Perinatal Substance Use Opioids
1st Edition October 2018
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A Letter to You about Harm Reduction In a perfect world, abstaining from all recreational substance use during pregnancy and breastfeeding is the safest option for just about everybody. Since we don’t live in a perfect world, we understand that some people have trouble achieving abstinence, or simply don’t want to. If you are one of those people, your health and your pregnancy still matter! Substance use is just one of many things that influence your health and your pregnancy outcome. This booklet will give you the tools you need to be as healthy as you can be, whether or not you decide to stop using. This booklet is the first version of a much larger work that is continually evolving and growing. We will be periodically adding sections and releasing new versions. The ultimate goal is a guide to everything you need to know to achieve your goals around reproductive health as a person who uses or used substances. We have a long way to go, and we want your feedback! Please let us know if you think there are any changes we need to make, ideas for future sections, or how you can help our work. Erika Goyer – erikagoyer@gmail.com Joelle Puccio – joellepuccio@outlook.com Glyceria Tsinas – gtsinas@gmail.com
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What is Substance Use Disorder (SUD)? Substance Use Disorder is diagnosed based on 11 signs: 1. Taking the substance in larger amounts or for longer than you meant to 2. Wanting to cut down or stop using the substance but not being able to 3. Spending a lot of time getting, using, or recovering from use of the substance 4. Cravings and urges to use the substance 5. Not managing to do what you should at work, home, or school because of substance use 6. Continuing to use, even when it causes problems in relationships 7. Giving up important social, occupational or recreational activities because of substance use 8. Using substances again and again, even when it puts you in danger 9. Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance 10. Needing more of the substance to get the effect you want (tolerance) 11. Development of withdrawal symptoms, which can be relieved by taking more of the substance. You might not have any of these, you might have a few, or you might have all of them. Every person’s journey looks and feels different. Most people try several times before they can kick their habits.
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If a treatment does not work for you, try something else! Remember, the treatment failed, not you. The only way you can fail is if you stop trying, so keep at it and don’t beat yourself up for not being perfect. (Since there is very little scientific information about pregnancy safety for certain drugs like MDMA, acid (LSD), mushrooms, and the newer synthetic “designer drugs”, in this booklet, we will be talking about only 6 kinds of drugs: opioids, stimulants, tobacco/nicotine, alcohol, cannabis, and benzodiazepines.)
Alternatives to Injecting Smoking Smoking anything is bad for your lungs and respiratory system. It can cause burns, tightening of the airway, and other problems. Taking good care of your lips and mouth is very important in preventing skin breaks. Lip balm and chewing gum should be used to keep lips and mouth moist and intact. Oral herpes (HSV, “cold sores”), tuberculosis (TB), and other respiratory and gastrointestinal infections can be spread by spit or blood on a pipe. Hepatitis C can be spread by invisible specks of blood and can survive on a pipe for a long time. Using found objects to smoke with can be dangerous. Light bulbs are filled with toxic chemicals, pens melt and expose you to plastic fumes, broken off car antennae are sharp and can cut up your mouth, pop cans are sharp, break down quickly, and are inefficient. If you use a pipe, try to use a proper crack, meth, tobacco, or cannabis pipe. You can often find
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tobacco or cannabis pipes at smoke shops and convenience stores. Crack and meth pipes are available at certain syringe access programs or through some drug user unions. They are also sold at some smoke shops and convenience stores, usually under a code name such as “rose stem” for crack pipes, or “oil burner” for meth pipes. Be careful asking for any pipe which may be used to smoke a substance that is illegal. Do not use words like cocaine, crack, meth, and weed (unless you are in a legal state). You don’t have to smoke out of a pipe. You can also put your substance in with whatever else you’re smoking, roll it up in a cigarette paper, or if it’s sticky, put some on the end of a small metal object like a safety pin or straightened out paper clip, heat it up with a lighter, and inhale the smoke. Make sure your equipment is clean. It only takes a few seconds to feel the effect when you smoke.
