Postpartum Addiction

The months after the birth of a child are supposed to be among the happiest in a woman’s life. But there is another side to the postpartum experience that is not blissful or enlightening. Nestled amongst the joys of motherhood is a recipe for disaster. The basic ingredients are the usual discomforts women experience after birth—exhaustion, pain or soreness, worry sometimes bordering on paranoia, and emotional mood swings. Mixed in with these ingredients is anywhere from just a drop to a heaping cup of psychiatric illness, depending on whether the new mom suffers from the baby blues, postpartum depression, or full-blown psychosis. Once mixed, the concoction is popped in the oven to be surrounded by the pressures of new motherhood and the new mom is left to hope that doctors and loving spouses don’t get her addicted to drugs while she waits the year for her body to return to normal. The finished product is something that can easily be toxic. Fortunately, the problems of perinatal (defined as the time during pregnancy and postpartum) women are receiving more attention from health care professionals. As a result, there are continually new findings regarding the nature and treatment of issues facing postpartum women. One issue that has not garnered much attention in the past but is becoming a vital area of research now is postpartum addiction. Within the first months after the birth of a child, a woman is physically and psychologically vulnerable and can become easily addicted to painkillers or antidepressants. There are two main reasons for this. The first requires a look at some of the risk factors for addiction: · Fatigue · Overwork · Depression · Dependency · Poor self-concept After giving birth to my youngest daughter, I fit all of those criteria. I was tired, overworked and depressed. I had become dependent on the opinions of others to guide my life. And I knew that once I delivered my baby my big belly and breasts would no longer be cute. Doctors are the second reason postpartum women are more likely to become addicted to drugs. In the process of trying to cure their patients efficiently, doctors prescribe medications that carry with them a higher risk of addiction. Included among these drugs are at least four of the top twenty most abused drugs in the country.1 In weighing the risks of prescribing a particular medication, many doctors choose to base their decisions on current trends rather than current research. For example, researchers have known since 2000 that certain antidepressants can be habit-forming. However, most doctors still do not warn their patients as to the side effects of these medicines or the fact that they must be weaned off of them because of their popularity. To understand just how devastating postpartum addictions can be, it is important to evaluate just how antidepressants and painkillers function and what makes them so addictive to the new mother. After giving birth, whether by natural or surgical means, the issue of pain must be addressed. After I delivered my daughter by Cesarean, I was given Percocet to alleviate the pain. Without question I took the little blue pills every four hours as they brought them to me. Soon, I began to realize that the pills made me feel even better when I wasn’t experiencing much pain. So I took them. It was a welcome relief for the stresses of three a.m. feedings, and when I was released from the hospital with a prescription of the very same drug, I had no problem filling it. Inadvertently I had become addicted to prescription drugs. The pain pills became an outlet, a panacea to new motherhood. In between the fourth and fifth feeding of the day I fed my habit, stooped in a corner just waiting for the buzz to kick in. When my prescription ran out I found myself looking for other drugs to fill the niche that I had lost. I tried cough syrup; I tried nutmeg. I was even tempted to steal a Vicoden from a friend’s cabinet. Fortunately, my addiction didn’t have time to fully take root. But how many women became full-blown addicts after having a child? How many had access to the drugs they craved, allowing their habit to grow larger and more deadly? It is not the relief from pain that makes pain pills so addictive. So, what causes perfectly rational people to believe they can’t live without a drug? Let’s take a look at the effects certain pain pills have on the human body. One class of pain medicines that have addictive properties is the Opioid family. Included in this group are Percocet, Morphine, Oxycodone and Hydrocodone. Opioids, also called Narcotics, work in the central nervous system by binding to opioid receptors and causing a decreased ability to sense pain. But along with this action, they also interact with the area of the brain that perceives pleasure, creating a sense of ‘euphoria’ that can last up to four hours. For a woman who is overwhelmed and exhausted, and in many cases depressed, the chance to be happy, even if artificially, is too appealing to ignore. To avoid the possibility of becoming addicted to painkillers, a woman can ask her doctor for alternatives to narcotics. Tylenol, Ibuprofen and Advil can be just as effective as the stronger drugs, and they are non addictive. While in the hospital, Toradol, a very strong analgesic and non-narcotic, is an option, though it carries risks of severe side effects and should be used no more than five days at a time. A newer approach is On-Q, a non-narcotic pain relief device surgeons attach to the surgery site. The FDA has recently approved the use of On-Q for post-surgical pain. It works by releasing a local anesthetic through a catheter that the woman herself can control. Like Toradol, it is non-addictive. For the woman who has already become addicted