Prescribing for Older Adults and Pregnant Women
8903Directions: Respond to at least two of your colleagues on 2 different days who selected different disorders. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature.
Respond to #1 K
Bipolar disorder is a mood disorder characterized by fluctuations between depression and mania. In some instances, this disorder can be quite debilitating and even require hospitalization during periods of severe mania. To minimize the effects of bipolar disorder on one’s daily life it is important that those diagnosed with bipolar disorder take any prescribed medications as directed. During pregnancy, a person and their doctor must be particularly careful about what is ingested into the body to minimize harmful effects on the fetus. The prescriber should weigh risks vs benefits when prescribing to pregnant women. While it may not be possible to eliminate risk to the fetus, the goal is to reduce risk while also maintaining a stability for the patient. Here are some options available for the safe and effective treatment of bipolar disorder in pregnant women.
Treatment Options
Olanzapine is FDA approved for the treatment of acute mania, bipolar maintenance, and bipolar depression (in combination with fluoxetine) (Stahl, 2013). A 2020 study on the prevention of mood episodes during the perinatal period found Olanzapine to be effective in preventing new mood episodes in pregnant women with bipolar disorder (Uguz, 2020). Controlled studies have not been conducted, but data on pregnant women who continued to take olanzapine during pregnancy shows infants exposed to it during pregnancy did not have adverse consequences (Stahl, 2013). Of course, without controlled studies it cannot be considered completely safe. There is a possibility of abnormal muscle movement and withdrawal in infants exposed to this medication during the third trimester (Stahl, 2013).
Lithium is a mood stabilizer that is also used for the off-label treatment of bipolar depression. It has been shown effective in the prevention of bipolar relapse in pregnant women, but there is a risk of increased fetal growth among other concerns (Poels et. al., 2021). Women who have already been on lithium have been able to continue taking it during pregnancy without harm to the baby. Clinical practice guideline state to weigh benefits for the mother against risks to the baby and slow taper if it is deemed necessary to stop the medication (Stahl, 2013). If lithium is continued, monitor serum lithium levels every 4 weeks, then every week beginning at 36 weeks (Stahl, 2013).
A good non-pharmaceutical option is electroconvulsive therapy (ECT). ECT has been shown effective in the treatment of bipolar depression and mania and is safe for pregnant women (Minick & Atlas, 2007). If I were treating a pregnant patient who was newly diagnosed with bipolar disorder and not already on medication, I would likely choose a non-pharmaceutical alternative for treatment.
References
Minick, G., & Atlas, M. (2007). What’s the best strategy for bipolar disorder during pregnancy? The Journal of Family Practice, 56(8), 665–668.
Poels, E. M. P., Sterrenburg, K., Wierdsma, A. I., Wesseloo, R., Beerthuizen, A., van Dijke, L., Lau, C., Hoogendijk, W. J. G., Marroun, H. E. l., van Kamp, I. L., Bijma, H. H., & Bergink, V. (2021). Lithium exposure during pregnancy increases fetal growth. Journal of Psychopharmacology, 35(2), 178–183. https://doi-org.ezp.waldenulibrary.org/10.1177/0269881120940914
Uguz, F. (2020). Pharmacological prevention of mood episodes in women with bipolar disorder during the perinatal period: A systematic review of current literature. Asian Journal of Psychiatry, 52. https://doi-org.ezp.waldenulibrary.org/10.1016/j.ajp.2020.102145
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press
Respond to#2 T
Opioid use disorder is among the mental health issues that have been escalating in pregnant women. This disorder affects both unborn babies and their mothers. Neonatal assistance syndrome affects many infants, and there are increased cases of maternal mortality (Kondili, & Duryea, 2019). Opioid use disorder is characterized by the inability to control use, craving, and continued use despite the many negative consequences. According to DSM-5, opioid dependence was replaced with opioid use disorder, and its severity depends on the number of recurring symptoms individual experiences within a period of 12 months. During pregnancy, mothers who use opioids and health practitioners should understand and differentiate opioid misuse and cases of untreated opioid use disorder (American College of Obstetricians and Gynecologists, 2017). This will help inappropriate prescription of opioid medication.
