Increasing Treatment Completion Rates for …...Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders • Much easier to say “pregnant women with

Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders


Karol Kaltenbach, PhD

Emeritus Professor of Pediatrics

Sidney Kimmel Medical College

at

Thomas Jefferson University

FADAA May 30, 20171

Increasing Treatment Completion Ratesfor Pregnant Women with Substance Use Disorders

Increasing Treatment Completion Ratesfor Pregnant Women with Substance Use Disorders

Outline

• Addressing barriers to treatment

• Understanding factors that influence treatment retention for women

• Identifying components of treatment that facilitate engaging and retaining women in treatment

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• Much easier to say “pregnant women with substance use disorders”

• However, substance use disorder is not specific to pregnancy

• Ignores the experiences that contributed to their substance use disorder and leads to marginalization and stigma

• Will discuss gender issues related to treatment and retention in addition to specific issues related to pregnancy


Why Focus on Engagement and Retention?Why Focus on Engagement and Retention?

• Treatment retention is one of the most consistent predictors of positive treatment outcomes.

• It is critical that pregnant women be engaged in obtaining treatment and once in treatment be successfully retained in treatment.


The well being of an infant is improved with the well being of the mother

The well being of an infant is improved with the well being of the mother


Barriers to TreatmentBarriers to Treatment

• Pregnancy and lack of substance use treatment services for pregnant women

• Fear of losing custody of child(ren)

• Reliance on public insurance to pay for treatment

• Resistance from partner and/or family members


Barriers to TreatmentBarriers to Treatment

• Lack of child care

• History of trauma and victimization

• Homelessness


Barriers to Treatment: Specific to Women with Opioid Use Disorders


• Federal statute requires pregnant women be given priority in Opioid Treatment Programs but some have long waiting lists

• Programs often limited to urban areas

• 1450 opioid treatment programs in the US; estimated that no more than 12 provide specialized services for pregnant women

• Buprenorphine expected to increase access to care but 43% of US counties have no buprenorphine provider*

• Less than 10% of buprenorphine providers treat at least 75 patients*

* Stein, et al. JAMA, 2016


DCF Approved Methadone ProvidersDCF Approved Methadone Providers




• Fear of losing custody due to Neonatal Abstinence Syndrome

• Child Abuse Prevention and Treatment Act (CAPTA) 2010 reauthorization and the Comprehensive Addiction and Recovery Act of 2016 (CARA) requirement to report neonatal abstinence syndrome.

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Understanding Factors that Influence Treatment Retention for Women

Understanding Factors that Influence Treatment Retention for Women

First you need to understand the complex bio-psychosocial characteristics associated with women with substance use disorders.

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Keep a mother in mind in order for her to keep her child in mind….Bio-psychosocial

concerns??

Keep a mother in mind in order for her to keep her child in mind….Bio-psychosocial

concerns??

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Personal and Family CharacteristicsPersonal and Family Characteristics

• Education <11 years• Unemployed 85% • Receiving Public Assistance 80%• Married <20%• Long term relationship <30%• Homeless in past 3 years 68% residential

21% outpatient• Majority live with family/friends or father of the baby

*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999

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• History of Substance Use in Family• History of Victimization• 90% experienced one or more of

Domestic violence Rape Childhood abuse and/or neglect

• History of legal problems Family legal problems Arrests Incarceration

*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999FADAA May 30, 2017 14


Psychiatric History

• High incidence of depression and anxiety disorders > 60%

• Prescribed medications 20%

• Inpatient psychiatric treatment 22%

• Outpatient psychiatric treatment 32%

*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999

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Demographics of MOTHER Study Participants*

Demographics of MOTHER Study Participants*

Demographics Mean (SD)Age (years) 27.3 (5.9)Estimated Gestational Age (weeks) 17.1 (6.3)Education completed (years) 11.4 (2.0)

Race/Ethnicity: n (%)White 145 (83.3)Black 24 (13.8)Other 5 (2.9)