Heroin The most common method of smoking is “chasing the dragon”. This involves placing a line of heroin on some tinfoil and heating it from below with a flame. You then use a tube to suck up the resulting smoke. Only Shiva has enough hands to smoke this way alone using a lighter. Using a zippo or a candle can free up your hands to hold the foil and the tube. Using a straw can be very wasteful, so try to get a wider tube, like from a toilet paper roll. Ingestion (Eating) You don’t need to cook up before ingestion, but if it’s already in liquid form it will start to work faster. Ingestion can take longer for effect, around 30 minutes, and your peak will be in roughly an hour, depending on the substance. Ingestion is less efficient than
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injecting or smoking. You may have to use about twice as much for the same effect, because part of your dose is processed by the liver before entering your bloodstream. You can decrease absorption time and increase the strength if you hold a mixed liquid solution under your tongue until it is absorbed.
Booty Bumping Cook up your drugs as if you were going to inject, and then put your solution into a syringe with the needle removed. Then lay down and insert the syringe into your anus (butthole) and push in the drugs. Lube can make insertion more comfortable, and a friend to help can make this a less difficult process. Afterward, you need to stay down with your butt above your head like a cat for a few minutes, until all of the liquid is absorbed, otherwise, when you stand up, your drugs may leak out. You will start to feel the effect within a few minutes. Inhaling If your drug is easily crushable, or already comes in powder form, you can sniff it up your nose with a straw. To improve absorption, put your powder through a clean flour sifter, loose leaf teapot basket, or other fine screen to ensure that there are no clumps. Be sure to use your own clean new straw each time, and cut it to your desired length, usually 1-3 inches. If you’re using with friends, try to each use a different color, so they don’t get mixed up. Never use a straw that has been used to drink something, because your powder will get stuck in the remaining drops of liquid inside the straw. Before you sniff
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your line, exhale while facing away so you don’t accidentally blow it away. Sometimes this method gives you a runny nose, so hang your head upside down off the edge of a bed until it stops, to avoid losing part of your dose in the snot. You can also cook up your drugs as if you were going to inject, and then put the solution in an empty nasal spray bottle, to be squirted up your nose conveniently and discreetly. (The longer you store cooked drugs, the more likely it will start growing bacteria. Try to use it up within a few days. Store it in the refrigerator, in a paper bag or something to block out light, which can cause it to start breaking down.) You may want to use as little water as possible to make the solution more potent, so you don’t have to use a zillion sprays to get the effect you want. Snorting is effective in just a few minutes.
OPIOIDS What are opioids and how do they work? Opioids include heroin, morphine, hydromorphone (Dilaudid®), fentanyl, hydrocodone (Vicodin®, Norco®), oxycodone (Percocet®), oxycontin, tramadol, buprenorphine (Subutex®, Suboxone®), nalbuphine (Nubain®), methadone, meperidine (Demerol®), and codeine (some cough syrups). These drugs work by slowing things down in your body. They make you feel sleepy. They slow down the movement in your intestines, which can make it hard to poop (constipation). They decrease the amount of pain you feel, both in your body and in
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your mind. They also slow down your breathing and lie to your brain, telling it you don’t need as much oxygen. If you have a cough, taking opioids will make you cough less, which can be a good thing, unless there is gunk in your lungs that needs to come up. You might feel sick to your stomach, dizzy, itchy, or confused. When someone takes opioids, the black part of their eye (pupil) will get very small. Overdose from opioids causes death by stopping a person from breathing. Most of the time, overdose happens after a person takes an opioid and something else, like alcohol or benzodiazepines (benzos, Xanax®, Valium®). When you detox or stop using opioids it can cause you to have a lower tolerance. This means that when you use opioids again, your risk of overdosing is higher than it was before. People are especially vulnerable to overdose during treatment for their SUD, when they are trying to quit, during or after a hospital, jail, or prison stay. Someone who is overdosing: • • • •
has slow, shallow, or no breathing may be making sounds like they’re snoring or struggling to breathe is turning purple or blue around their mouth or fingertips doesn’t wake up
If you think someone might be overdosing: •
call 911
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give them mouth-to mouth rescue breathing
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administer Narcan (naloxone) by following the instructions that came with your prescription
Go to page ** for details on what to do! If you haven’t already been given a Narcan (naloxone) prescription, ask your provider to write you one. Review this information often, so you can remember if you need it. To find the nearest overdose prevention program and get naloxone, visit: hopeandrecovery.org Withdrawal from Opioids Withdrawal from opioids happens when you have become physically dependent on an opiate substance and it is leaving your system. Your body has become accustomed to functioning with the drug in your system and when it is no longer there you develop withdrawal symptoms. Withdrawal can happen a few hours or days after your last dose. People in withdrawal experience: • • • • • • • • • • •
joint pain nausea vomiting sweating diarrhea trouble sleeping anxiety enlarged pupils racing heartbeat runny nose shakes
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yawning goose bumps
Withdrawal during pregnancy is associated with higher risks of miscarriage and medical complications like preterm birth. If you have withdrawal, especially while pregnant, it is important to drink fluids. If you can’t keep anything down, or you can’t stop vomiting, seek immediate medical attention. Which treatments can I get while I’m pregnant? Doctors, scientists, and the medical community have agreed that treatment with methadone or buprenorphine (Subutex®) is not only safe for you and baby, but is the standard treatment offered to pregnant people. Studies have shown that babies born to people who are taking these medications have lower risk of being born prematurely or underweight when compared to babies born to people who are using unprescribed opiates. If you want to detox during pregnancy, you should only do it with supervision from your provider, because medical help can make it safer for you and baby. Detox, even for a short time, can lower your tolerance, and make it easier to overdose. If you decide with your provider to try it, the best time is in the second trimester.
