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Short VL, Hand DJ, Mancuso F, Raju A, Sinnott J, Caldarone L, Rosenthall E, Liveright E, Abatemarco DJ. Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care. Birth 2024; 51:144-151. [PMID: 37800365 DOI: 10.1111/birt.12775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not. METHODS This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described. RESULTS G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology. CONCLUSION Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.
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Affiliation(s)
- Vanessa L Short
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dennis J Hand
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Amulya Raju
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jacqueline Sinnott
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Elizabeth Liveright
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Diane J Abatemarco
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Bass R, Flinchum G, Ramage M, Galvin SL, Cabello-De la Garza A, Caron O, Marietta A. Accessing perinatal substance use disorder care in your local community: A case study of an innovative hub and spoke network in western North Carolina. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 158:209268. [PMID: 38097044 DOI: 10.1016/j.josat.2023.209268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION The incidence of substance use disorders (SUD) in the general population and in the pregnant person population has risen over the last 20 years. Concurrently, both perinatal and SUD care in rural areas is laden with access barriers including but not limited to geographical distance from potential treatment and stigma. An integrated outpatient perinatal substance use disorder (PSUD) clinic in an urban area in western North Carolina (WNC) found that patients who traveled further for prenatal care were less likely to continue seeking care in the postpartum period. Acknowledging that the risk of overdose increases in the postpartum period, the PSUD clinic utilized a hub and spoke model to promote healthcare accessibility. METHODS The clinic adapted the Vermont hub and spoke model and the CHARM (Children and Recovering Mothers) collaborative. The urban hub in WNC has now developed eight spokes in rural communities. The hub provides education and technical assistance to the rural spokes, and the two engage in bidirectional referral pathways. This manuscript details the model and analyzes the existing strengths and barriers at two spokes, a family medicine Federally Qualified Health Center and a hospital affiliated obstetrics and gynecology practice and analyzes their process of implementation of integrated outpatient perinatal substance use care. RESULTS Both spokes found coaching relationships and the sharing of resources such as clinical guidelines useful to begin prescribing buprenorphine for PSUD. Their context led one spoke to begin prescribing within one year while the other took two years. CONCLUSION Comparing and contrasting these spokes serves to demonstrate that across many contexts, a hub and spoke model is a replicable intervention for rural perinatal substance use access to care barriers. Comparing the two spokes emphasizes the need for adaptation as well as standardization of the model to improve evidence-based PSUD care most effectively.
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Affiliation(s)
- Rebekah Bass
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA.
| | - Grace Flinchum
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Melinda Ramage
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Shelley L Galvin
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Ana Cabello-De la Garza
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
| | - Olivia Caron
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA; Department of Pharmacotherapy at Mountain Area Health Education Center (MAHEC), 125 Hendersonville Road, Asheville, NC 28803, USA; UNC-Chapel Hill Eshelman School of Pharmacy, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA
| | - Amy Marietta
- Department of OB/GYN Project CARA at Mountain Area Health Education Center (MAHEC), 119 Hendersonville Road, Asheville, NC 28803, USA
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Witcraft SM, Johnson C, Guille C. The Psychiatrist's Role in Treating Perinatal Opioid Use Disorder and Reducing Maternal Mortality. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:25-34. [PMID: 38694152 PMCID: PMC11058912 DOI: 10.1176/appi.focus.20230018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Drug overdose is a leading cause of maternal mortality. Psychiatrists can play a critical role in reducing these deaths by delivering effective evidence-based treatments for perinatal opioid use disorder (POUD), including the use of buprenorphine. Medications for POUD (i.e., buprenorphine, methadone) are life-saving treatments, but only half of those who are diagnosed as having POUD will receive this treatment, which can result in an increased risk for return to opioid use, overdose, and death. Psychiatrists are well positioned to prescribe buprenorphine given the Drug Enforcement Administration's (DEA) removal of the requirement to submit a Notice of Intent to prescribe buprenorphine for the treatment of opioid use disorders. Psychiatrists who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorders; the training requirements to do so are outlined herein. This article reviews the standard of care for screening, diagnosis, and treatment of POUD, and prescribing buprenorphine for POUD, as well as shared decision-making for medication selection, induction, and maintenance of buprenorphine during pregnancy, labor and delivery, and the postpartum year.
