© 2018 Lehigh Valley Health Network

Making the Connection

Unique opportunities and challenges

in maternal opioid use disorder

Courtney Boyle, DO

Obstetrician/gynecologist with LVPG Ob/Gyn

Amanda Flicker, MD

Division Chief of Obstetrics, LVHN

Objectives

▪ Review screening tools for substance abuse

▪ Discuss the opportunities and challenges in caring for

pregnant women with opioid use disorder (OUD)

▪ Build the case for the need for coordinated care for

pregnant women with OUD

▪ Discuss MAT in pregnancy

▪ Review current challenges being faced in the Lehigh

Valley for pregnant women with OUD

It starts with a case . . .

▪ Young pregnant woman overdosed with heroin in her home and was pronounced “brain dead.”

▪ Patient remained in ICU until fetus was near term at which time her baby was delivered.

▪ Family withdrew support and the patient died within days of giving birth.

▪ Baby recovered from neonatal abstinence syndrome (NAS) in the NICU.

▪ What if we had a program that could have helped her?

Universal Screening

▪ SBIRT

▪ Recommended by ACOG

using validated screening tools

•4 P’s

•NIDA quick screen

•CRAFFT

Biologic (urine) testing

▪ May be used to detect or confirm substance abuse

▪ CONTROVERSIAL TO USE ROUTINELY

•Not in and of itself diagnostic of OUD or its severity

•Only assesses current or recent use, not sporadic

•May not detect certain substances, esp synthetic or designer

•False positive results can occur and have consequences

▪ Patient consent or notice

▪ Need for reporting to government agencies

Pennsylvania Mandatory Reporting

▪ Mandatory reporting of children under one year of age.

▪ (a) When report to be made.--A health care provider shall immediately make a report or cause a report to be made to the appropriate county agency if the provider is involved in the delivery or care of a child under one year of age who is born and identified as being affected by any of the following:

▪ (1) Illegal substance abuse by the child's mother.

▪ (2) Withdrawal symptoms resulting from prenatal drug exposure.

▪ (3) A Fetal Alcohol Spectrum Disorder.DOMESTIC RELATIONS CODE (23 PA.C.S.) - MANDATORY REPORTING OF INFANTS BORN AND IDENTIFIED AS BEING AFFECTED BY

ILLEGAL SUBSTANCE ABUSE

Act of Jan. 22, 2014, P.L. 6, No. 4

Opportunities and Challenges

▪ More motivation for treatment

•Concern for effects on fetus

•Fear of losing her child(ren)

▪ Treatment needs are different

•Less likely to pursue inpatient care if other children in the home

•Detoxification is currently not recommended in pregnancy as standard of care

•Medication-assisted treatment (MAT) options

Medication-assisted Treatment

Methadone

▪ Decades of experience

▪ More willing to accept pregnant

women and more accessible

▪ Requires daily visit for treatment

▪ ANOTHER CASE STUDY . . .

Buprenorphine▪ Without naloxone

▪ Less risk of NAS and if occurs, less severe

▪ Easier commitment with weekly prescriptions and not daily observed treatment

▪ Must be in withdrawal to initiate

▪ Challenging to find prescribers willing to treat pregnant women

▪ Needs for addiction treatment beyond medication prescription

Care Coordination

▪ Obstetrical care

▪ Addiction medicine

▪ Behavioral health

▪ Case management

▪ Successful programs across the country CONNECT these services together for one stop shopping, meeting the patients where they are.

▪ Patients will generally make greater efforts to go to obstetrical appointments or for buprenorphine prescription so link the other services to them.

Inpatient Care for Childbirth

▪ Analgesia and Anesthesia

•Avoid opioid partial agonists in women on chronic opioids

•Avoid full opioid agonists in women on buprenorphine

•Use of alternative options – scheduled NSAID/acetaminophen, heat/ice, early mobilization, abdominal binder, set reasonable limits

▪ Confirm MAT dosing during inpatient care

▪ Document what was given in hospital and for discharge to provide to treatment facility

Going home . .

▪ Postpartum period is stressful physically, emotionally,

hormonally, psychologically, etc so mothers are at

greater risk of relapse.

▪ ANOTHER CASE STUDY . . .

▪ What if we had a program that could have helped her?

Postpartum care coordination

▪ Family-centered

•Mother’s ongoing addiction medicine and rehabilitation needs

on top of those of a new mother

•Newborn’s needs for NAS treatment and for surveillance for

growth and development

•Family’s needs for education and support of mother and infant

▪ Accessible

▪ Coordinated

CONNECTIONS Clinic

▪ OUR GOAL: to educate and support women

with opioid dependence and addiction to have

an optimal pregnancy outcome resulting in a

healthy infant living in a positive family environment.

▪ Program includes:• Screening all pregnant woman using 4P’s and non-judgmental inquiry

• Proper referral for LOC assessment and treatment

• Internal program for buprenorphine initiation and maintenance

• Partnering with services in the community for addiction counseling

• NAS surveillance and treatment

• Consultation with Child Advocacy Center and referral to CYS as indicated

• Postnatal connection to ongoing addiction treatment

Local issues we have experienced

▪ Criteria for inpatient admission for pregnant and

postpartum women

▪ Access to outpatient programs especially for MAT using

buprenorphine

▪ Complexity of care coordination

▪ Streamlining care for patients who have logistical and

compliance challenges

▪ All pregnant women should be screened for substance abuse using validated screening tool

▪ Pregnant women with OUD should not undergo detox, but should utilize MAT, preferably with buprenorphine.

▪ Optimal outcomes for mother and infant are achieved with coordination of multidisciplinary care.