TALES FROM THE CLINIC
-Series Editor Nidal Moukaddam, MD, PhD
In this instalment of Tales of the Clinic, The Art of Psychiatry, we visit a case of a young woman struggling with opioid use disorder while pregnant. This woman was lucky enough to have access to a multidisciplinary treatment clinic, including psychiatry and maternal-fetal-medicine, and to have family support. Pregnancy is often a time of renewed interest in being off drugs and trying to build a healthy mom-baby dyad, but also a time of struggle, given hormonal changes and lack of specialized treatment guidelines for this population. Cooccurring issues such as mental illness, trauma history, and negative social determinants of health often make treatment extremely challenging.
“Ms Landry” is a 25-year-old female with generalized anxiety disorder, reported history of bipolar disorder, opioid use disorder (OUD), methamphetamine use disorder, cocaine use disorder, benzodiazepine use disorder, and tobacco use disorder. She presented in September 2020 to the emergency department (ED) for management of opioid withdrawal, as she found out several weeks prior that she was pregnant. She wanted to be off drugs for her baby. Due to irregular menses, she was unable to state how far along she was in the pregnancy. She reported using intravenous heroin over the last 4 to 5 years, with her last use 2 days ago. She stated that she has used 1.5g per day for the past year-and-a-half, since she has been homeless.
At the time of presentation, she endorsed worsening symptoms of withdrawal, including rhinorrhea, diarrhea, nausea/vomiting, abdominal pain, flushing, and chills. After workup and imaging, she was estimated to be 8 weeks pregnant. Consult-liaison psychiatry was consulted by OB/GYN for medication-assisted treatment initiation. Ms Landry reported that she had been tried in the past on both methadone and buprenorphine. She described her primary motivation for seeking treatment as her pregnancy and the opportunity to be a mother. She explained that it is her responsibility to ensure the physical well-being of her baby and agreed to start suboxone 4mg BID (buprenorphine 4mg/naloxone 1mg).
At time of treatment initiation, Ms Landry was living at multi-site residential and outpatient substance use treatment center, which also provides care for pregnant and parenting women, along with their children. Following initiation of suboxone and resolution of withdrawal symptoms, they discussed a plan for discharge to her mother or return to the facility. Ms Landry was inpatient for a total of 4 days. On the evening of her last day, she approached the obstetrician, requesting to leave the hospital. She described frustration that her boyfriend was not able to visit with her during nonvisiting hours. After brief discussion, she agreed to stay and follow the agreed-upon treatment plan. Several hours later, she left her room with her boyfriend and did not return. Attempts to contact her were unsuccessful.
Past History and Background
Ms Landry started drinking with her father when she was 13 years old. She explained that it was used as a “bonding activity” and something they could do “behind mom’s back.” Her father also introduced her to marijuana use. In later years, she was estranged from him due to other mental health issues (reported borderline personality disorder and suicidality) and threats of physical violence made against her mother. Her parents later divorced, and her father died from complications related to alcoholism. Ms Landry described her mother as a consistent source of support, and she later lived with her mother, following delivery. She also has a younger brother and reported no additional substance use disorder (SUD) in her family.
Following a sexual assault between the ages of 15 and 16 years old, she began to experiment with ecstasy and cocaine. At 18 years old, she moved out of her parents’ home and into the home of friend who used methamphetamine. Shortly after, she began using methamphetamine as well, both intravenously and via smoking. She described enjoying the energy it provided and how it “unbridled” her creativity. After being caught intoxicated at school around 19 years old, she was referred to and seen by a psychiatrist. She was given the diagnosis of bipolar disorder, due to “erratic behavior,” although she continued actively using substances at that time. She says she was tried on both Vraylar and Latuda, with good effect. She also described multiple suicide attempts (SAs) around this time, including cutting and intentional overdosing on substances. She denied additional SAs following this period.
Several years later, Ms Landry met the father of her baby, who she continued to have an on/off relationship with over several years, leading to the pregnancy. At times, she reported the relationship as physically abusive. She stated that he introduced her to IV heroin, which was her substance of choice, when she initially presented to the ED. She has been to inpatient substance use rehabilitation programs several times and was able to maintain sobriety for 2- to 3-month periods. However, after programs concluded, she relapsed almost immediately each time she left. Her substance use has resulted in multiple arrests and DWIs.