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Affiliation(s)
- Sara M Witcraft
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
| | - Claire Johnson
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
| | - Constance Guille
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
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Knittel AK, Swartzwelder RA, Zarnick S, Tsujimoto TM, Horne T, Lin FC, Edwards J, Amos E, Alexander J, Thorp J, Jones HE. Neonatal Outcomes after Medications for Opioid Use Disorder during Pregnancy in a State Women's Prison Facility, 2016-2019. J Addict Med 2023; 17:587-591. [PMID: 37788614 PMCID: PMC10593980 DOI: 10.1097/adm.0000000000001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Although medications for opioid use disorder improve both maternal and neonatal outcomes, little is known about opioid-exposed infants born during episodes of incarceration. The study sought to examine birth outcomes for infants born with opioid exposure during perinatal incarceration. METHODS Participants were identified from clinic rosters in a Southeastern women's prison (2016-2019). Included infants born to pregnant people with opioid use disorder incarcerated in the study facility at the time of delivery. We abstracted hospital length of stay, neonatal opioid withdrawal syndrome (NOWS) severity, and discharge plan from hospital records and report descriptive statistics, analysis of variance F tests, and chi-square tests to compare outcomes by opioid exposure type. RESULTS There were 125 infants born after exposure to methadone (n = 34), buprenorphine (n = 15), oxycodone (n = 22), or no opioid medication (n = 54) during prenatal incarceration. Most infants exposed to methadone or buprenorphine had difficulty with eating, sleeping, or consoling (97% and 80%), and 59% and 47% were treated with medication for NOWS, respectively. The majority with prenatal opioid exposure required intervention for NOWS symptoms after their birthing parent was discharged to the prison. The average hospital length of stay was different for infants with no opioid, methadone, buprenorphine, and oxycodone exposure during incarceration (4, 15, 12, and 9 days, respectively, P < 0.001). CONCLUSIONS Neonatal hospitalization experiences of infants with perinatal opioid exposures during maternal incarceration mirror those of similarly exposed infants born outside the context of incarceration, except for hospital length of stay. Consideration of avoiding separation of the parent-infant dyad may be needed to improve outcomes for these infants.
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Affiliation(s)
- Andrea K Knittel
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Rita A Swartzwelder
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Samantha Zarnick
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Tamy Moraes Tsujimoto
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Timeli Horne
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Feng Chang Lin
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Elton Amos
- North Carolina Department of Public Safety, Raleigh, NC
| | | | - John Thorp
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hendree E Jones
- UNC Horizons, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Green C, George N, Park Y, Denny CH, Weber MK, Meaney-Delman D, Kim SY. Screening and Brief Interventions for Alcohol Use During Pregnancy: Practices Among US Primary Care Clinicians, DocStyles 2019. Prev Chronic Dis 2023; 20:E25. [PMID: 37055155 PMCID: PMC10109479 DOI: 10.5888/pcd20.220226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
INTRODUCTION Alcohol use during pregnancy can cause birth defects and developmental disabilities. From 2018 through 2020, 13.5% of pregnant women reported current drinking. The US Preventive Services Task Force recommends evidence-based tools (eg, AUDIT-C and SASQ) for implementing screening and brief interventions to reduce excessive alcohol use among adults, including pregnant people, for whom any alcohol use is considered excessive. METHODS We used DocStyles 2019 data to conduct a cross-sectional analysis to examine current screening and brief intervention practices that primary care clinicians conduct among pregnant patients; clinicians' confidence levels in conducting screening, brief interventions, and referral to treatment; and the documentation of brief interventions in the medical record. RESULTS A total of 1,500 US adult medicine clinicians completed the entire survey. Among the respondents who conduct screening (N = 1,373) and brief interventions (N = 1,357) in their practice, nearly all reported implementing screening (94.6%) and brief interventions (94.9%) with their pregnant patients for alcohol use, but fewer than half felt confident about conducting their screening practices (46.5%). Two-thirds (64%) reported using a tool that met the criteria recommended by the US Preventive Services Task Force (USPSTF). Over half documented brief interventions in electronic health record notes (51.7%) or designated space (50.7%). CONCLUSION Pregnancy presents a unique opportunity for clinicians to incorporate screening into routine obstetric care and encourage behavior change among patients. Most providers reported always screening their pregnant patients for alcohol use, but fewer used evidence-based USPSTF-recommended screening tools. Increased clinician confidence in screening and brief intervention, the use of standardized screening tools tailored to pregnant people, and maximal use of electronic health record technology may enhance the benefits of their application to alcohol use, which ultimately can reduce adverse outcomes associated with alcohol use during pregnancy.
