> THE PATIENT: 23-year-old woman being treated for opioid dependence Unexpected weight gain

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Abstract

> THE CASE

We were treating a 23-year-old woman in our clinic for opioid dependence. She had begun using hydrocodone/acetaminophen, oxycodone, and heroin at age 17. Her parents and relatives had a history of alcohol and drug addiction and her brother had died from a heroin overdose.

> THE CASE

The patient was taking buprenorphine/naloxone 12 mg/3 mg daily. She attended weekly counseling sessions at a community outreach center. We explained to her the potentially dangerous effects of buprenorphine/naloxone. Urine toxicology was negative for substances other than buprenorphine/naloxone.

> THE CASE

Over 8 months, our patient gained 33 pounds and began wearing loose clothing to her appointments. When we asked her about it, she said that she had been “eating more bagels” lately.

> THE CASE

▪ What the patient wasn't telling us was that she was pregnant. (We learned of her pregnancy only after she delivered.) In addition, she didn't disclose to her obstetrician (OB) that she was taking buprenorphine/naloxone until she was nearly full term.

> THE CASE

At that point, the OB consulted maternal fetal medicine, and the buprenorphine/naloxone was continued through delivery. The patient had an uncomplicated spontaneous vaginal delivery of an 8.19 lb girl with an APGAR score of 8 at 1 minute and 8 again at 5 minutes.

> THE CASE

▪ Concerned about neonatal abstinence syndrome (NAS), which is characterized by tremors, increased body tone, feeding intolerance, vomiting, sweating, and fever, the healthcare team used the NAS scoring system to assess the newborn's need for pharmacologic therapy. The newborn's score at birth was 16/45. It then dropped to 11/45 indicating that she was experiencing mild withdrawal, but her symptoms—grunting, tachycardia, increased tone, tremors, irritability, and sweating—suggested she was experiencing severe withdrawal. The infant remained hospitalized for 29 days and received oral morphine titrated to her NAS score. The drug regimen for treatment/tapering was oral morphine given at 0.1 mg/kg/dose every 4 hours. This dose was lowered by 10% each time her NAS score was <8. At discharge, the infant's NAS score had decreased to 3/45.

> THE CASE

▪ After discharge, the mother admitted to us that she concealed her pregnancy because she was afraid of being placed on methadone. She said she didn't want to have to go to a clinic to receive the medication.

> THE CASE

▪ Continued good health. The child has since reached all of her developmental milestones appropriately and has normal height and weight.

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