Clinical Education Series
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Women, Pregnancy, and Substance Use

From Telescoping to the Fourth Trimester

Target Audience: Psychiatry Residents, Addiction Fellows, OB/GYN
Epidemiology
02 / 16

The Closing Gender Gap

+84%
Women's AUD increase (2000-2013)
+35%
Men's AUD increase (2000-2013)
#1
Cause of pregnancy-associated death (overdose)
Physiology
03 / 16

The Telescoping Effect

Biological Factors

  • Lower gastric ADH → higher BAC per drink
  • Lower total body water → higher peak concentrations
  • Higher body fat % → altered distribution
  • Faster progression to liver disease

Clinical Implication

Women get "sicker, quicker" despite lower absolute consumption. Screen with lower thresholds.

Perinatal OUD
04 / 16

MOUD vs. Detox in Pregnancy

🚨 Standard of Care

MOUD (methadone or buprenorphine) is first-line. Medically supervised withdrawal has relapse rates of 59–90%.

Withdrawal is more dangerous to the fetus than stable opioid maintenance.

Pharmacokinetics
05 / 16

The "4 PM Wall"

Mechanism

  • Progesterone induces CYP3A4 (2-3× increase)
  • Plasma volume expands 30-50%
  • Methadone/buprenorphine half-life shortens
  • Afternoon withdrawal despite AM dose

Management

  • Split dosing (BID/TID)
  • Increase total daily dose 25-50%
  • 2nd/3rd trimester adjustments
  • Stable mom = stable baby
NOWS
06 / 16

Neonatal Opioid Withdrawal Syndrome

Assessment Shift

From Finnegan (counting symptoms) to Eat-Sleep-Console (ESC)

  • Functional assessment over symptom counting
  • ~50% reduction in morphine need

Non-Pharmacologic First

  • Rooming-in
  • Breastfeeding (encouraged on MOUD)
  • Low stimulation environment
  • Skin-to-skin (kangaroo care)
Stimulants
07 / 16

Stimulant Use in Pregnancy

Risks

  • Placental abruption
  • Pre-eclampsia
  • Preterm birth
  • IUGR

Treatment

No FDA-approved medications for stimulant use disorder.

Contingency Management (incentives for negative UDS) is the gold standard.

Critical Stat
08 / 16

The Fourth Trimester Cliff

7-12 months

Maternal overdose deaths peak 7-12 months postpartum—not during pregnancy.

Drivers: Loss of insurance (Medicaid cliff), loss of tolerance, sleep deprivation, PPD, CPS stress
Prevention
09 / 16

Postpartum Overdose Prevention Bundle

☐ Naloxone: Dispense to patient AND support person before discharge
☐ MOUD Continuity: Appointment within 7 days; bridge prescription
☐ Mental Health: PHQ-9 screen; treat PPD aggressively
☐ Contraception: LARC discussion/placement
☐ Support: Peer recovery specialist contact
Systems
10 / 16

Warm Handoffs & Dyadic Care

The Gap

OB care ends at 6 weeks; pediatric care continues but focuses on baby. Mother falls through cracks.

The Fix

  • Co-located appointments (Mom + Baby)
  • Clinician-to-clinician warm handoff
  • Pediatrician as key touchpoint
Legal/Ethics
11 / 16

CAPTA vs. CPS

CAPTA (Federal)

  • Requires notification
  • Data tracking
  • Plan of Safe Care
  • Public health approach

CPS (State)

  • May require abuse report
  • If imminent harm
  • Can lead to removal
  • Punitive approach
Interactive Case
12 / 16

Case: The 4 PM Wall

Patient: 29-year-old pregnant (30 weeks) on stable methadone maintenance reports new onset anxiety, lacrimation, and yawning daily around 5:00 PM. Last dose at 7:00 AM.

Question: What is the mechanism?

A Increased renal clearance of methadone
B Induction of CYP3A4 and increased plasma volume
C Behavioral conditioning
Correct Answer: B

Progesterone induces CYP3A4 and plasma volume expands 30-50% in pregnancy, shortening methadone half-life. This is the "Third Trimester Trough." Management: split dosing or increase total daily dose by 25-50%.
Summary
13 / 16

Must-Not-Miss Points

1. Increase methadone in 3rd trimester (CYP3A4 induction)
2. NOWS: Rooming-in + breastfeeding reduce pharmacologic treatment
3. Highest overdose risk is 7-12 months postpartum
4. CAPTA requires notification, not necessarily prosecution
5. No FDA meds for stimulant use disorder—CM is the answer
Resources
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Key Resources

Guidelines

  • ACOG Committee Opinion 711
  • ASAM National Practice Guideline
  • SAMHSA TIP 51
  • AIM Patient Safety Bundle

Key Studies

  • MOTHER Study (Jones et al., NEJM 2010)
  • Postpartum Overdose Prevention Bundle
  • ESC Protocol Research
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