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Affiliation(s)
- Caitlin Green
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
- Centers for Disease Control and Prevention, 4770 Buford Hwy NE, MS S106-3, Atlanta, GA 30341
| | - Nisha George
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
- Eagle Global Scientific, LLC, Atlanta, Georgia
| | - Youngjoo Park
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Clark H Denny
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mary Kate Weber
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Meaney-Delman
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shin Y Kim
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia
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Preis H, Whitney C, Kocis C, Lobel M. Saving time, signaling trust: Using the PROMOTE self-report screening instrument to enhance prenatal care quality and therapeutic relationships. PEC INNOVATION 2022; 1:100030. [PMID: 35465253 PMCID: PMC9020232 DOI: 10.1016/j.pecinn.2022.100030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/25/2022] [Accepted: 03/17/2022] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Comprehensive screening of psychosocial vulnerabilities and substance use in prenatal care is critical to promote the health and well-being of pregnant patients. Effective implementation of new screening procedures and instruments should be accompanied by an in-depth investigation to assess their feasibility and impact on care delivery. METHODS In 2020, following implementation of the Profile for Maternal and Obstetric Treatment Effectiveness (PROMOTE) an innovative self-report screening instrument developed for outpatient prenatal clinics in the U.S., we conducted individual interviews and focus groups with twenty-two midwives, nurse practitioners, and obstetric residents focused on the PROMOTE and its impacts on care delivery. We used interpretive description for the qualitative analysis of the interviews. RESULTS Five themes were identified: Guiding Time Efficiently: "The Time I Don't Have," Preventing Missed Care, Signaling Trustworthiness, Establishing Trauma-Informed Foundations, and Promoting "Honest" Patient Disclosure. CONCLUSION Interviews suggest that patient completion of the PROMOTE before the medical encounter helps reduce previously reported barriers, is more time-effective, and makes history-taking easier. It also facilitates the patient-provider relationship. INNOVATION Findings offer insight into the breadth and depth of clinical impact resulting from the PROMOTE, and provide guidance for the implementation of such tools to optimize health outcomes.
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Affiliation(s)
- Heidi Preis
- Department of Psychology, Stony Brook University, Stony Brook, NY 11794, USA
- Department of Obstetrics and Gynecology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Clare Whitney
- School of Nursing, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Christina Kocis
- Department of Obstetrics and Gynecology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Marci Lobel
- Department of Psychology, Stony Brook University, Stony Brook, NY 11794, USA
- Department of Obstetrics and Gynecology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
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Lim G, Soens M, Wanaselja A, Chyan A, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE, Terplan M, Bateman BT. A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine. Anesth Analg 2022; 135:912-925. [PMID: 36135926 PMCID: PMC9588509 DOI: 10.1213/ane.0000000000006167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | - Mieke Soens
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Anne Wanaselja
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
| | - Arthur Chyan
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Brendan Carvalho
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
| | - Ruth Landau
- Columbia University Department of Anesthesiology & Perioperative Medicine, New York City, NY
| | - Ronald B. George
- University of California San Francisco Department of Anesthesiology & Perioperative Care, San Francisco, CA
| | - Mary Lou Klem
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - Sarah S. Osmundson
- Vanderbilt University, Department of Obstetrics & Gynecology, Nashville, TN
| | - Elizabeth E. Krans
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | | | - Brian T. Bateman
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
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Austin AE, Di Bona V, Cox ME, Proescholdbell SK, Naumann RB. Differences in Mortality Among Infants With Neonatal Opioid Withdrawal Syndrome. Am J Prev Med 2022; 63:619-623. [PMID: 35489960 DOI: 10.1016/j.amepre.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/01/2022] [Accepted: 03/14/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Prior studies are mixed regarding whether infants diagnosed with neonatal opioid withdrawal syndrome have a higher risk of mortality than other infants. However, these studies have not accounted for whether mothers of infants with neonatal opioid withdrawal syndrome received medication for opioid use disorder in pregnancy. METHODS Linked data from 2016‒2018 North Carolina birth certificates, maternal and infant Medicaid claims, and infant death certificates were analyzed in summer 2021 to compare mortality and causes of mortality before age 1 year among infants diagnosed with neonatal opioid withdrawal syndrome whose mothers did and did not have claims for medication for opioid use disorder in pregnancy (N=4,480). RESULTS Compared with mothers with medication for opioid use disorder claims in pregnancy (45.5%), mothers without medication for opioid use disorder claims (55.5%) were younger, more likely to be Black non-Hispanic, less likely to have paternity established, and more likely to have no prenatal care. The proportion (1.3%, n=31 vs 1.0%, n=21) and rate (3.5 vs 2.9 deaths per 100,000 infant days) of mortality was higher among infants of mothers without medication for opioid use disorder claims than infants of mothers with medication for opioid use disorder claims. Sudden unexpected infant death syndrome was the primary cause of death for infants of mothers with (90.5%) and without (58.1%) medication for opioid use disorder claims. CONCLUSIONS Results highlight the importance of assessing for potential differences in outcomes according to whether infants with neonatal opioid withdrawal syndrome were exposed to medication for opioid use disorder. Efforts to ensure equitable access to medication for opioid use disorder and other support services in pregnancy are needed to promote healthy maternal and infant outcomes.
