be then followed by the sampling of the relevant participants, and then attention will be sought. The participants will have to be clearly informed about the main aim of the research and the expectation they should have in as much as the questions they will be asked are concerned. The interviewees will also have to be informed of the potential risks that may be involved in the research process (Ahmadi, 2002).

Finally, the interviewees will be given the questionnaires to fill, but only after being given assurance that the information they will provide will not be used by any person or organization to victimize them or any other third parties that may be mentioned in findings of the research. The interviewees will then fill the forms at their own pace. It is worth noting here that interviewees who will not be ready to fill the form during the meeting will be given an allowance of about one week to fill it. This move will assist in ensuring that the interviewees do not hurriedly fill the questionnaires with their attention focused elsewhere as that can easily result in incorrect information being gathered.

Data Analysis Plan

This step will involve interpreting the results from research findings and comparing them with the past findings. The information taken from the interviews of knowledge about the various impacts certain maintenance therapy drugs have on pregnant mothers will be discussed. In addition, there will be a detailed analysis of the findings in terms of the extent of stigma prevalence in childcare facilities.

The results will be presented in form of tables and charts to effectively communicate the message. In addition, there will be succinct comparisons with other previous findings from literature.

Ethical Issues

The only ethical issue that will be encountered is whether it is right to question a nurse or a clinician and seek information that may be deemed private and confidential.

Feasibility

This research will involve interviewing pregnant mothers who have a history of drug addiction. This could increase the lack of cooperation from the interviewees, who may feel bothered. Such an action could easily result in incomplete interviews that may in the long run affect the research process. Similarly, the nurses that will be questioned may not cooperate fully as is expected due to the fear of being intimidated by their seniors. This might then affect the accuracy of the findings (Ahmadi, 2002).

There are no major risks involved in this interview, but there might be few cases of psychological breakdown in some of the interviewees as a result of the questions asked in the interview. There is a potential benefit of the interviews for the childcare institutions in that the information collected might help the institutions in their plans to improve service delivery.

Translation to Practice

The findings from this research will be crucial in improving the quality of service delivered at the healthcare centers in which pregnant women addicted to drugs are admitted to deliver safely. The studies will help agencies that champion the usage of maintenance therapies such as buprenorphine and methadone to invest in investigating the various side effects they may have on the people that use them or those around them (Ahmadi, 2002).

In addition, the findings of this research could serve as a solid foundation upon which those that intend to study the effects of other maintenance therapies on the pregnant women who are also drug addicts will further their studies and come up with even more specific findings.