OPIOID 101:

WHAT EVERY FOSTER PARENT AND KINSHIP FAMILY NEEDS TO KNOW ABOUT OPIOID USE

APRIL 30, 2019

SPONSORED BY THE FLORIDA ALCOHOL & DRUG ABUSE ASSOCIATION (FADAA)

AND THE STATE OF FLORIDA, DEPARTMENT OF CHILDREN AND FAMILIES

LEARNING OBJECTIVES

Identify a common pathway that can lead a parent to use opioids in ways that potentially contribute to child maltreatment.

Discuss the many effects of caregiver opioid use on children. Listen to stories and engage in discussion with Florida foster and adoptive

parents to learn firsthand about the unique challenges of caring for the children of the opioid epidemic.

Describe effective treatment and recovery responses to address parental opioid use.

A COMMON PATHWAY TO OPIOID USE

Pain Management

FLORIDA FOSTER PARENT QUOTE1

“Developing a relationship with the foster child’s bio parent humanizes them. It helps my level of compassion to know where they came from, where they have been, and why they made the decisions they made.” Florida foster parent quote

VAST PRESCRIPTION MISUSE: HOW DID WE GET HERE? 2

The U.S. Food and Drug Administration (FDA) approved OxyContin and other opioid pain meds in the mid-1990s (for short-term pain only).

However, physicians quickly started prescribing the effective new pills for long-term/chronic pain management.

When patients built up a tolerance (about every 4 to 8 weeks) and the pills stopped working, pain experts and drug company representatives instructed doctors to give higher doses.

They assured doctors that the pills were safe and non-addictive. THEY WERE WRONG!!!!!

OTHER FACTORS3

Other factors led to the opioid crisis facing us today, including: Pressure to fully relieve pain and measure it as the “fifth

vital sign,” promoted by the American Pain Society and adopted by the Veterans Administration and the Joint Commission on Accreditation of Healthcare Organizations;

Inclusion of pain control as part of patient satisfaction scores that could affect provider and hospital reimbursement;

Inadequate healthcare professional education on treatment of pain and addiction; and

Diversion of prescription opioids by distributors, pharmacies, prescribers, and patients.

FLORIDA’S PROGRESS

FL is reducing the number of and access to opioid prescriptions according to, and in part because of, the state’s Prescription Drug Monitoring Program (PDMP).

The FL Department of Children and Families (DCF) is contracting with physician peer prescriber mentors, Florida Alliance for Healthy Communities, and Area Health Education Centers (AHECs) to provide education and training on pain management, alternatives, prevention and treatment of opioid use disorder.

COMMON PRESCRIPTION OPIOIDS

Codeine

Morphine

Oxymorphone

Oxycodone and Hydrocodone

Fentanyl

OPIOID PRESCRIPTIONS 4

11

Source Where Pain Relievers Were Obtained for Most Recent Misuse among People Aged 12 or Older, NSDUH 2016 5

PARENT TO CHILD ACCESSIt is not atypical for a child welfare system-involved parent with an OUD to have begun their use by intentional or unintentional access from their own parents.

12

PRESCRIPTIONS MAY RUN OUT6

Monica’s Case Scenario The timing and severity of the opioid crisis varies among communities around

the country. However the tragic pattern is all too similar— prescription opioids first…but then those prescriptions end (sometimes abruptly) leaving some users desperate enough to try street heroin. That’s what happened to Monica. She was prescribed Percocet painkillers after a high school car wreck, then started buying stolen pills and finally heroin.

CONNECTED ADVERSITIES 7, 8

Women who have been diagnosed with OUD: Are more likely to have experienced DV, sexual

violence, and childhood sexual abuse. Are more likely to have been prescribed opioids

for chronic pain. Are more likely to self-medicate to cope with

trauma.Whether OUD increases risk for victimization or victimization leads to OUD, adverse consequences abound.

