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Continuing Education Webinar
The Pregnancy Opioid Epidemic:
An Outpatient Medical Home Approach to Treatment
This webinar will be recorded and available on the NPIC/QAS website www.npic.org.
Nurse Planner: Carolyn L. Wood, PhD, RN, Clinical Nurse Consultant Purpose/Goal(s) of this Education Activity: The purpose/goal(s) of this activity is to enable the learner to expand knowledge on the management of addiction in pregnancy. 1.0 Contact Hour: This continuing nursing education activity was approved by the Northeast Multistate Division (NE-MSD), an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. 1.0 AMA PRA Category 1 Credit™: Accreditation: Women & Infants Hospital is accredited by the Rhode Island Medical Society to sponsor intrastate continuing education for physicians. Women & Infants Hospital designates this online educational activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Disclosures and Successful Completion of this Activity
No commercial support has been provided for this activity.
No one involved in planning or presenting this program has a conflict of interest.
There will be no discussion of off-label usage of any products.
In order to successfully complete this activity and receive 1.0 Contact Hour(s) or 1.0 AMA PRA Category 1 Credit™, you must attend/watch the webinar and return the completed post-test/evaluation to NPIC/QAS.
Dennis English, MD, MMM FACOG Clinical Professor (Emeritus) Obstetrics & Gynecology
Department of Obstetrics, Gynecology, and Reproductive Sciences
University of Pittsburgh School of Medicine
Senior Medical Advisor NPIC
Pregnancy Recovery Center A Medical Home Model Approach for Pregnant Women
Suffering from Substance Use Disorders
11/1/16 National Perinatal Information Center (NPIC) Webinar
Currently serve as Senior Medical Director NPIC
Continue to work (intermittently) in the Magee-Womens
Hospital of UPMC Pregnancy Recovery Center
Member Board of Directors Magee Womens Hospital
DISCLOSURES
6
• Addiction to Opioid drugs: – a major national problem
– causes impaired health, harmful behaviors
– creates major economic and social burdens
• Treatment of drug addiction: – Efficacy equivalent to other chronic conditions:
hypertension, asthma, diabetes mellitus
– Treatment during pregnancy effective in decreasing maternal and
neonatal adverse effects
– Options of Methadone and buprenorphine (Medication Assisted
Treatment: MAT)
– Medical Home approach i.e. (Magee Womens of UPMC: Pregnancy
Recovery Center)
OVERVIEW
7
• Obstetrical providers and the Nation are facing an increasing number of Drug
Addicted Pregnant women
• The number of past users of heroin has increased from 373,000 in 2007 to
914,000 in 2014 (National Survey on Drug Use and Health: NSDUH)
• The misuse and abuse of prescription drugs, particularly opioid pain relievers
has been called a public epidemic (CDC)
• Estimated 4.3 million people engaged in non medical use of pain relievers and
1.9 million have a pain reliever disorder includes ~ 4.0% of pregnant women
using within the last 30 days (NSDUH)
• In 2013 16,235 drug overdose deaths were related to Prescription opioid and
there were 8,257 Heroin deaths (triple from 2010)
• The CDC estimates that in 2012 providers wrote over 259 MILLION
prescriptions for opioids
• The estimated societal costs of opioid abuse was $55 BILLION in 2007,
45% of which were health care related
Prevalence and Incidence
Prevalence and Incidence
• Substance use varies among and within different
cultural groups
• Present among all socioeconomic, cultural and
ethnic groups
• White women more likely to abuse prescription
drugs than any other race or ethnicity
Diagnostic Criteria: Substance Abuse
• A maladaptive pattern of substance use leading to clinically significant impairment or distress
manifested by 1 or more of the following occurring within a 12 month period:
1. Use results in failure to fulfill major role obligations:
• work: absences, poor performance • school: absences, suspensions, expulsions • home: neglect of children or household
2. Recurrent use in physically hazardous situations
3. Recurrent substance-related legal problems
4. Continued use despite resulting persistent or recurrent social or interpersonal problems
Diagnostic Criteria: Substance Dependence
• A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period:
1. tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount
2. withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms
Substance Dependence (continued)
3. larger amounts of substance taken or over a longer period than was intended
4. persistent desire or unsuccessful efforts to cut down or control use
5. great deal of time spent in activities to obtain, use or recover from the substance’s effects
6. important social, occupational and recreational activities given up or reduced because of use
7. continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use
Role of Ob/Gyn Physician
• Screening, identifying and counseling women
regarding substance use
• Routine screening in history taking: – no physical symptoms in majority of abusers
– screen everyone since no predictors (increases identification from 3% to 16%)
– Screening Tools : 4P’s, CRAFFT (ACOG committee opinion #524)
• Know and Triage to local community resources
Screening Questions
• First, use ubiquity statements:
– “Substance use is so common in our society that I now ask
all my patients what, if any, substances they are using?”
• Then, ask direct questions: – “Have you ever tried . . .?”
– “How old were you when you first used . . .?”
– “How often; what route; how much?”
– “How much does your drug habit cost you?”