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Affiliation(s)
- Anna E Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Vito Di Bona
- North Carolina State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Mary E Cox
- Injury and Violence Prevention Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Scott K Proescholdbell
- Injury and Violence Prevention Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Rebecca B Naumann
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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False-positive Fentanyl Urine Detection After Initiation of Labetalol Treatment for Hypertension in Pregnancy: A Case Report. J Addict Med 2022; 16:e417-e419. [PMID: 35972891 DOI: 10.1097/adm.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Labetalol hydrochloride (LH) is a pharmacologic treatment for hypertensive disease (HD) in pregnancy. However, for pregnant persons with substance use disorders (SUDs), LH may interfere with urine drug testing. CASE SUMMARY We present 3 pregnant or postpregnant persons with SUDs who experienced presumptive positive urine immunoassays for fentanyl while prescribed LH for perinatal HD. DISCUSSION Labetalol hydrochloride treatment for HD in pregnancy can result in presumptive positive urine immunoassays for fentanyl. Unrecognized or misinterpreted, this phenomenon can lead to significant consequences for pregnant and postpartum persons with co-occurring substance use and hypertensive disorders. Clinicians caring for pregnant persons with SUDs must be aware of this phenomenon and its sequelae when ordering and interpreting urine immunoassays for fentanyl.
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Guille C, Hall C, King C, Sujan A, Brady K, Newman R. Listening to women and pregnant and postpartum people: Qualitative research to inform opioid use disorder treatment for pregnant and postpartum people. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100064. [PMID: 36845990 PMCID: PMC9948937 DOI: 10.1016/j.dadr.2022.100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/13/2022] [Accepted: 05/09/2022] [Indexed: 11/22/2022]
Abstract
Background The diagnosis of Opioid Use Disorder (OUD) during pregnancy has increased 2-to-5-fold over the past decade and barriers to treatment are significant. Technology-based solutions have the potential to overcome these barriers and deliver evidence-based treatment. However, these interventions need to be informed by end-users. The goal of this study is to gain feedback from peripartum people with OUD and obstetric providers about a web-based OUD treatment program. Methods Qualitative interviews were conducted with peripartum people with OUD (n = 18) and focus groups were conducted with obstetric providers (n = 19). Feedback from these interviews informed the development of text message-based screening, brief phone-based intervention and referral to treatment program, called Listening to Women and Pregnant and Postpartum People (LTWP). Once developed, further qualitative interviews with peripartum people with OUD (n = 12) and obstetric providers (n = 21) were conducted to gather feedback about the LTWP program. Results Patients reported that a relationship with a trusted provider is paramount for treatment engagement. Providers reported that time constraints and complex patient needs prohibit them from treating OUD and that evidence-based Screening, Brief Intervention and Referral to Treatment (SBIRT) are not implemented effectively in routine prenatal care. Neither patients nor providers were enthusiastic about our web-based intervention for OUD; thus, results were used to guide the development of LTWP to improve implementation of SBIRT during prenatal care. Conclusions End-user informed, technology-enhanced SBIRT has the potential to improve the implementation of SBIRT during routine prenatal care, and in turn, improve maternal and child health.