OPIOID USE AND SEXUAL EXPLOITATION

A perpetrator can leverage opioids: To exacerbate a parent’s/survivor’s vulnerability To coerce a parent/survivor to submit To offer to a parent/survivor for coping with the

physical and mental traumas of exploitation

HELPING PROFESSIONAL REMINDER 9

"If you take away substances and don't deal with the trauma and pain underneath, then you leave [survivors] completely bare and exposed, with no anesthesia." Angela Browne speaking at the Faces of Family Violence and Trauma conference, New Haven, CT, May 12, 2000

EFFECTS OF CAREGIVER OPIOID USE ON CHILDREN

Toxic Stress Older Children and Adolescents

Excessively High Levels or Prolonged Exposures to Stress10

• Increases in stress hormones are protective and even essential for survival.

• Excessively high levels or prolonged exposures can be harmful or toxic, and can lead to a chronic “wear and tear” effect on multiple organ systems, including the brain.

OUD IMPACT ON VERY YOUNG CHILDREN

During this period, a child’s brain produces more than one-million neural connections each second—faster than any other time in life.

During the 1st year, a child’s brain doubles in size and by age 3, has reached 80 percent of its volume.11

Excess neural connections make a child’s brain especially sensitive to external input (aka relationships and their environment).12

“Serve and return” interactions between young children and their caregivers are a major ingredient in healthy development.13

EARLY EXPERIENCES

Early experiences and environmental influences can leave a lasting signature on the genetic predispositions that affect emerging brain architecture and long-term health.Increasing investments are being made in the preschool years to promote the foundations of learning.

OUD IMPACT ON OLDER CHILDREN AND ADOLESCENTS14

Among children who grow up in homes with a parent with an OUD: 30-33% meet diagnostic criteria

for disruptive disorder 21-30% meet diagnostic criteria

for anxiety or mood disorder 47-59% exhibited substance

misuse behaviors

Health Effects of Early and Prolonged Stress on Adolescents

Stressful childhood events are linked to inflammation in adolescence.These bio markers could help health

providers identify kids at risk for long-term health problems.

EFFECTS OF PARENTAL OPIOID USE ON CHILDREN 15, 16, 17

Children are likely to experience significant neglect, trauma, toxic stress, or at a minimum, lack of a responsive parent.

Parent-child relationship is likely to be problematic. Parental capacities are likely to be impaired. Parental sobriety will not necessarily by itself address child/adolescent

development, mental health, or substance use disorders (SUDs).

FOSTERING RESILIENCE18

Resilience is the ability to overcome serious hardship. It is evident when a child’s health and development tips toward positive outcomes, even when a heavy load of factors is stacked on the negative outcome side.

Though the brain and other biological systems are most adaptable early in life, the capabilities that underlie resilience can be strengthened at any age. It is never too late.

EFFECTIVE TREATMENT AND RECOVERY RESPONSES TO PARENTAL OPIOID USE

Medication-Assisted Treatment (MAT) MAT and Pregnancy

Opioid Use: What We Know19

• After an initial pleasurable “rush,” people who use opioids may be verydrowsy for several hours, with clouded mental functioning.

• Repeated use often results in addiction –where seeking and using the drug becomes the primary purpose in life.

EFFECTS ON THE BODY AND BRAIN 20

Drowsiness Mental confusion Nausea Constipation Respiratory depressionOpioid meds act on the brain’s reward centers, and can induce euphoria (particularly when taken at a higher-than-prescribed dose or administered in other ways than intended).

OPIOID WITHDRAWAL:21

Excessive perspiration Shaking and muscle

spasms Severe muscle and bone

pain Vomiting, nausea, and

diarrhea Irritability Insomnia/restlessness Dilated pupils Rapid heart rate/anxietyDeath is not likely from opioid withdrawal, but people may feel like they’re dying

USE TO AVOID BEING “DOPE SICK”

“I had nothing. My life was broken down into four- to five-hour increments to get high, to put off feeling sick.”22

NATURAL ENDORPHINS (INTERNAL OPIOIDS)23

Humans produce several endogenous (within the body) opioids. The most common are known as “beta-endorphins,” or simply “endorphins.”