In most hospitals, screening, brief intervention, and referral treatments are conducted to help identify, reduce, and prevent problematic use of substances and alcohol. Screening helps in assessing the substance use behaviors that may be risky, while the brief intervention is supposed to be an engagement between a health practitioner and the patient, which illustrates the risky substance use disorders through a conversation.
Methadone is among the FDA-approved drug to treat opioid use disorder during pregnancy. Methadone is a drug that is dispensed by a registered opioid treatment program and is often used as a part of a comprehensive treatment (Salinas-Miranda, 2019). The maternal methadone doses can be managed by specialists in addiction treatments, and this should be within the opioid treatment programs. There should be communication between the obstetric team and the opioid treatment program to enhance good care. During pregnancy, the methadone dose cannot be adjusted because it may cause withdrawal symptoms. Additionally, methadone has pharmacokinetic interactions with other medications, for instance, antiretroviral agents. In most cases, it prolongs the QTc intervals, and this should be considered before introducing new medications (Salinas-Miranda, 2019). Some pregnant mothers require titration of doses until they are asymptomatic. This is because inadequate methadone doses may cause moderate opioid withdrawal and other symptoms that cause maternal drug cravings and fetal stress.
Suboxone is considered an off-label drug in the treatment of opioid use disorder in pregnant women. The drug is composed of two drugs, buprenorphine and naloxone (Upadhyay, & Granger, 2021).. Although buprenorphine is not to be very effective during pregnancy, there may not be adequate information on naloxone. It is known that Suboxone may have some side effects when used in pregnancy and may also cause neonatal opioid withdrawal syndrome in infants. Some of the symptoms may include diarrhea, irritability, vomiting, trouble sleeping, and failure to gain weight. Whenever women use Suboxone during pregnancy, they require more pain medication during labor and childbirth. The American Society of Addiction Medicine suggests pregnant mothers be treated with methadone instead of suboxone if they have opioid use disorder.
Cognitive-behavioral therapy can be used in the treatment of opioid use disorder as clients use a structured format when working with specified problem behaviors. CBT can be used in monotherapy and in a combination of other treatment strategies. According to McHugh et al. (2010), CBT can be used because it attends to the functional cues for opioid use. Whenever individual CBT packages are used, behavioral strategies may be applied to reduce triggers. This builds drug refusal, problem-solving, and coping skills in individuals. Although the use of CBT has no side effects, it may be combined with pharmacotherapy to bring about enhanced treatment outcomes.
In conclusion, various treatment strategies can be used in the treatment of opioid use disorders in pregnant women. Methadone is one of the FDA-approved medications that treat this disorder. Suboxone is an off-label drug that is also used in the treatment of opioid use disorder, but it may have adverse effects on the mother and the unborn child. Eventually, there is CBT, which may be used as a monotherapy or in combination with other medications. CBT may be slow, but it has no side effects. The most appropriate treatment is the use of psychotherapy in conjunction with an FDA-approved drug.
References
American College of Obstetricians and Gynecologists. (2017). Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. Obstet Gynecol, 130(2), e81-e94.
Kondili, E., & Duryea, D. G. (2019). The role of mother-infant bond in neonatal abstinence syndrome (NAS) management. Archives of psychiatric nursing, 33(3), 267-274.
McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010). Cognitive-behavioral therapy for substance use disorders. Psychiatric Clinics, 33(3), 511-525.
Salinas-Miranda, A. A. (2019). Opioid Use and Opioid Use Disorder in Pregnancy.
Upadhyay, P., & Granger, J. (2021). Importance of Nor-naloxone Detection in Compliance Drug Monitoring of Suboxone Medication-Assisted Treatment for Opioid Use Disorder. J Pain Relief, 10(393), 2.
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