to painkillers, there is help. First, the family doctor should be notified. He/she may be able to wean her off of the medication safely and with as little discomfort as possible. If she doesn’t want to take her problem to someone so close, there are treatment centers in all areas of the country. Simply find “Drug Addiction” in the local phone book for area treatment centers. There is also help on-line at the government web site for the Substance Abuse and Mental Health Services Administration.2 So, let’s say that a woman has navigated the waters of post-pregnancy pain and has come out unscathed. She’s not out of danger yet. There are approximately 1.6 million women who will suffer from some form of postpartum mood disorder each year. The causes of these disorders have been speculated for decades. There are accounts of ‘mania’ and ‘agitation’ amongst new mothers as far back as 460 BC. 3 It is possible that the sudden drop in hormones after birth instigates mood disorders. Both Progesterone and Estrogen fall by 90% to 95% in the first 48 hours after delivery.4 It is known that Estrogen holds an important role in the brain as one of the mood hormones, however, no link has been established between the fall in Estrogen and the occurrence of the more serious mood disorders. After my daughter’s birth I found myself weepy and irrationally moody. During my first week home I alternated between crying and fits of hysteria over things as simple as missing socks or lack of ice cream. I was experiencing the “baby blues.” It is estimated that eighty percent of new mothers will be struck with this ‘side effect’ of pregnancy within seventy-two hours of birth.5 Since the effects can last up to three weeks (after beginning in the first week postpartum) it can sometimes be confused with other, more serious disorders. Psychosis, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder and postpartum depression are all possible postpartum complications. Psychosis is rare, afflicting only one to two women in a thousand births.6 However, the effects of this disease are most pronounced. Suffice it to say that if one comes into contact with a woman exhibiting the symptoms of psychosis, including hallucinations, delusional thinking (about infant being demon, for example) or delirium shortly after the birth of her child, it is important that she gets immediate treatment. Many women who experience mood disorders change their future plans, resorting to adopting or sterilization to avoid the same problem. Therefore, it is important to identify the symptoms early and get treatment as soon as possible. Affecting 15-25% of postpartum women, Postpartum Depression, or PPD, is one of the most common psychiatric disorders women face after the birth of a child. A month after Cerrie’s birth, I was still not adjusting to having a new child. I was irritable, angry, emotionally unstable and unfocused. I yelled at my kids (yes, the baby too!) and then felt guilty about my inhumanity. I thought many times of suicide. Unbeknownst to me these were all symptoms of PPD. Among others: Excessive worry or anxiety, indecision, a constant feeling of being overwhelmed, depression, guilt, phobia, hopelessness, problems with sleep, discomfort around the baby, loss of focus, and changes in appetite. A woman doesn’t have to have all the symptoms of PPD to be afflicted by the disease, so if in doubt consult a doctor. Also, these symptoms can appear anytime within the first year. In treating PPD, medication is usually chosen over psychotherapy because it is believed that postpartum depression is a result of chemical imbalances in the brain rather than prior events in a woman’s life. Also, drugs are less expensive and time consuming than therapy. To date, prophylactic treatment for women with risks of postpartum depression has not been extensively studied. There has been one double blind, placebo-controlled trial aimed at treating postpartum depression with Estrogen.7 It showed a quick and stable fall in the patients’ depression among the Estrogen-treated group with only 20% of treated patients depressed at four months. By contrast, 69% remained depressed in the placebo group. Even with the supposed success of hormone therapy in treating postpartum depression, it will be some time before hormones will be used for treating the disease. For women who suffer now, this means being prescribed an antidepressant. Typically, they are taken for 4 to 6 months, although some women need a longer course of treatment. In any event, the family should know the side effects of the medication that is prescribed, and any possible withdrawal symptoms. Some antidepressants need to be gradually reduced in dosage to avoid rather unpleasant side effects. Most antidepressants are believed to work by slowing the removal of certain chemicals from the brain called neurotransmitters. Serotonin and norepinephrine are two examples. They are believed responsible for controlling mood. There are two main classes of antidepressants, and which a woman chooses depends on the effects, whether she feeds by breast or bottle, and personal preference. The first class is the Tricyclics. These have been used to treat depression for a long time. They act on both serotonin and norepinephrine, and may also interact with other chemicals throughout the body. They include brand names Elavil, Norpramin, Tofranil, Aventyl and Pamelor. Due to the fact that they interact with the entire body, tricyclics have a lot of side effects, many of which new moms find unacceptable, including weight gain, sedation, dry mouth, and cardiovascular effects. These drugs also have a higher overdose potential, which makes the potential for suicide greater. On the other hand, for breastfeeding women, tricylics have