Beta-endorphins are released during periods of extreme excitement or pain, such as:• Delivering a baby or watching the birth of a

baby, having sex, enjoying a good meal.• Experiencing pain such as breaking an ankle

(the pain is muted for several seconds to allow the person time to stop).

BETA-ENDORPHINS (EXTERNAL OPIOIDS)24

Beta-endorphins look and function like exogenous (introduced from outside the body) opioids, such as morphine, heroin, or oxycodone.

Beta-endorphins bind with a receptor in the brain and spinal column known as the mu (µ) receptor, creating a sensation of analgesia (pain blocking) and releasing dopamine (pleasure and euphoria).

OPIOIDS AND THE BRAIN25

As individuals take more exogenous (external) opioids, their body’s production of beta-endorphins (within the body) decreases, creating an increased sensitivity to pain, both physical and emotional, when they stop using exogenous opioids.

WHY MEDICATION?26

Typically, the changes in the brain caused by opioid dependence will not correct themselves right away, even though the opioid use has stopped.

These changes can trigger cravings for the drug months and even years after a patient has stopped using opioids.

Overcoming opioid dependence is not simply a matter of eliminating opioid substances from the body (e.g., detox/withdrawal management).

Unless restorative, rebalancing treatment is provided, these functional brain imbalances can result in worsening or sabotage of recovery attempts.

MAT BENEFITS: MAT IS EVIDENCE BASED27

MAT is a well-studied, effective, evidence-based treatment that significantly improves treatment outcomes.

Patients taking medication for OUD are considered to be in recovery. MAT increases social functioning and retention in treatment. Numerous studies have documented that patients treated with medication are

more likely to remain in therapy compared with patients receiving treatment that does not include medication.

MAT BENEFITS: MAT IS EVIDENCE BASED28

Research has documented that the combination of medication with counseling and recovery support is more effective than substance use treatment without medications in treating OUD.

Available research indicates that MAT improves treatment adherence, reduces the risk of overdose death, and reduces the risk of contracting associated infectious diseases, such as HIV and hepatitis B and C, among other outcomes.

MAT BENEFITS FOR PARENTS IN THE CHILD WELFARE SYSTEM WITH OUD29

While some clients with OUD may be stabilized with medications alone, the parents involved with the child welfare system typically have a range of interrelated problems for which counseling and recovery supports are essential.

A study that specifically examined the use of MAT with child welfare clients found that MAT treatment improved the likelihood that program participants retained custody of their children.

ASSISTANT SECRETARY FOR PLANNING AND EVALUATION (ASPE) FINDINGS: MAT SUCCESSES30

A program in Kentucky found that clients with a history of opioid use who received a year of MAT increased the odds of retaining custody of their children by 120%, compared with those who did not receive MAT. However, fewer than 10% of opioid-using clients in the program received MAT, a factor the authors attribute largely to stigma against MAT.

FDA-APPROVED MEDICATIONS31

Methadone may be provided only through opioid treatment programs (OTPs) that are regulated, certified, and accredited through the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA).

FDA-APPROVED MEDICATIONS32

Buprenorphine (e.g., Suboxone and Subutex) can be provided either by an OTP or by office-based providers, who may be primary care providers (physicians, nurse practitioners, and physician assistants) who have received training on the medication, as well as a waiver issued by SAMHSA in coordination with the DEA.

These waivers are called DATA waivers after the Drug Abuse Treatment Act of 2000, which permits qualified practitioners to treat OUD with certain narcotic-controlled substances that have been approved by the FDA for that purpose.

THE FDA-APPROVED MEDICATIONS33

Naltrexone (e.g., Vivitrol) can be provided by any physician or health care provider who has the authority to issue prescriptions and who is operating within their scope of practice, without special certification or training.

In addition to these pharmacotherapy medications, naloxone (e.g., Narcan) is a medication that rapidly reverses opioid overdose. It is used to treat overdose but does not address the underlying OUD.