Marital status: Never married 125 (71.8)Married 22 (12.6)Widowed 3 (1.7)Divorced 12 (6.9)Separated 12 (6.9)

Unemployed 152 (87%)Psychiatric co-morbidity 110 (63%) Legal status:

No Legal Issues 140 (80.5)Parole 4 (2.3)Probation 24 (13.8)Impending trial 3 (1.7)Unknown/Other 3 (1.7)

Jones et al., New England Journal of Medicine, 2010.FADAA May 30, 2017 16

Impact of Co-occurring DisordersImpact of Co-occurring Disorders

Individuals with co-occurring disorders have a more challenging pathway to recovery

• Higher rates of relapse and re-hospitalization

• More ER visits, homelessness, violence, and suicide

• Increased morbidity and mortality

• Poorer treatment adherence

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History of Violence and TraumaHistory of Violence and Trauma

• Pervasive history of violence and trauma among women with substance use disorders (SUD)Rates of physical and/or sexual abuse range from 55%-99%*.

• Women with PTSD have been found to be 5 times more likely to have a SUD than women without PTSD rates have been reported to range between 14% and 60%^.

• *Greenfield et al., Psychiatric Clinics in North America 2010

^Najavits et al., American Journal of Addiction1997

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History of Sexual AbuseHistory of Sexual Abuse

• Women may report fear of inability to protect themselves and/or their children or conversely are over protective of their children

• Residual problems develop from her sense of powerlessness.

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Impact of Physical and Sexual AbuseImpact of Physical and Sexual Abuse

• Women often have mood disorders, anxiety disorders, and low self esteem.

• Children who witness abuse may present with a spectrum of symptoms.

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Impact of Co-Occurring DisordersImpact of Co-Occurring Disorders

The history of co-occurring psychiatric disorders and trauma have a significant impact on treatment, both in terms of barriers to seeking treatment and treatment retention.

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Additional Issues for WomenAdditional Issues for Women

• Telescoping is accelerated progression from initiation of substance use to substance use disorder found for women

• Typically present with more severe clinical profile, i.e. more medical, behavioral, psychological, and social problems than men

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• Difficulty with transportation to treatment sites

• Inadequate health insurance

• Relationship with a partner with substance use disorder

• Less likely to have someone actively supporting them in treatment

• Often have sole responsibility for children

• Treatment entry often results from a social work referral

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• Last but not least – STIGMA

• Significant stigmatization of substance use disorder in general, but more so for women, especially women who are pregnant

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Women with Substance Use Disorder who are Pregnant

Women with Substance Use Disorder who are Pregnant

• The well being of the infant is improved with the well being of the mother

• Engaging and Retaining women in Treatment ??

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Treatment for Pregnant and Parenting Women

Treatment for Pregnant and Parenting Women

Comprehensive, women-centered services offering a continuum of care is essential

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Treatment Models of CareTreatment Models of Care

• Scientific foundation of clinical practice: Opiate use in pregnant women (Finnegan, Hagan, Kaltenbach, 1991)

• Pregnancy and addiction: a comprehensive care model (Jansson, Svikis, et al, 1996)

• Comprehensive treatment for pregnant substance abusing women (Kaltenbach & Comfort, 1996)

• Gender specific substance treatment (Finkelstein, Kennedy, Thomas, & Kearns, 1997)

• Substance Abuse Treatment: Addressing the specific Needs of Women TIP 51 (SAMHSA, 2009)

• Treating women with substance use disorders during pregnancy: a comprehensive approach to caring for mother and child (Jones & Kaltenbach, 2013)

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Framework for TreatmentFramework for Treatment

Woman-centered

• Responsive to the specific needs of women

Trauma-informed

• Recognizes the role of trauma and violence

Strength based• Focus on strengths rather than deficits

Culturally competent• Acknowledges the role of culture, ethnicity,

race, racism, and sexual orientation

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Framework for Treatment: Engaging and Retaining Women in Treatment


