I am pleased to give the presentation at the American Association of Nursing and Anesthesiology 2021 Conference, and my conference topic is Anesthesia Pain Management Strategies for Proterance on Medication-Assisted Treatment. Disclosure Statement. I have no financial relationships with any commercial interests in relation to the content of this activity, and I will not be disclosing any off-label use during my presentation. Learning Objectives. We're going to describe the three medications commonly used in medication-assisted treatment programs. We're going to discuss the impact on the ceiling effects for medication-assisted treatment medication, and we're going to describe some non-operative pain management strategies for proterance on medication-assisted treatment. Medication-assisted treatment is an epidemic. Opioid use disorder is an epidemic within the United States. You can see from the graph, 70,000 people have died. There's been 10.1 million misuse of prescription opiate use, and really the genesis has occurred from probably in 1990, early 1990s, when it was discussed that pain is the fifth vital sign, and from that, there has been an overabundance of over-prescribing of pain medication to people that have had surgeries and that have had different procedures, and this has caused the overuse of opioids as we know it. Now, how to diagnose opiate use disorder. You have to use the DSM-5 diagnosis criteria, and you basically, from this diagram, you can see the different types of severity. You have mild, you have two, three symptoms, moderate, four to five symptoms, and severe. Mainly, the mild and the moderate are the ones that are very treatable in terms of what medication-assisted treatment. Now, exactly the dynamics of what goes on with opiate use disorder. It is a chronic exposure to opioids as a result of the brain abnormalities. These brain abnormalities can lead to developing of addiction, also known as opiate use disorder. It's treatable, and it's a chronic disease process. Again, as we said earlier, it's impacting over 1.6 million people in the United States. How do we manage that? How do we, as anesthesia providers, manage that by medication-assisted treatment? Many of our patients that we encounter, many proturants that we encounter will be on these medications. Now, opiate use disorder, the whole genesis of this presentation, has rose more than four times among pregnant women from 1999 to 2014. This number has continued to increase. The impact of the pandemic has even caused it to rise even more in terms of patients that have opiate use disorder. What is medication-assisted treatment? As we talked about, medication-assisted treatment is the combined use of federal drug administration medications, and we'll discuss this further in this presentation, along with behavior therapy. This combination with the FDA-approved medication or the behavior therapy constitutes medication-assisted treatment. Now, one of the major things in terms of opiate use disorder or people that have opiate abuse is prescription drug monitoring programs. Every state has a different type of prescription drug monitoring program to really ensure that patients that might be prescribed a medication in this particular state don't get the medication in this other state. If I get prescribed with Dr. X, I can't go in the next county and get another medication. It communicates with the pharmacies so that the healthcare providers do not over-prescribe on a patient that has been already prescribed the opioid. This communication piece is not in the VA. They don't use it as well as the military, so it does have some pitfalls, but this is a good system to prevent the epidemic. Medication-assisted treatment for opiate use disorder or imperturbance. Imperturbance, often, as you saw in the earlier slide, they are four times as likely to have opiate use disorder. What imperturbance that do have opiate use disorder, MAT improves maternal and fetal outcomes. The treatment, and we'll discuss this earlier more further, methadone or buprenorphine is recommended during pregnancy. Discontinuation of existing MAT during pregnancy is not recommended because it can cause them to relapse, and then there's a high likelihood of neonatal abstinence syndrome for patients that have opiate use disorder. The FDA-approved medications for opiate use disorder, there are three medications that have been approved. Methadone has been around since probably the early 60s, buprenorphine, 2000s, and naltrexone is recent, but methadone is taken by either liquid, edible, wafer, or tablet. You have buprenorphine, there's different forms of buprenorphine. You can have it oral or buccal, and there's different types of buprenorphine combined with naltrexone. We'll discuss that later on, and naltrexone itself. They're all long-acting for the long-term effect of opiate use disorder treatment. Naltrexone is an opioid agonist, methadone is an agonist, buprenorphine is a partial agonist, and naltrexone is an antagonist. That means it has a high affinity to the mu receptor site for methadone. For buprenorphine, that's extremely high, six times the affinity for the receptor site, and naltrexone completely blocks it. We'll talk about that and what that means to the pregnant patient. Again, so this diagram is a really great diagram to really understand the whole opiate receptor site. Opioids, they have a full agonist effect on the receptor. These are medicines such as heroin, oxycozone, fentanyl. We talked about methadone, which is one of the FDA-approved medications. It's a full agonist. It activates the receptor site just like a regular opioid. It does have some abuse potential, but methadone has been very effective for patients that have opiate use disorder. Buprenorphine, I think that this is the one that has really increased over the last couple of years. It has a partial agonist, it has a high affinity, it has a ceiling effect, and we'll discuss what a ceiling effect means later on in the discussion. And naltrexone, it's a full antagonist. So you can see from the diagram what exactly, how it impacts the mu receptor. This diagram is a great diagram, and it really shows what each medication does. The full agonist, methadone, you can see it has pretty much, it does the side effect of respiratory depression. Partial agonist, buprenorphine, you can see from the diagram, you can see that it has a ceiling effect, so meaning no matter what amount of dose that you give, it's not going to continue to exhibit an effect on the individual. The antagonist, naloxone, again, it completely blocks