MAT BENEFITS34

Methadone and buprenorphine (which are themselves opioids) both reduce the patient’s cravings and suppress symptoms of withdrawal, essentially by tricking the brain into thinking it is still getting the abused drug but without the euphoric effects of most commonly abused opioids.

Naltrexone blocks the euphoria as well as other effects (including pain relief) by preventing the opioids from attaching to the opioid receptors in the brain. The result is that even if a person relapses and uses an opioid, its euphoric effects are limited, which may help motivate the patient to reengage in treatment.

MAT BENEFITS AND SUBSTITUTION MYTH35

Methadone and buprenorphine DO NOT substitute one addiction for another. When patients are treated for opioid addiction, the

dosage of medication used does not get them high; it helps reduce opioid cravings and withdrawal.

These medications restore balance to the brain circuits affected by addiction, allowing the patient’s brain to heal while working toward long-term recovery.

MAT AND PREGNANCY

The transition to parenthood is often a critical opportunity for intervention because parents often experience heightened motivation levels for addressing their addictions at this juncture in their lives.36

NEONATAL ABSTINENCE SYNDROME (NAS) 37, 38, 39

Opioid medications taken by pregnant women also get into the baby’s system. Shortly after birth, many of these babies experience temporary withdrawal symptoms such as fussiness or shaking. This is called neonatal abstinence syndrome (NAS).

NAS occurs in 30%-80% of opioid pregnancies, and is an expected and treatable consequence of opioid exposure.

There has been a sustained increase in both maternal OUD and NAS diagnoses among rural residents.

PATIENT AND FAMILY EDUCATION ON NAS

Infant withdrawal usually begins a few days after the baby is born but may begin as late as 2 to 4 weeks after birth.

Reducing the dose of pharmacotherapy before delivery will NOT reduce NAS expression or severity.

Smoking cessation and minimization of other substance use can reduce NAS expression and severity.

BREASTFEEDING40

Highly recommended

Breastfeeding has positive physical and behavioral effects for the mother–infant dyad.

Safe in most cases

Women who are stable on buprenorphine, combination buprenorphine/naloxone, or methadone should be advised to breastfeed, if appropriate.

Women living with HIV or women with ongoing illicit drug use should not breastfeed.

The mother can be reassured that the amount of prescribed pharmacotherapy to which the baby is exposed via breast milk is extremely small, while the risk of harm

to the infant from her return to substance use is much greater.

MAT AND PREGNANCY41

Withdrawal of pharmacotherapy for OUD and tapering during pregnancy have a high failure rate (American Society of Addiction Medicine, 2015; Jones, O’Grady, Malfi, & Tuten, 2008; Substance Abuse and Mental Health Services Administration [SAMHSA], 2014; World Health Organization, 2014), and expectant women with OUD often return to opioid misuse and its attendant risks (e.g., Kaltenbach, Berghella, & Finnegan, 1998; Mattick, Breen, Kimber, & Davoli, 2009).

MAT AND PREGNANCY42

SAMHSA’s guidance is clear: Pregnant women with OUD should not be encouraged to withdraw from pharmacotherapy for OUD during their pregnancy or shortly after delivery. Pharmacotherapy is the recommended standard of care, and it is the best option for a pregnant woman with OUD. Remaining on pharmacotherapy will help her avoid a return to substance use, which has the potential for overdose or death. A decision to withdraw from pharmacotherapy should be made with great care on a case-by-case basis, and additional supports such as close observation should be put in place.

MAT AND PREGNANCY43

Caring for a young child can be viewed by a parent as a deeply meaningful opportunity to successfully navigate their addiction recovery.

Motivation can be harnessed by encouraging parents to take steps they have long been considering and are now ready for, including taking better care of themselves and their family.

RECOVERY SUPPORT SERVICES (RSS) 44

Recovery support services (RSS) refer to the collection of community services that can provide emotional and practical support for continuing remission as well as daily structure and rewarding alternatives to substance use.

