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

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• 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

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• 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

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• 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

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• 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

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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

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• 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

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• 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

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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

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• 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

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Questions & Comments

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