Woman- centered

• Childcare assistance

• Pregnancy

• Parenting

• Domestic violence

• Sexual trauma and victimization

• Psychiatric co-morbidity

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Woman-centered

• Housing

• Income support

• Education

• Social Services

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Trauma –Informed Services

• Recognizes signs and symptoms of trauma in patients, families, and staff

• Responds by fully integrating knowledge about trauma into policies, procedures, and practices

• Provides trauma-informed training to all staff, including medical staff, administrative staff, and support staff

• Seeks to actively resist re-traumatization

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Understanding trauma

• Trauma results from an event, or series of events, that is experienced by the individual as physically or emotionally harmful and that has lasting effects on the individual’s functioning.

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Effects of trauma

• Inability to cope with normal stress of daily living

• Inability to trust

• Inability to manage cognitive processes such as memory and attention

• Inability to regulate behavior or to control the expression of emotion

• Hyper-vigilance or constant state of arousal

• Emotional numbing or avoidanceFADAA May 30, 2017 33



Key Principles of Trauma-informed Approach

• Safety

• Trustworthiness

• Peer support

• Collaboration and mutuality

• Empowerment, voice, and choice

• Cultural, historical, and gender respect

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Safety

• All staff and patients feel physically and psychologically safe.

• The physical setting is safe.

• Interpersonal interactions promote a sense of safety.

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Trustworthiness and Transparency

• Operations and decisions are conducted

with transparency with the goal of maintaining trust.

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Peer Support

• Peer support and mutual self help important for establishing safety and hope, building trust, enhancing collaboration, and utilizing lived experiences to promote recovery and healing.

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Empowerment, Voice, and Choice

• Individual strengths and experiences are recognized and support is provided for shared decision making, choice, and goal setting.

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Cultural, Historical, and Gender Respect

• Incorporate policies, protocols, and processes that are responsive to the racial, ethnic, and cultural needs of served individuals served and recognize and address historical trauma.

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Strength Based

• Identifies and builds on the woman’s strengths.

• Uses available resources to develop and enhance resiliency and enhance recovery skills, deepen a sense of competency and improve the quality of her life.

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Culturally competent

• Understands the world views and experiences of women from different racial, ethnic, and cultural backgrounds.

• Understands the interaction among gender, culture and substance use.



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Issues Specific to Opioid Use Disorder (OUD) during Pregnancy

• Need to ensure women are receiving appropriate treatment, i.e. medications should be based on what is best for the mother/fetal dyad.

• Education may be required for woman, partner and/or family regarding risk/benefits of medication for treatment of OUD.

• Dose should be determined on an individual basis in order to achieve a therapeutic effect.

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Issues specific to OUD during pregnancy

• Medical withdrawal or taper from methadone or buprenorphine is not recommended

Very high rate of relapsePlaces fetus at additional risk

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Recommendations in support of treatment rather than withdrawal

• WHO 2014 Guidelines

• American College of Obstetricians and Gynecologists and American Society of Addiction Medicine Joint Opinion 2012

• Treatment Improvement Protocol, US Department of Health and Human Services 2005

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Issues specific to OUD during pregnancy

• Relationships should be established with obstetrical provider to ensure continuity of care

• Liaisons should be established with child protective services to provide support for women who adhere to treatment

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Components of Comprehensive Services for Pregnant and Parenting Women


Multidisciplinary treatment approach needs to include• Medical, obstetrical, and psychiatric services• Prenatal education and women’s health• Individual and group psychotherapy• Family therapy• Trauma counseling• GED training• Comprehensive case management • DHS liaison• Transportation• Parent child services including developmental

child care, individual parenting counseling, parent education groups and parenting activities

• Mindfulness Based ParentingFADAA May 30, 2017 46



• Often difficult to provide within one program

• New models of collaboration have been developed

Vermont Charm Collaborative

The Maternal Opiate Medical Supports (MOMS) project

Project ECHO

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Collaborative ModelsCollaborative Models