RSS EXAMPLES45

Examples of recovery services and resources include: Housing Education Employment Social resourcesOverall health and well-being

IT’S MORE THAN CHECKING A BOX

5-MINUTE BREAK

UNIQUE CHALLENGES OF CARING FOR CHILDREN OF THE OPIOID EPIDEMIC

Discussion with Florida foster parents

FOSTER PARENT DISCUSSION

Circumstances surrounding the foster child(ren) impacted by opioid use Unique effects of parental opioid use on the children Bio parents’ experience with MAT or other substance use disorder treatment Insight for other foster parents, adoptive parents, and kinship providers on

caring for the children of the opioid epidemic. What foster parents wished they had known, or STILL wish they knew, about

opioid use and/or its impact on children.

FOSTER PARENT DISCUSSION

Circumstances surrounding the foster child(ren) impacted by opioid use Unique effects of parental opioid use on the children Bio parents’ experience with MAT or other substance use disorder treatment Insight for other foster parents, adoptive parents, and kinship providers on

caring for the children of the opioid epidemic. What foster parents wished they had known, or STILL wish they knew, about

opioid use and/or its impact on children.

FOR QUESTIONS OR FOR ADDITIONAL INFORMATION

http://www.training.fadaa.org/

RESOURCES

Substance Abuse and Mental Health Services Administration. (2018). Medications for opioid use disorder. Treatment Improvement Protocol (TIP) Series 63. HHS Publication No. (SMA) 185063FULLDOC. Rockville, MD: SAMHSA. Retrieved March 21, 2019, fromhttps://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-/SMA18-5063FULLDOC

RESOURCES

Substance Abuse and Mental Health Services Administration. (2018). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: SAMHSA. Retrieved March 21, 2019, from https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054

OTHER RESOURCES

Substance Abuse and Mental Health Services Administration. (2016). Decisions in Recovery: Medications for Opioid Use Disorder. HHS Publication No.(SMA)16-4994. Rockville, MD: SAMHSA. Retrieved March 21, 2019, from https://store.samhsa.gov/product/Decisions-in-Recovery-Treatment-for-Opioid-Use-Disorders/SMA16-4993

OTHER RESOURCES

Werner, D., Young, N.K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with substance use disorders: History, key elements and challenges. U.S. Department of Health and Human Services, SAMHSA. Retrieved March 21, 2019, from https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf

QUESTIONS?

CITATIONS

1. Florida foster parent interviewed on 4.5.19 to inform this presentation.

2. Vestal, C. (2016). States, CDC seek limits on painkiller prescribing. Retrieved March 21, 2019, from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/03/03/states-cdc-seek-limits-on-painkiller-prescribing

3. Gold, S., & Wong, S. (2018). Supporting prevention and treatment of opioid addiction; System-level changes to enable integrated behavioral health. Retrieved March 21, 2019 from https://makehealthwhole.org/wp-content/uploads/2018/04/System-level-Changes-to-Address-Opioid-Epidemic-March-2018.pdf

4. Centers for Disease Control and Prevention. (2018). Prescription Opioid Data. Retrieved March 21, 2019, from https://www.cdc.gov/drugoverdose/data/prescribing.html

5. SAMHSA. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Rockville, MD: Center for Behavioral Health Statistics and Quality. Retrieved March 21, 2019, from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm

CITATIONS6. Vergano, D. Here’s How One Small Town Beat The Opioid Epidemic. Retrieved March

22, 2019, from https://www.buzzfeednews.com/article/danvergano/overdose-prevention-little-falls-minnesota

7. Warshaw, C. (2018). Letter from guest editor DR. Carole Warshaw. Retrieved March 21, 2019, from https://www.futureswithoutviolence.org/wp-content/uploads/Health-eBulletin-DVAM-18.pdf

8. Smith, P. H., Homish, G. G., Leonard, K. E., & Cornelius, J. R. (2012). Intimate partner violence and specific substance use disorders: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychology of Addictive Behaviors, 26(2), 236–245. Retrieved March 21, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3883081/pdf/nihms535008.p