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Treatment Options Methadone and buprenorphine have been thoroughly studied and are deemed the most appropriate treatment during pregnancy as well as during postpartum care. In addition, they can reduce HIV and hepatitis C transmission, improve social functioning, reduce the risk of law enforcement intervention, and as well as significantly reduce the risks of an opioid overdose. However, it is your own decision on which treatment (if any) to use and this decision should be respected and supported by all care providers. Methadone • • • •
Highly regulated--patients are supervised with daily clinic visits Sometimes take home dosing is allowed with progression in treatment Can cause NOW in newborns, however these effects are expected, temporary, treatable, and non-life-threatening. Travel time going to the clinic daily or finding appropriate childcare while at the clinic are important to consider since it is not common for clinics to offer childcare or transportation vouchers.
Buprenorphine (Subutex) and buprenorphine/naloxone (Suboxone • • •
Available in primary care and allowed take-home dosing or pharmacy pick up, not only drug treatment programs Medication is taken under the tongue until it is fully dissolved Can cause NOW in newborns, however these effects are expected, temporary, treatable, and non-life-threatening.
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Naltrexone (Vivitrol) • • •
Blocks the effect of all opioids Patients must fully detoxify from all opioids before treatment No research for treating pregnant people
Opioid Detox/Withdrawal and Pregnancy Opioid withdrawal during pregnancy may cause problems or death to a fetus. If you are pregnant and want to stop using drugs, it is recommended you seek medical supervision. If you really feel like you can’t seek medical help, at least slow down your using gradually. Don’t try to stop all at once. The best time to detox during pregnancy is the 2nd trimester. Withdrawal in newborns, known as Neonatal Opioid Withdrawal (NOW), is an expected, temporary, and treatable condition, and non-life-threatening, and should not be a reason to try to detox. Best practices for treating NOW include skin-to-skin contact (constant holding, cuddling) breastfeeding, and rooming-in with parents. You are your baby’s best medicine! What is pregnancy with opioid use like? When you are pregnant, your body goes through changes that can make drugs work differently. You make more blood, and your metabolism may speed up or slow down depending on how far along you are in your pregnancy. This means drugs may hit you harder or less hard than they used to. Constipation and hemorrhoids are a side effect of both pregnancy and opiate use, so it can become a big problem for some people. If you are having trouble pooping, get more exercise, drink more fluids, and eat
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more high fiber foods like whole grains and dried fruit. You can also talk to your provider about stool softeners, laxatives, and suppositories. Get medical help right away if you don’t poop for 4 days. What is breast feeding with opioid use like? It is safe to breastfeed on opioids. In fact, there is some evidence that it might make your baby’s withdrawal less severe. We are not sure whether this is because of small amounts of opioids in your milk, the fact that your baby feels better and closer to you while breastfeeding, or both! In the United States, it is best not to breastfeed if you are using heroin, since you can’t know the exact dose you’re taking and there may be cut that isn’t safe for you or baby. It’s not the heroin itself, but the other factors that make safety an unknown. When we study other opioids like methadone, we find that only about 2% of your total dose makes it into your milk. This is usually not enough to treat your baby’s withdrawal symptoms, but it might help a little.
