[Pregnant opioid addicted patients and additional drug intake. Part II: Comorbidity and their therapy]

Abstract

The majority of opioid dependent patients suffer from various psychiatric and somatic comorbid diseases like mood and anxiety disorders, psychotic diseases, personality disorders, HIV infection, Hepatitis B and C. If medical treatment is needed, grouping active substances to FDA Pregnancy Categories (A, B, C, D or X) may be helpful. The majority of substances reported here only fulfill the FDA-categories C or D, which means that they could have teratogenic effects, but with probably different rank order. First of all, referring to mood, personality and anxiety disorders, the focus should be laid on non-pharmacological treatment by offering psychotherapeutic and supporting psychosocial interventions to the patients. However, opioid dependent pregnant patients who suffer from severe diseases such as psychosis, bipolar affective disorder or severe depression, may need psychoactive medication like antipsychotics, antidepressants or mood stabilizers to prevent them from harm caused by psychotic ideas and actions and/or suicidality. However these medications may comprise fetal risks, especially when taken together, and therefore should only be used when benefit and risks are considered together with patients and their relatives. It is important to avoid acute or renewed psychiatric decompensation. We present the current differentiated knowledge for therapy of opioid dependent patients with antipsychotics, antidepressants (e.g. higher fetal risk in case of treatment with fluoxetine and paroxetine) or mood stabilizers. All of them should only be used after considering benefit and risks. During pregnancy, there should not be switched between different antidepressant drugs. Referring mood stabilizers, the intake of valproic acid should be avoided in pregnancy or at least, dosage should be kept as low as possible since severe teratogenetic effects are known. In addition the specific drug treatment of HIV and hepatitis B during pregnancy is described. During childbirth HIV-infected patients should receive zidovudine intravenously to prevent vertical transmission. Co-infection with hepatitis C cannot be treated during pregnancy, since interferons are associated with a severe risk of fetal malformations and ribavirin has teratogenic effects; for this reason interferon therapy should be started after delivery.