9. Illinois Department of Human Services. (2005). Safety and sobriety manual. Best practices in domestic violence and substance abuse. Retrieved March 21, 2019, fromhttps://www.dhs.state.il.us/page.aspx?item=38459

CITATIONS

10. TECHNICAL REPORT The Lifelong Effects of Early Childhood Adversity and Toxic Stress; American Academy of Pediatrics; www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663

11. The Urban Child Institute. (n.d.) Baby’s brain begins now: conception to age 3. Retrieved March 21, 2019, from http://www.urbanchildinstitute.org/why-0-3/baby-and-brain#r8

12. Nowakowski, R. S. (2006). Stable neuron numbers from cradle to grave. Proceedings Of The National Academy Of Sciences Of The United States Of America, 103(33), 12219–12220. Retrieved March 21, 2019, from https://www.pnas.org/content/103/33/12219

13. National Scientific Council on the Developing Child. (2012). The science of neglect: The persistent absence of responsive care disrupts the developing brain: Working Paper 12. Retrieved March 21, 2019, from https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2012/05/The-Science-of-Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the-Developing-Brain.pdf

CITATIONS14. Morton, C., & Wells, M. (2017). Behavioral and substance use outcomes for older youth living with a

parental opioid misuse: A literature review to inform child welfare practice and policy. Journal of Public Child Welfare, 11(4–5), 546–567. Retrieved March 21, 2019, from https://doi.org/10.1080/15548732.2017.1355866

15. Slesnick, N., Feng, X., Brakenhoff, B., & Brigham, G. S. (2014). Parenting under the influence: The effects of opioids, alcohol and cocaine on mother-child interaction. Addictive Behaviors, 39(5), 897-900. Retrieved March 21, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4012539/

16. Ashrafioun, L., Dambra, C. M., & Blondell, R. D. (2011). Parental prescription opioid abuse and the impact on children. The American Journal Of Drug And Alcohol Abuse, 37(6), 532–536. Retrieved March 21, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/21851201

17. Katz, L., Lederman, C., & Osofsky J. (2011). Profile of infants, toddlers, and parents Involved in the child welfare system (pp 1-16). In Katz, L. F., Lederman, C. S., & Osofsky, J. D. (Eds.). Child-centered practices for the courtroom and community: A guide to working effectively with young children and their families in the child welfare system. Baltimore, Maryland: Brookes Publishing. (available at https://products.brookespublishing.com/Child-Centered-Practices-for-the-Courtroom-and-Community-P123.aspx)

CITATIONS

18. Harvard University. Center on the Developing Child. (2017). Resilience: Key concepts. Retrieved March 21, 2019, from https://developingchild.harvard.edu/science/key-concepts/resilience/

19. National Institute on Drug Abuse. (2018). Heroin. Retrieved March 21, 2019, from https://www.drugabuse.gov/publications/research-reports/heroin/what-are-immediate-short-term-effects-heroin-use

20. National Institute on Drug Abuse. (2018). Misuse of prescription drugs. Retrieved March 21, 2019, from https://www.drugabuse.gov/publications/misuse-prescription-drugs/what-classes-prescription-drugs-are-commonly-misused

21. Substance Abuse and Mental Health Services Administration. (2018). Medications for Opioid Use Disorder. Treatment Improvement Protocol (TIP) Series 63. HHS Publication No. (SMA) 185063FULLDOC. Rockville, MD: SAMHSA. Retrieved March 21, 2019, from https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-/SMA18-5063FULLDOC

CITATIONS22. Sample client response (not FL client)

23. Sprouse-Blum, A. S., Smith, G., Sugai, D., & Parsa, F. D. (2010). Understanding endorphins and their importance in pain management. Hawaii Medical Journal, 69(3), 70–71. Retrieved March 21, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104618/

24. Ibid

25. Ibid

26. National Council on Alcoholism and Drug Dependence, Inc. (2012). NCADD’s consumer guide to Medication-Assisted Recovery. Retrieved March 21, 2019, from https://www.ncadd.org/images/stories/PDF/Consumer-Guide-Medication-Assisted-Recovery.pdf