History: Red Flags
• Maternal chaotic lifestyle: – psychosocial stresses – spouse/partner of an alcoholic or drug abuser – domestic violence, physical and sexual
• Psychiatric diagnosis: – depressions, psychosis, anxiety, PTSD – lack of functional coping skills – unexplained mood swings, personality changes
• Late or no prenatal care: – missed appointments and compliance problems – STDs, sexual promiscuity
Physical Examination
Nothing unusual is the most frequent
finding in users of illicit drugs.
Nothing unusual is the most
frequent finding in users of illicit drugs.
Toxicology Testing: Principles
• Random checks without clinical suspicion: – many consider this unethical (ACOG only with informed consent)
– may be illegal in some locales
• Nonemergency and competent patient: – verbally inform prior to testing
– document permission in medical record
• First Line Screening urine: – major route of excretion and concentration
– inexpensive and quick
– Confirmatory tests: – gas chromatography, mass spectrometry
Toxicology Drug Screen: Urine
• Time frame for drug or metabolite to be present:
– marijuana, acute use 3 days
– marijuana, chronic use 30 days
– cocaine 1–3 days
– heroin 1 day
– methadone 3 days
Pregnancy: Generic Issues
• Educate patient about adverse outcome effects
• Screen for domestic violence
• Screen for STDs, hepatitis B and C, TB
• Co-manage or refer to multispecialty clinic
• Refer to drug counseling program
• Monitor with urine toxicology
• Sequential antepartum assessment of growth
• Refer newborn to pediatrics
• Close postpartum follow up
Treatment: Principles
• Pregnancy offers a “Golden” moment to intervene
• Drug addiction is a treatable disease
• No single treatment is appropriate for all individuals (Methadone, Buprenorphine, Inpatient Drug rehabilitation)
• Recovery from drug addiction is a long-term process: – multiple treatment episodes with relapses
• Effectiveness is dependent on remaining in treatment for
a dedicated period of time
• Matching multiple needs is critical: – medical, psychological, social, legal, vocational
• 2002: After the loss of the only treatment center for addicted pregnant
women in the region, Magee developed an Inpatient Methadone
conversion center and averages 300-350 conversion/year
• 2010 NEJM article: Medical Home approach with the use of
Buprenorphine for the treatment of opioid addiction in pregnancy
demonstrated shorter withdrawal phase for infants who’s mothers were
converted to Subutex compared to methadone in pregnant patients
• In 2013, Magee did 343 inpatient Methadone conversions of addict
(average 3 day inpatient stay) and had 250 NAS (neonatal abstinence
syndrome) babies withdrawing from Methadone with an average NICU
LOS of 15+ days
• Increasing (and unknown) # of patients are delivering at Magee on
Suboxone (mostly from illicit sources)
Magee Pregnancy Recovery Program: History
21
• 2014: Magee, and 4 local Medicaid insurers develop a
shared savings approach to establish a Pregnancy
Recovery Program (Medical Home Approach) at Magee
Womens Hospital
• 4 OB/GYNs complete (Data 2000 waiver) training to become
Buprenorphine prescribers (www.samhsa.gov)
• Magee PRC opens July 24, 2014
• Thru July 2016, 210 pregnant patients have been evaluated
and treated in the PRC
• 2016: Magee receives a $500,000 grant to expand their
program to other sites in Pennsylvania
Magee Pregnancy Recovery Program: History
22
• The Pregnancy Recovery Center’s goal is to offer comprehensive
care for women suffering from opiate addiction by providing
Medical Assisted Treatment (MAT) to prevent withdrawal during
pregnancy, minimizing fetal exposure to illicit substances and
engaging the mother as a leader in her recovery.
• Pregnancy Recovery Center operates as an outpatient program
and provides consistent, collaborative care throughout the
patient’s pregnancy.
• Treating pregnant patients with buprenorphine is a relatively new
practice. Early research suggests babies born to mothers taking
it instead of undergoing methadone treatment recover more
quickly after birth.
Magee Pregnancy Recovery Program
• Pregnant women with SUD are often judged negatively by
caregivers, especially women addicted to alcohol or drugs.
As a result pregnant women with SUD are often reluctant to
disclose their problems to caregivers and may be reluctant
to seek timely prenatal care.
• Recent advances in brief screening techniques and
improved therapies for SUD emphasize taking a non-
judgmental, empathic stance.
• Research strongly suggests that increased integration and
coordination of services improves clinical outcomes and
reduces costs during pregnancy.