Ms Landry had difficulties maintaining employment due to ongoing substance use. After finishing high school, she was able to complete 2 years of college. She previously worked at one of the local airports, and also had jobs as a waitress and as a dancer.
From the initial presentation through multiple clinic follow-ups, a similar pattern emerged where Ms Landry would skip follow-up for both obstetrics care and psychiatry appointments, or where she would present to the hospital with symptoms of withdrawal and leave shortly after against medical advice. During this time, she lived between her mother’s home, hotels, and the local SUD treatment facility, with intermittent periods of homelessness. To pay for hotels, she would steal and sell objects.
She was forthcoming regarding her continued substance use and difficulty managing cravings on suboxone.Initially she reported she was relapsing on IV heroin, but later into her pregnancy, various collected UDSs were consistent with fentanyl, cocaine, and cannabis use. During her initial presentations, she expressed interest in resuming methadone, but due to the daily dosing, was concerned about having regular transportation to the clinic. Toward the latter portion of her pregnancy, dosage of suboxone was titrated to 16mg. After delivery, transition to methadone was discussed, given inability to adhere to buprenorphine requirements including drug screens and clinic visits.
In addition to difficulties with transportation and housing, Ms Landry frequently did not have consistent access to a phone, adding another barrier to treatment. Her mother would be unaware of her whereabouts and unable to get into contact with her. When members of the team were able to contact her, she indicated that the baby’s father was present, and it was suspected that he encouraged guardedness during these conversations.
By the end of the pregnancy, Ms Landry stated she had ended her 5-year relationship with the father of the baby, due to continued substance use and physical abuse. She delivered her baby in early March 2021 at roughly 35 weeks. She presented via EMS to the ED for preterm premature rupture of membranes, and following delivery, her baby was transferred to the neonatal intensive care unit for prematurity. Child Protective Services became involved after the baby tested positive for cocaine. She again shared her intention to return to the local SUD facility. Shortly after, she left the facility against the advice of the treatment team. Following the baby’s discharge from the hospital, Ms Landry took the baby home. It was reported that she was sober for a total of 9 days throughout the remainder of her pregnancy.
Over the next 3 months, Ms Landry missed several appointments in the obstetrics and psychiatry clinics. On a few occasions, she would call the clinic following missed appointments to reschedule or reengage in SUD treatment, but then failed to present to clinic. The last documented encounter in her chart was when she presented to the ED, endorsing worsening withdrawal symptoms from recent IV fentanyl use. When she was called from the waiting room for further examination, staff were unable to locate her.
Throughout the United States, there has been a sharp up-tick in deaths involving synthetic opioids over the last decade. This is largely thought to be due to the rapid proliferation of illicitly manufactured fentanyl and fentanyl analogs (eg, acetylfentanyl, carfentanil), which are highly addictive and very potent.1 These substances are sold as a standalone product (ie, tablet or powder), as an additive to increase the potency of heroin at little cost, or as a substitute ingredient for more expensive sedative-hypnotic and opioid drugs, such as alprazolam, oxycodone, and hydrocodone.1
In 2016, the national mean opioid overdose death rate in the United States was 14.98 per 100,000, with a median of 13.88 deaths per 100,000. The highest rate of opioid overdose-related death occurred in West Virginia (40.03 per 100,000), at roughly ~169% higher than the national average. In contrast, the lowest mortality rates were found in Texas (4.93 per 100,00), at approximately 3 times lower than the national average.2 However, results of a recent study at the University of Texas at San Antonio showed that although Texas has consistently had rates of mortality significantly lower than the national average, opioid-related deaths are on the rise. The study revealed that between 1999 and 2019, opioid-related deaths among persons aged 15 to 64 increased over 402% (from 3.8 per 100,000 in 1999 to 8.2 per 100,000 in 2019).3 Women accounted for 32.9% of those reported deaths.3