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Affiliation(s)
- Constance Guille
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St, 5 South, MSC861, Charleston, SC 29425, USA
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Casey Hall
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Courtney King
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St, 5 South, MSC861, Charleston, SC 29425, USA
| | - Ayesha Sujan
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St, 5 South, MSC861, Charleston, SC 29425, USA
- Department of Psychological and Brain Sciences, Indiana University – Bloomington, Bloomington, IN, USA
| | - Kathleen Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St, 5 South, MSC861, Charleston, SC 29425, USA
- Department of Psychological and Brain Sciences, Indiana University – Bloomington, Bloomington, IN, USA
| | - Roger Newman
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
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Camden A, To T, Ray JG, Gomes T, Bai L, Guttmann A. Categorization of Opioid Use Among Pregnant People and Association With Overdose or Death. JAMA Netw Open 2022; 5:e2214688. [PMID: 35622361 PMCID: PMC9142862 DOI: 10.1001/jamanetworkopen.2022.14688] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/13/2022] [Indexed: 12/12/2022] Open
Abstract
Importance Early identification of people who use opioids in pregnancy may improve health outcomes for pregnant people and infants. However, characterization of diverse circumstances surrounding type of opioid use and indications for opioid use are lacking. Objective To develop clinically distinct groups of people who use opioids in pregnancy and to evaluate their association with drug overdose or death up to 1 year post partum. Design, Setting, and Participants This is a population-based, repeated cross-sectional study conducted in Ontario, Canada, with participants who used opioids in pregnancy who had a live birth or stillbirth between January 1, 2014, and December 31, 2019, identified in health administrative databases. Data were analyzed from August 2020 to January 2021. Exposures Prenatal opioid use. Main Outcomes and Measures Latent class analysis (LCA), based on prenatal opioid use and 19 socioeconomic and medical characteristics, first identified clinically distinct groups of opioid users. Then, within the optimally derived LCA-derived group, adjusted relative risks (aRRs) were generated for the outcome of drug overdose or all-cause death within 1 year post partum, adjusting for birthing parent age and year of delivery. Results The analysis included 31 241 people with prenatal opioid use (mean [SD] age, 30.0 [5.6] years; 86.1% [26 908 individuals] Canadian-born; 30.6% [9574 individuals] lived in low-income neighborhoods). LCA generated a 5-group model that optimally distinguished opioid users in pregnancy as follows: short-term analgesia with low comorbidity (group 1), analgesia in young people (group 2), medication for opioid use disorder or unregulated opioid use (group 3), pain management with comorbidity (group 4), and mixed opioid use plus high social and medical needs (group 5). The overall risk of postpartum drug overdose or death was 1.5%. Using the 5-group model, compared with people in group 1, the aRR of overdose or death was highest among those in group 5 (aRR, 14.0; 95% CI, 10.1-19.5), followed by group 3 (aRR, 4.6; 95% CI, 3.3-6.5), group 2 (aRR, 3.3; 95% CI, 2.2-4.7), and group 4 (aRR, 3.2; 95% CI, 2.3-4.4). Conclusions and Relevance In this cross-sectional study, distinct groups of people with opioid use in pregnancy were associated with increasing degrees of risk of postpartum drug overdose or death. Group characteristics can be used to identify people with high risk and inform harm reduction, home visiting programs, and other interventions.
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Affiliation(s)
- Andi Camden
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Teresa To
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joel G. Ray
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, St Michaels Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin SH Leong Centre, University of Toronto, Toronto, Ontario, Canada
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12
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Kane C, Topmiller M. Expanding Opioid Use Disorder Treatment in Priority Areas: The Role of Certified Nurse-Midwives. J Midwifery Womens Health 2022; 67:314-320. [PMID: 35506768 DOI: 10.1111/jmwh.13364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Perinatal opioid use disorder (OUD) is associated with maternal and neonatal morbidity, and treatment has been definitively shown to improve outcomes for both. As of 2018, certified nurse-midwives (CNMs) can prescribe buprenorphine for the treatment of OUD by obtaining a Drug Addiction Treatment Act waiver. This research aims to identify the number of CNMs who are waivered to prescribe buprenorphine for the treatment of OUD and who practice in priority areas for treatment expansion. METHODS Through a descriptive study design, authors collected and analyzed publicly available data from August 2020 to January 2021. Using the software GeoDa, authors identified priority counties in the United States and the number of waivered and nonwaivered CNMs in these areas. Counties were designated as priority if they had drug-poisoning mortality rates in the top 20th percentile of all US counties and no health care providers waivered to treat OUD or had a waivered health care provider per population rate in the bottom 20th percentile. RESULTS Analysis identified 141 priority counties in 23 states concentrated in rural areas throughout the Appalachian region of the United States. Tennessee had the most priority counties of any state. As of 2020, only 26 CNMs in the United States were waivered to prescribe buprenorphine, none of whom practiced in priority counties. Of the CNMs practicing in priority counties and without waivers, 59% (39 of 66) practiced in states where CNMs have independent practice authority. DISCUSSION CNMs are uniquely positioned to treat perinatal OUD given their scope of practice as primary and reproductive health care providers, especially in rural, underserved areas. To increase the number of midwives prescribing buprenorphine and expand treatment access, researchers, educators, practice leaders, and policy makers must address barriers to and experiences of treating OUD.