27. National Institute on Drug Abuse. (2016). Effective treatments for opioid addiction. Retrieved March 21, 2019, from https://www.drugabuse.gov/effective-treatments-opioid-addiction-0

CITATIONS

28. Connery, H. S. (2015). Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions. Harvard Review of Psychiatry, 23(2), 63–75. Retrieved March 21, 2019, from https://journals.lww.com/hrpjournal/Fulltext/2015/03000/Medication_Assisted_Treatment_of_Opioid_Use.2.aspx

29. Hall, M. T., Wilfong, J., Huebner, R. A., Posze, L., & Willauer, T. (2016). Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system. Journal of Substance Abuse Treatment, 71, 63–67. Retrieved March 21, 2019, from https://www.sciencedirect.com/science/article/pii/S0740547216301532

30. Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Medication-assisted treatment for opioid use disorder in the child welfare context: Challenges and opportunities. ASPE Research Brief. Retrieved March 21, 2019, from https://aspe.hhs.gov/system/files/pdf/260121/MATChildWelfare.pdf

CITATIONS

31. Ibid

32. Substance Abuse and Mental Health Services Administration–Health Resources Services Administration Center for Integrated Health Solutions (2014). Expanding the use of medications to treat individuals with substance use disorders in safety-net settings. Retrieved March 21, 2019, from https://www.integration.samhsa.gov/clinical-practice/mat/FINAL_MAT_white_paper.pdf

33. Radel, L., Baldwin, M., Crouse, G., Ghertner, R., & Waters, A. (2018). Medication-assisted treatment for opioid use disorder in the child welfare context: Challenges and opportunities. ASPE Research Brief. Retrieved March 21, 2019, from https://aspe.hhs.gov/system/files/pdf/260121/MATChildWelfare.pdf

34. Ibid

35. National Institute on Drug Abuse. (2016). Effective treatments for opioid addiction. Retrieved March 21, 2019, from https://www.drugabuse.gov/effective-treatments-opioid-addiction-0

CITATIONS36. Shea, K. & Graham, M. (2018). Early childhood courts: The opportunity to respond to children and

families affected by the opioid crisis. ZERO TO THREE Journal, 38(5). Retrieved March 21, 2019, from https://www.in.gov/children/files/EarlyChildhoodCourts.pdf

37. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. (2017). Obstetrics And Gynecology, 130(2), e81–e94. Retrieved March 21, 2019, from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy

38. Jones, H. E., Chisolm, M. S., Jansson, L. M., & Terplan, M. (2013). Naltrexone in the treatment of opioid-dependent pregnant women: The case for a considered and measured approach to research. Addiction (Abingdon, England), 108(2), 233–247. Retrieved March 21, 2019, from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1360-0443.2012.03811.x

39. Patrick, S. W., Dudley, J., Martin, P. R., Harrell, F. E., Warren, M. D., Hartmann, K. E., … Cooper, W. O. (2015). Prescription opioid epidemic and infant outcomes. Pediatrics, 135(5), 842–850. Retrieved March 21, 2019, from https://pediatrics.aappublications.org/content/135/5/842

CITATIONS

40. Alter, M. J., & Margolis, H. S (1998). Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Centers for Disease Control and Prevention. MMWR, 47(RR-19):1–39. Retrieved March 21, 2019, from https://www.cdc.gov/mmwr/preview/mmwrhtml/00055154.htm

41. Substance Abuse and Mental Health Services Administration (2018). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: SAMHSA. Retrieved March 21, 2019, from https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054

42. Ibid

CITATIONS

43. Shea, K. & Graham, M. (2018). Early childhood courts: The opportunity to respond to children and families affected by the opioid crisis. ZERO TO THREE Journal, 38(5). Retrieved March 21, 2019, from https://www.in.gov/children/files/EarlyChildhoodCourts.pdf

44. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General (2016). Facing addiction in America: The Surgeon General’s report on alcohol, drugs, and health. Washington, DC: HHS. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/chapter-5-recovery.pdf

45. Ibid