Between 1992 and 2012, the rate of substance use treatment admissions among pregnant women with OUD increased from 2% to 28%.4 Similar to Ms Landry, demographic characteristics reflected a predominance of younger, unmarried, white non-Hispanic women; criminal justice referrals; and those with psychiatric comorbidity becoming more common (p < 0.01).4 In 2018, recognizing increasing incidence of mothers with OUD, the Substance Abuse and Mental Health Services Administration (SAMHSA) responded to the unique needs of women by outlining specific clinical guidance for pregnant and parenting women with OUD.5
The guides highlighted the complex needs of a women-centered approach to OUD treatment. These needs included the importance of adjusting the dose of MAT to account for the increased metabolic demands during pregnancy, breastfeeding, and breastmilk to decrease neonatal abstinence syndrome (NAS) severity among opioid-exposed infants; the provision of family-planning services that include highly effective contraceptive options to decrease high rates of unintended pregnancy; and engagement with obstetric, social services, and behavioral health providers during pregnancy and after delivery.5 Evaluation of 13,000 substance abuse treatment facilities across the United States found that only 40% offered women-centered OUD, listed in the aforementioned recommendations by SAMHSA.6
In 2019, the Texas Health and Human Services Commission (HHS) was awarded $750,000 in federal funding to help increase access to treatment for pregnant and postpartum women with OUDs and enrolled in Medicaid.7 Goals for the initiative include establishing a multidisciplinary clinic designed to lessen stigma, reduce barriers to prenatal care, and improve the quality of maternal care for women with SUDs. Texas was 1 of 10 states chosen to implement this model of care, with aims closely related to the clinical guidelines by SAMHSA.
Ms Landry was able to utilize similar multidisciplinary services during her treatment course. However, as seen in her case, higher rates of intimate partner violence and sexual abuse, and cooccurring psychiatric disorders among women with OUD adversely affect levels of engagement and retention.6 Studies present mixed rates of continuation into the postpartum period, with some showing high rates of continued engagement into the postpartum period and others with rates of relapse as high as 56% at 6 months postpartum.8 Other factors in Ms Landry’s case—such as significant trauma history, history of substance use in her family, and misdiagnosis of psychiatric disorder leading to delays in care—add to the complexity of her presentation. These factors are not unique to her case, and further research should be done to develop additional modalities in treating pregnant and postpartum women with OUD.
Dr Laster is a PGY3 psychiatry resident at Baylor College of Medicine, in Houston, TX. She is currently on the Women’s Mental Health track and has additional clinical interest in addiction psychiatry, in which she plans to complete fellowship. Dr Ojeda is assistant professor at the Menninger Department of Psychiatry, Baylor College of Medicine. He specializes in addiction and women’s health/reproductive psychiatry, and serves as the primary psychiatrist on the maternal perinatal addiction treatment program.
1. Baldwin GT, Seth P, Noonan RK. Continued increases in overdose deaths related to synthetic opioids: implications for clinical practice. JAMA. 2021;325(12):1151-1152.
2. Lyle Cooper R, Thompson J, Edgerton R, et al. Modeling dynamics of fatal opioid overdose by state and across time. Prev Med Rep. 2020;20:101184.
3. Salazar CI, Huang Y. The burden of opioid-related mortality in Texas, 1999 to 2019. Ann Epidemiol. 2022;65:72-77.
4. Martin CE, Longinaker N, Terplan M. Recent trends in treatment admissions for prescription opioid abuse during pregnancy. J Subst Abuse Treat. 2015;48(1):37-42.
5. Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. Substance Abuse and Mental Health Services Administration; 2018.
6. Krans EE, Bobby S, England M, et al. The pregnancy recovery center: a women-centered treatment program for pregnant and postpartum women with opioid use disorder. Addict Behav. 2018;86:124-129.
7. Phillips C. Texas awarded funding to help pregnant and postpartum women affected by opioid use disorders in Houston. Texas Health and Human Services Commission. December 20, 2019. Accessed February 28, 2022. https://www.hhs.texas.gov/sites/default/files/documents/mom-press-release.pdf
8. Krans EE, Patrick SW. Opioid use disorder in pregnancy: health policy and practice in the midst of an epidemic. Obstet Gynecol. 2016;128(1):4-10.