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Affiliation(s)
- Claire Kane
- Visiting Scholar, Robert Graham Center for Policy Studies in Family Medicine, Washington, District of Columbia.,ABSN-DNP Nurse Midwifery Student, University of Washington School of Nursing, Seattle, Washington
| | - Michael Topmiller
- Health GIS Research Specialist in, HealthLandscape Department at the American Academy of Family Physicians, Leawood, Kansas
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Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019. Drug Alcohol Depend 2022; 232:109308. [PMID: 35074696 PMCID: PMC8946772 DOI: 10.1016/j.drugalcdep.2022.109308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration. METHODS We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration. RESULTS Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD. CONCLUSIONS Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.
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14
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Courchesne-Krak NS, Kepner W, Rubano A, Marienfeld C. Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis. Am J Obstet Gynecol MFM 2022; 4:100559. [PMID: 34990875 PMCID: PMC8891059 DOI: 10.1016/j.ajogmf.2021.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND As a vulnerable population, pregnant women with a substance-related diagnosis (ie, substance use, misuse, or dependence) may use healthcare disproportionately. OBJECTIVE The primary goal of this study was to evaluate the differences in the use of outpatient clinical visits, emergency department visits, and inpatient days in the hospital among women with and without a substance-related diagnosis during the antepartum period. STUDY DESIGN This retrospective study retrieved electronic health record data on women (age, 18-44 years) who delivered a single live birth or stillbirth at ≥20 weeks of gestation from April 1, 2012, to September 30, 2019. Imbalance in measured maternal sociodemographic and obstetrical characteristics between women with and without a substance-related diagnosis was attenuated using propensity score matching on key demographic characteristics (eg, age), yielding a matched 1:1 sample. Unadjusted and adjusted logistic regressions models were used to determine the association between a substance-related diagnosis and outpatient visits, emergency visits, and inpatient days. RESULTS From the total sample (n=16,770), the matched cohort consisted of 1986 deliveries. Of these, most were White (51.0%), or mixed or of some other race (31.1%). The mean age was 29.8 (standard deviation, 5.6). A substance-related diagnosis was identified in 993 women (50%) because of matching. Women with a substance-related diagnosis were more likely to have ≤10 outpatient visits than women without a substance-related diagnosis (adjusted odds ratio, 1.81 [95% confidence interval, 1.44-2.28]; P<.0001). Alcohol-, opioid-, and stimulant-related diagnoses were independently associated with ≤10 outpatient visits (adjusted odds ratio, 3.16 [95% confidence interval, 1.67-6.04]; P=.0005; adjusted odds ratio, 3.02 [95% confidence interval, 1.79-5.09]; P<.0001; adjusted odds ratio, 2.18 [95% confidence interval, 1.39-3.41]; P=.0007, respectively). Women with a substance-related diagnosis were more likely to have ≥1 emergency visit than women without a substance-related diagnosis (adjusted odds ratio, 1.36 [95% confidence interval, 1.00-1.85]; P<.0001). Opioid-, stimulant-, and nicotine-related diagnoses were independently associated with ≥1 emergency visit (adjusted odds ratio, 2.28 [95% confidence interval, 1.09-4.77]; P=.0287; adjusted odds ratio, 2.01 [95% confidence interval, 1.07-3.78]; P=.0301; adjusted odds ratio, 3.38 [95% confidence interval, 1.90-6.02]; P<.0001, respectively). Women with a substance-related diagnosis were more likely to have ≥3 inpatient days than women without a substance-related diagnosis (adjusted odds ratio, 1.69 [95% confidence interval, 1.07-2.67]; P=.0256). Opioid-, stimulant-, and nicotine-related diagnosis were independently associated with ≥3 inpatient days (adjusted odds ratio, 3.52 [95% confidence interval, 1.42-8.75]; P=.0067; adjusted odds ratio, 3.51 [95% confidence interval, 1.31-9.34]; P=.0123; adjusted odds ratio, 2.74 [95% confidence interval, 1.11-6.73]; P=.0285, respectively). CONCLUSION Women with a substance-related diagnosis during the antepartum period who delivered a single live birth or stillbirth at ≥20 weeks of gestation were experiencing fewer outpatient visits, more emergency department visits, and more inpatient days than women without a substance-related diagnosis. The type of substance-related diagnosis (eg, alcohol, opioids, stimulants, or nicotine) was associated with different patterns of healthcare use. The results from this study have reinforced the need to identify substance-related diagnoses in pregnant women early to minimize disproportionate healthcare service utilization through intervention and treatment.