Opioid Overdose and Treatment
(OD)
Prevention
An opioid overdose happens when there are too many opioids in a body and breathing slows down, eventually stops, and can end in death. An opioid overdose is usually caused by opioids combined with other drugs like alcohol or benzodiazepines, but can happen with opioids alone. Overdose prevention includes the training and distribution of naloxone and rescue breathing. You are optimal trainees for opioid overdose prevention. There is not
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much information on the use of naloxone during pregnancy and the effects on the fetus; however, naloxone should always be used if anyone is experiencing an overdose, in addition to respiratory support, like mouth-to-mouth breathing. Signs and Symptoms of an overdose include: • • •
Unresponsive (you cannot wake the person up)* Turning blue or ashy due to the lack of oxygen. Snoring or gurgling sound (this is the body’s reaction to slowed/lack of breathing).
*To confirm a person is completely unresponsive and not just in a heavy nod (very high), you can shake them by their shoulders and shout their name. Then, you can perform a ‘sternal rub’ making a fist and forcefully rubbing your knuckles up and down their chest (between their nipples). Sometimes the best way to get a person to respond is to tell them you are going to Narcan them! If the person remains unresponsive, call 911 or administer naloxone (whichever is closest at the time and then do the other one). To find the nearest overdose prevention program and get naloxone, visit: hopeandrecovery.org Naloxone (Narcan) •
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Naloxone, also known by the brand name, Narcan, is a short acting opioid blocker, which means that it kicks out opioids and blocks the receptors in your brain for 30 – 90 minutes. This means the drug causing the overdose is still in your body, but won’t work until the Narcan wears off. Safe to use for any age and should be used without hesitation even if you are unsure what is happening
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The only thing that naloxone does is restore a person’s ability to breathe during an opioid overdose. It has no other effects. In people who are opioid dependent, naloxone may induce temporary opioid withdrawal symptoms including agitation, vomiting, and diarrhea—however, this will only last 30-90 minutes. There are two forms of naloxone administration: intranasal and intramuscular To administer intramuscular (needle and syringe): Give 1mL in thigh or upper arm. Do not inject into a vein, as this can take too long, possibly cause seizures and complications, and does not even work faster or better. To administer multi-step intranasal (Amphastar) formulation: Remove the colored caps and assemble the device by gently twisting the nasal applicator, capsule of naloxone, and the barrel onto each other. Tilt the head back, spray half of the naloxone up one nostril and half of the naloxone up the other nostril. To administer one-step intranasal (Narcan) formulation: Remove the device from its blister pack, tilt the head back, spray up one nostril. Each formulation takes about 1-3 minutes to wake someone up Repeat administering a naloxone dose every 3 minutes until the person wake up. While you wait for them to wake up, give rescue breathing (mouth to mouth) or CPR If you can, call 911. Say, “my friend is not breathing.” Many states have a Good Samaritan law, which protects against prosecution when responding to an overdose. Unfortunately, common limitations to these laws do not protect you if you have previous drug convictions or specific quantities of drugs found on the scene, etc, and
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some police and 911 dispatchers may be unaware of the laws or choose to disregard them If someone is opioid dependent, they will wake up sick and upset. DO NOT LET THEM USE DRUGS AFTER AN OD. People who wake up sick may want to use, however, they won’t be able to get well as long as the naloxone is in effect. Additionally, if the person uses more opioids, this can lead to a second overdose. Naloxone wears off enough so that you feel well after 3090 minutes, but it continues wearing off for several hours. Do not let the person be alone or use again for at least 3-6 hours post overdose, and longer if they used a long acting opioid, like methadone
How to Give Rescue Breathing (mouth to mouth) •
Tilt the head back a little bit lift the chin.
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Plug the nose with the hand that is on their forehead. Place your mouth completely over the other person’s and give a slow breath until you see the chest rise. If you do not see the chest rise, reposition and look to see if there is anything in the mouth blocking the airway. Once you get chest rise, give one small breath every 5 seconds. They may throw up. Turn the person to their side so their head is facing the ground—this prevents them from choking on their own vomit.
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Call your provider RIGHT AWAY if you experience: • • •
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Difficulty breathing Bleeding from your vagina Leaking amniotic fluid (breaking your water) Preterm labor Severe headache that doesn’t go away with Tylenol Severe abdominal pain Trouble seeing The baby is not moving, or is moving much less than normal Nausea so bad you can’t keep anything down