Pregnant Women with Substance Use Disorder
Plan of Care
• Establish a supportive relationship
• Educate the patient: – ask the patient to describe her understanding of the situation
and correct misunderstandings
– link substance use to patient’s signs & symptoms
– describe the importance of stopping or cutting down
– explain consequences of continued use
• Refer to specialists for assessment and initiation of a
treatment plan (Pregnancy Recovery Center)
Medication Assisted Treatment (MAT) : Critical Components
• Induction and Stabilization/Maintenance (Methadone is full agonist, Buprenorphine is partial MU agonist)
• Counseling/Behavioral therapies: skill-building,
problem-solving to prevent relapse
• Assess for and treat coexisting conditions: – mental disorders
– infectious diseases
– family planning
Babies born to pregnant women with Substance Use Disorders
(SUD) are at increased risk for:
• Neonatal Abstinence Syndrome (NAS)
• Prematurity (late pre-term), low birth weight, perinatal death
• Cognitive, behavioral and physical problems during
childhood, high rates of child abuse and neglect,
involvement in the foster care system, challenges in
maternal-infant attachment and developmental delays
Babies of the Substance Use Disorder Patients
Magee’s Medical Home Approach
29
Heroin/Opioid: Withdrawal Syndrome
• Symptoms: – drug craving
– anorexia, nausea, abdominal cramping
– increased sensitivity to pain
• Signs: – hypertension, hyperventilation, tachycardia
– lacrimation, mydriasis, rhinorrhea
– yawning, sweating
– vomiting, diarrhea
– chills, flushing, muscle spasms
– restlessness, tremors, and irritability
– Piloerection
The abrupt withdrawal of opioids is associated with an
increase risk of fetal loss.
• General Medical dosing levels established in men or non
pregnant women: Max dosing 16mg/day (all MU receptors
are bound at that level)
• No literature for dosing of Pregnant women
• PRC dosed based on COWS scores and patient symptoms
• Doses range from 4mg to 32 mg
• Pharmaceutics study at Magee demonstrated therapeutic
levels changed with gestational age and are different than
non pregnant subjects
Dosing Pregnant Women with Buprenorphine
35
• Of the current active patients:
– 9 patients are prescribed less than 16mg daily
– 17 patients are prescribed 16mg daily
– 10 patients are prescribed greater than 16mg daily
– 72% of active patients are on 16mg daily or less
Buprenorphine Daily Dose
25%
47%
28%
<16mg
16mg
>16mg
3%
36%
25%
36% First Trimester
Second Trimester
Third Trimester
Postpartum
• 210 Patients that completed
induction (active patients)
• 36 Active patients
• 83 Graduates to Community
Recovery
• 91 Unsuccessful Discharges
• Average Age: 29 years old
• Average length of use: 7 years
• Success rate 57%
Graduates vs. Discharges
17%
40%
43% Active Participants
Graduates
Unsuccessful Discharges
39
• First Trimester
(Earliest admissions: between 5-7 weeks)
• Third Trimester
(Latest admission: 39 weeks)
Gestational Age on Admission
50% 45%
5%
Active PRC Patients
First Trimester
Second Trimester
Third Trimester
• Comparison includes initial opioid used and opioid using when entering PRC
– Data includes all inductions into PRC
– Non-Prescribed is defined by illicit prescription medication (i.e. Percocet)
– 76% of first opioid contact is with a prescription medication (either prescribed or illicit)
– 50% enter the PRC on a buprenorphine product
Opioid Use History
40
42%
34%
23%
1% First Opioid Use
Non-Prescribed
Prescribed
Heroin
Buprenorphine
8%
5%
37% 50%
Entering the PRC
• 93 Deliveries
– 57 newborns did not require medication for NAS (62%)
– 36 newborns required medication for NAS treatment
– 7 deliveries took place outside of Magee-Womens Hospital
• Data was collected from delivering facility
NAS Treatment
61%
39%
No NAS Treatment
Treated for NAS
Median Charges: $50,114 $21,431 $17,804
78% of babies had charges of
$50,000 or less
• 93 Deliveries
– 50 mothers are breast feeding
– 43 are bottle feeding only
Breastfeeding vs. Bottle feeding
54% 46%
Breastfeeding
Bottlefeeding
• Opioid addiction is a growing problem in the US and
pregnant women are affected similarly to the US population
• Opioid addiction is a chronic health problem and should be
treated as such
• A non judgmental, empathic holistic approach by Health
Care providers can improve treatment results for mothers
and babies
• Treatment team should be multidisciplinary
• Pregnant women may require higher doses of
Buprenorphine as opposed to non pregnant patients
• A Medical Home approach can improve outcomes and save
health care dollars
SUMMARY
45
• Substance Abuse and Mental Health Services Administration
(www.samhsa.gov)
• Physician Leadership on National Drug Policy at Brown University,
Providence, Rhode Island. (www.plndp.org)
• ACOG Committee Opinion #524 (Opioid Abuse, Dependence and
Addiction in Pregnancy)
• ACOG Committee Opinion #538 (Nonmedical use of Prescription Drugs)
• ACOG Committee Opinion #473 (Substance Abuse Reporting and
Pregnancy: The Role of the OB/GYN)
• American Society of Addiction Medicine
• National Survey on Drug Use and Health
• Michael England MD, Elizabeth Krans MD ,Stephanie Bobby RN CARN (Magee Womens Hospital of UPMC Pregnancy Recovery Center)
Resources & Acknowledgements
46
Questions & Comments
Participants are encouraged to ask questions and share comments.
• Please use the chat box for questions or comments.
• Questions and comments are visible only to presenters.
• Questions will be answered in the order in which they are submitted.
• Should there not be enough time to address your question(s), please email [email protected] so we may follow-up with you.
Thank You for Attending!
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