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Affiliation(s)
- Natasia S Courchesne-Krak
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld).
| | - Wayne Kepner
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld)
| | - Amanda Rubano
- University of Rochester School of Medicine and Dentistry, Rochester, NY (Ms Rubano)
| | - Carla Marienfeld
- Department of Psychiatry, University of California San Diego, La Jolla, CA (Dr Courchesne-Krak, Mr Kepner, and Dr Marienfeld)
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15
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What Obstetrician–Gynecologists Should Know About Substance Use Disorders in the Perinatal Period. Obstet Gynecol 2022; 139:317-337. [DOI: 10.1097/aog.0000000000004657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
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16
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Assessing the Impact of Prenatal Medication for Opioid Use Disorder on Discharge Home With Parents Among Infants With Neonatal Opioid Withdrawal Syndrome. J Addict Med 2022; 16:e366-e373. [PMID: 35245916 PMCID: PMC9433459 DOI: 10.1097/adm.0000000000000987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The number of women with opioid-related diagnoses in the United States has significantly increased in recent decades, resulting in concomitantly higher rates of infants born with neonatal opioid withdrawal syndrome (NOWS). Addressing prenatal opioid exposure is a priority for Alaska health systems. The objectives of this study were to: (1) identify maternal and neonatal factors associated with receipt of Medication for opioid use disorder (MOUD) and (2) determine the impact of prenatal MOUD on discharge to parents among infants with NOWS in 3 Alaska hospitals. METHODS A retrospective chart review using a standard abstraction form was conducted to collect data on neonatal and maternal characteristics, neonatal treatment, and infant discharge disposition for infants with NOWS born at the 3 hospitals between July 2016 and December 2019. A multivariable logistic regression model was used to determine factors associated with discharge to parents. RESULTS There were 10,719 births at the 3 hospitals during the study period, including 193 infants (1.8%) with NOWS. Among the 193 mothers, 91 (47.2%) received MOUD during pregnancy. Among infants with NOWS, 136 (70.5%) were discharged to parents, 51 (26.4%) were discharged to a relative or foster care. Infants were significantly (odds ratio 3.9) more likely to be discharged to parents if the mother had received prenatal MOUD. CONCLUSIONS MOUD among pregnant women with opioid use disorder furthers the goal of keeping families together and is a critical step towards reducing the impact of the ongoing opioid epidemic on Alaska families, communities, and the child welfare system.
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Geissler KH, Pearlman J, Attanasio L. Physician Referrals During Prenatal Care. Matern Child Health J 2021; 25:1820-1828. [PMID: 34618308 PMCID: PMC9887992 DOI: 10.1007/s10995-021-03236-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Referrals are an important component of patient care, and have been increasing over time. During pregnancy, people have intensive contact with the healthcare system, but little is known about the involvement of different physicians for pregnant patients during this period. This study examines referral patterns during prenatal care visits. METHODS Using the 2006-2015 National Ambulatory Medical Care Survey and national birth certificate data, we estimate the number of referrals per pregnancy from prenatal care visits with OB/GYN and family medicine physicians. We use multivariable regression analysis to compare the probability of receiving a referral during a prenatal visit for visits with family medicine and OB/GYN physicians, controlling for visit, patient, and physician characteristics. Analyses are weighted to make results nationally representative. RESULTS 224,335,436 prenatal visits over 19,893,015 pregnancies were included; 60% of these visits were covered by private insurance. On average, 0.3 referrals are made per pregnancy (95% confidence interval [CI] 0.22, 0.38). A prenatal visit with an OB was 5.5% points less likely to result in a referral than a visit with a family medicine physician, controlling for other characteristics. CONCLUSIONS Referrals are relatively common in prenatal care, and are more commonly initiated by family medicine physicians than by OB/GYNs. Understanding the contribution of multiple clinicians to a pregnant person's health during the prenatal period and how coordination among clinicians impacts care receipt is an important next step. As healthcare becomes more specialized, better understanding care teams of individuals during the perinatal period is important for improving prenatal care.