been better evaluated and their safety to the infant is not questioned. Selective serotonin reuptake inhibitors, or SSRIs, are relatively new antidepressants. They act only on one body chemical, serotonin, and since they don’t affect the rest of the body they have fewer side effects. Examples of SSRIs are Lexapro, Celexa, Prozac and Paxil. Symptoms include dry mouth, nausea, nervousness, insomnia, headache and sexual problems. Monoamine oxidase inhibitors (MAOIs) like Nardil and Parnate are rarely used now owing to the necessary dietary restrictions, but if prescribed them, a woman should be prepared for side effects such as weakness, dizziness, headaches and tremor. Also keep tabs on what over-the-counter medications are taken, as these can interact negatively with the MAOIs. A risk of all antidepressants is serotonin syndrome, a drug reaction resulting from the over-stimulation of serotonin receptors. This can occur when an antidepressant is taken either with another antidepressant, with certain recreational and other drugs. Symptoms include hyperactivity, mental confusion, agitation, shivering, sweating, fever, lack of coordination, seizure, and diarrhea. Drugs that may induce serotonin syndrome when taken with antidepressants (not a complete list) include St. John’s Wort, DXM (found in cough suppressants,) medicine for Parkinson’s disease, anti-epileptics, appetite suppressants, analgesics, and anti-migraine drugs to name a few. To minimize the risk of serotonin syndrome, there must be a ‘washout’ period of at least two weeks when switching from one antidepressant drug to another. This is a period of time in which no medicine is taken to allow the first drug to flush itself out of the patient’s body. There has recently been backlash against antidepressants, in particular the popular brand name Paxil, charging that it can cause suicidal incidence amongst teenagers and children. It has also been accused of being addictive. In fact, there are currently lawsuits filed in thirty-one states charging that Paxil is a habit-forming drug. There have been reports of patients having difficulty with withdrawals from Paxil and other SSRI antidepressants. But does this constitute addiction? To be considered addictive, a drug must compel a person to acquire it regardless of the consequences. In this definition Paxil isn’t usually considered habit-forming. I was prescribed Paxil for PPD and never woke up with the need to take my Paxil. However, that’s not the end of it. Another facet of the definition of an addiction states that a drug addict will continue to take a drug simply to avoid the withdrawals. Cocaine is a good example of such a drug. So is Paxil. When my doctor prescribed me Paxil, I was told nothing of the effects that it would have on my body or what I would experience when I tried to stop taking them. After quitting cold turkey, I spent the first day thinking I was near death. I felt disconnected from everything, walking around in a vivid dream of which I wasn’t really a part. The next day and the week after I couldn’t walk straight. I was provoked to going to my family doctor, who ran tests and still couldn’t tell me what it was, even after I told him I had just stopped taking an antidepressant. The fact is that my body had become addicted to Paxil. In order to combat that, patients are supposed to be weaned from the drug over time—which can be an expensive and tedious process. So, what seems to be a solution to PPD turns into its own problem. And Paxil is not alone. Withdrawal symptoms, including gastrointestinal and somatic complaints, sleep disturbances, movement disorders and psychological symptoms, are reported to occur in up to 30 percent of patients who abruptly discontinue SSRIs.8 Many antidepressants are now being labeled with warnings based on the side effects and nasty withdrawals. For a woman experiencing postpartum depression, worrying about which drugs will hurt the baby if breastfeeding, or which will change her personality or which she will have to be weaned from is oftentimes too much. Family can help by asking for more information from the doctor before accepting a prescription. Postpartum addiction is a serious problem that deserves more attention from the medical community. As more and more women voice their concerns over postpartum issues, this will happen. For now, the Internet is an excellent place to find both information and support regarding issues relevant to postpartum women. Whether they suffer from painkiller addiction, post-partum depression, antidepressant withdrawals or just the baby blues, there is a place for every woman to share her story. Through these stories come information and through information comes enlightenment and insight, which can be used by researchers to better the lives of women in the future, the lives of the littlest victims of postpartum addiction. 1. Drug Abuse Warning Network Emergency Room Data. Based on drug mentions during emergency room visits in 2002. Hydrocodone (Lorcet and the like), Oxycodone (Percocet,) Paroxetine (Paxil,) and Alprazol (Xanax.) 2. See their web page, www.samhsa.gov. 3. The Greek philosopher Hippocrates theorized that suppressed lochial discharge was transported to the brain, where it produced what he called “mania.” 4. Women’s Primary Health Grand Rounds at the University of Michigan; Timothy R.B. Johnson, MD, and Barbara Apgar, MD, Series Editors, Kathryn A. Leopold, MD, Lauren B. Zoschnick, MD. 5. Women’s Primary Health Grand Rounds 6. Women’s Primary Health Grand Rounds 7. Postpartum Depression, Kathryn A. Leopold, MD, Lauren B. Zoschnick, MD; Women's Primary Health Grand Rounds at the University of Michigan. 8. Psychopharmacology Update Alert, December 13, 2001; Manisses Communications Group, Inc.