� Vermont Charm Collaborative

Substance Abuse Mental Health Administration (2016) A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No(SMA) 16-4978

Available online

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� Maternal Opiate Medical Support (MOMS)

www.momsohio.org

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� Project Echo

ATTC Center of Excellence on Behavioral Health for Pregnant and Parenting Women and their Families

www.attcppwtools.org

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Keep a mother in mind in order for her to keep her child in mind…

Keep a mother in mind in order for her to keep her child in mind…

Meeting the needs of pregnant women with substance use disorders includes not only substance abuse treatment, including medication assisted treatment for opioid use disorder, but requires a comprehensive model of care that addresses the complex array of bio-psychosocial problems associated with maternal addiction.FADAA May 30, 2017 51

ReferencesReferences

• Ashley OS, Sverdlov L, Brady TM. (2004) Health services utilization by individuals with substance abuse and mental health disorders. Rockville, MD: Substance Abuse Mental Health Administration.

• Center for Substance Abuse Treatment (2005) Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series, No. 43, Rockville, MD: Substance Abuse Mental Health Service Administration, USA.

• Center for Substance Treatment (2009) Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51, Rockville, MD: Substance Abuse Mental Health Service Administration, USA.

• Comfort ML, Kaltenbach K. (1999) Bio-psychosocial characteristics and treatment

outcomes of pregnant cocaine dependent women in residential and outpatient

substance abuse treatment. Journal of Psychoactive Drugs, 30(3:) 279-289.

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• Comfort ML, Loverro J, Kaltenbach K. (2000) A search for strategies to engage women in substance abuse treatment. Social work in Health Care, 31(14): 59-70.

• Comfort ML, Kaltenbach K. (2000) Predictors of treatment outcomes for substance

abusing women: a retrospective study. Substance Abuse, 21(1): 33-45.

Covington S. (2002) Helping women recover: creating gender-responsive

treatment. In Straussner SLA, Brown S, Eds. Handbook of Women’s Addiction

Treatment: Theory and Practice. San Francisco: Josey-Bass: 52-72.

• Covington S. (2008) Women and addiction: a trauma informed approach. Journal of Psychoactive Drugs, (Suppl 5), 377-385.

• Greenfield SF, Brooks AJ, Gordon CA, Kropp F, Lincoln M, Hien D, Miele GM. (2007) Substance abuse treatment entry, retention and outcome: a review of the literature. Drug and Alcohol Dependence, 86(1): 1-21.

• Greenfield SF, Back SE, Lawson K, Brady KT. (2010) Substance abuse in women. Psychiatric Clinics in North America, 33(2): 127-138.

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Jones HE, Kaltenbach K, Heil S, et al.,(2010) Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24):2320-2331.

Najavits LM, Weiss RD, Shaw SR. (1997) The link between substance abuse and post-traumatic stress disorder in women: a research review. American Journal of Addiction. 6(4): 273-283.

Opioid abuse, dependence and addiction in pregnancy. (2012) Committee Opinion No. 524, American College of Obstetricians and Gynecologists, Obstetrics and Gynecology, 119:1090-1076.

Stein BD, Gordon AJ, Dick RM, et al. (2016) Physician capacity to treat opioid use disorder with buprenorphine assisted treatment. JAMA, 316(11): 1211-1212.

Substance Abuse Mental Health Service Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma Informed Approach. HHS Publication No(SMA) 14-4884, 2014

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•Sun AP. (2006) Program factors related to women’s substance abuse treatment retention and other outcomes: a review and critique. Journal of Substance Abuse Treatment, 30(1): 1-20.

•Tuchman E. (2010) Women and addiction: the importance of gender in substance abuse research. Journal of Addictive Diseases, 29(2): 127-138.

•World Health Organization (2014) Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnant Women.

WHO Document Production Services, Geneva Switzerland

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Documents

Increasing Treatment Completion Rates for …...Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders • Much easier to say “pregnant women with