the receptor site. FDA-approved evidence-based medication, we talked about methadone. The type of medication for protuberance is buprenorphine, the monoproduct. It's the one without the naloxone is recommended. So this is the buprenorphine, they have a combined medication, suboxone, that is combined with naloxone, that is usually a 4 to 2 ratio, it usually comes in 4 milligrams of buprenorphine and 2 of naloxone and naltrexone, or 8 milligrams and 4, so it's like a 4 to 2 ratio. But with this product, for protuberance, they're recommending a monoproduct, and naltrexone is really not recommended during pregnancy because you would have a withdrawal effect. What is, you can see the full agonist, the partial agonist, the ceiling effect, what is exactly that means? It has limited respiratory depression, it's more safe, and limited euphoric effect. So the partial agonist, buprenorphine, is really what Evidence-Based has really recommended now that protuberance get to have, are impacted by opiate use disorder. Again, this is another diagram of what that partial agonist, buprenorphine, does in terms of ceiling effect. And so really with the protuberant that comes in, that they, if they have, they already have a child that's on the gravid uterus that might impact their respiration and cause them to have shortness of breath. But the partial agonist, buprenorphine, is something that is going to not have, cause additional respiratory effect on these individuals. So let's talk about the ceiling effect of buprenorphine, what that means. Again, partial agonists have more favorable safety profiles than full agonists. There's a decreased risk of overdose, respiratory depression, lower due to the ceiling effect increases, buprenorphine will not increase the effect as we've discussed earlier. Overdose is increased with ETOH and benzodiazepines to other opioids. So even though it is partial agonist, if it is combined with other medications, it does have abuse potential with benzodiazepines and alcohol and other opioids. So that caution as anesthesia providers, we really have to look out for that when we have protuberants that come to us that make sure they don't have any other additional medications that they are taking. And methadone, again, it's been used for over 40 years to treat protuberants. It can only be prescribed in a federally licensed methadone clinic requiring visits to get daily. Methadone has improved. Research has shown that methadone and buprenorphine improve maternal fetal outcomes. And that's something that we as anesthesia providers need to make sure that we understand that when we have patients that come to us that may be on buprenorphine or methadone, that they need to continue these medications, especially depending on their gestation. If they are taken and they are compliant, we need to make sure, ensure that they get that as soon as possible. What buprenorphine does, again, it approves for treatment, opiate use disorder, for protuberants, is recommended during pregnancy as a monoproduct, not suboxone. Again, we talked about suboxone as a combo with naltrexone. It can prescribe in outpatient as well as prescribe with special waivers. And again, it can be given by pill. We talked about receptors. Mu receptor has a partial agonist effect. It also has a kappa, strong antagonist, high affinity for both preventing other opioids from binding. Because of that partial agonist, it doesn't allow other opioids to get to the receptor site. Pharmacogenetics of it. It's eliminated by glucuronation, dealkylination, and cytochrome P4384, and has both renal and fecal elimination. Half-life for buprenorphine is 24 to 48 hours. What are some strategies that we can, as anesthesia providers, give patients that have protuberants that have opioid disorder besides opioids? For chronic practice goals includes minimal use of opioids. So quite naturally, one of the major things we could do is distraction techniques. You can also do stress reduction, mindfulness, meditation, hypnosis. One of the things that we, as anesthesia providers, always do is regional anesthesia. So epidurals and spinals, trigger point joint injections, spinal peripheral stimulators, spinal blocks and infusions. So regional anesthesia is a great way to minimize opioid use, and just that communication with the protuberant during this time period of our pain strategy and our pain plan to minimize opioid use. This diagram is great for, it really describes opioid use during pregnancy. The continued opioid use, we really want to not give any opioids at all, and that's, so we really want to have that strategic plan. Alternate to methadone, we want to minimize withdrawal symptoms and, consequently, improve compliance to prenatal care, reduce maternal risk behaviors. We want to, if you do discontinue, there is a chance of neonatal abstinence syndrome, maybe worse after exposure to continued use of other opioids. And then alternative to buprenorphine, we want to, methadone is the old standpoint. Again, buprenorphine has, as evidence-based, has caused more providers to use buprenorphine now, but again, it does have withdrawal symptoms. It can cause, when we combine it with buprenorphine, when we combine it with benzodiazepines or ETH, then it can cause some issues. But there is a disadvantage still of neonatal abstinence syndrome. What the literature shows, SAMHSA and ACOG, after delivery, women should continue MAT as postpartum. So this is something that we have to discuss prior, that as soon as possible, they need to continue their MAT therapy. The discontinue of MAT should be avoided for that very same reason, because you have potential of having withdrawal. Again, MAT is a long-term treatment for this chronic condition. Some infants exposed to methadone or buprenorphine may have neonatal abstinence syndrome, so this is a possibility. This is something that, as providers, that we will discuss during the whole process. Key points to this is, you know, contact addiction treatment centers and continue MAT if on buprenorphine or methadone split dose to TID or four times a day. Consider a nerve block or epidural. Consider patient's behavior and integrate treatments. Again, we talked about different comprehensive meditation, other alternative treatments. Use preemptive analgesia for surgery, and increased pain could indicate a compliance or relapse, complication or relapse. Questions? There are some questions that will be in this posttest, and thank you.

anesthesia pain management

medication-assisted treatment

opioid use disorder

pregnancy

neonatal abstinence syndrome