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Affiliation(s)
- Kimberley H. Geissler
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences; Amherst, MA
| | - Jessica Pearlman
- Institute for Social Science Research, University of Massachusetts Amherst; Amherst, MA
| | - Laura Attanasio
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences; Amherst, MA,Corresponding author: Address: 715 North Pleasant Street, 329 Arnold House, Amherst MA 01003, , Phone: 413-545-4480
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18
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Sufrin CB, Knittel A. Health care and social justice implications of incarceration for pregnant people who use drugs. Int Rev Psychiatry 2021; 33:557-571. [PMID: 34098837 PMCID: PMC9251864 DOI: 10.1080/09540261.2021.1887097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The experiences of and care for pregnant, incarcerated people with substance use disorders represent a convergence of numerous clinical, historical, racialized, legal, and gendered factors. Understanding how these forces shape how they became enmeshed in the criminal legal system as well as the context of the care they do or do not receive while in custody is essential for promoting equitable maternal health care. In this review, we describe the prevalence of SUD among pregnant people behind bars, the health care landscape of incarceration, access to treatment for opioid use disorder for incarcerated pregnant and postpartum people, and nuances of providing such treatment in an inherently coercive setting. Throughout, we highlight the ways that the child welfare system and mass incarceration in the U.S. have had a unique and discriminatory impact on pregnant and parenting people, and have done so in distinctly racialized ways. Situating the clinical care of incarcerated pregnant people who use drugs in this context sheds light on fundamental social justice and health care intersections.
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Affiliation(s)
- Carolyn B. Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA,Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrea Knittel
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
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19
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Hand DJ, Fischer AC, Gannon ML, McLaughlin KA, Short VL, Abatemarco DJ. Comprehensive and compassionate responses for opioid use disorder among pregnant and parenting women. Int Rev Psychiatry 2021; 33:514-527. [PMID: 34176410 DOI: 10.1080/09540261.2021.1908966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.
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Affiliation(s)
- Dennis J Hand
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Psychiatry & Human Behavior, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alice C Fischer
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Meghan L Gannon
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kimberly A McLaughlin
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vanessa L Short
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Diane J Abatemarco
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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Busse MM, Kim J, Unite M, Kantrowitz-Gordon I, Altman MR. Nurses' Priorities for Improving Pregnancy and Birth Care for Individuals with Opioid use Disorder. J Midwifery Womens Health 2021; 66:656-663. [PMID: 34398507 DOI: 10.1111/jmwh.13267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/06/2021] [Accepted: 05/12/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The motivation to seek treatment for opioid use disorder (OUD) can increase during the perinatal period. However, several identified barriers, such as poor access to services, lack of trained providers, stigma, and legal ramifications of OUD, limit the ability for individuals with OUD to receive safe and supportive care during pregnancy and birth. During the birth hospital stay in particular, nurses provide the majority of care for pregnant and birthing families. We aimed to engage nurses, with experience caring for pregnant and postpartum individuals with OUD, in priority setting as a way to identify areas of need in the current health care systems. METHODS Using community-engaged priority setting methods, we recruited a sample of 47 nurses (phase 1) and 20 nurses (phase 2), including nurse-midwives and other advanced practice nurses, at a statewide nursing conference, who reported regularly providing care for pregnant and postpartum individuals with OUD. We invited participants to submit questions and concerns regarding the provision of care for individuals with OUD (phase 1). A selection of those who submitted questions attended a focus group to rank and prioritize submitted questions into a set of priorities for research, policy, and care improvement (phase 2). RESULTS In phase 1, participants submitted a total of 165 questions and concerns. In phase 2, participants prioritized the following: funding to support improvements in OUD care in the perinatal period, increased access to services, supportive housing for individuals in recovery, standardization of care for individuals with OUD, and efforts to destigmatize care. DISCUSSION Nurses who work with pregnant and postpartum individuals with OUD have a unique insight as to how health care providers, including midwives, can better support this community and should be engaged setting priorities for research, changes to policy, and improvement in care.
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Affiliation(s)
- Morgan M Busse
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington
| | - Jane Kim
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington
| | - Marianne Unite
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington
| | - Ira Kantrowitz-Gordon
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington
| | - Molly R Altman
- Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle, Washington
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Pentecost R, Schmidt K, Grassley JS. Health Care Providers' Perceived Barriers to Screening for Substance Use During Pregnancy. Nurs Womens Health 2021; 25:272-277. [PMID: 34146524 DOI: 10.1016/j.nwh.2021.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 05/07/2021] [Accepted: 05/01/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore health care providers' perceived barriers to conducting standardized screening processes for substance use during pregnancy. DESIGN Descriptive survey. SETTING/LOCAL PROBLEM A health system in the northwestern United States where there was a lack of consistent substance use screening in prenatal clinics. PARTICIPANTS A convenience sample of 12 women's health care providers from two hospitals in the health system, including obstetricians/gynecologists, women's health nurse practitioners, women's health physician assistants, and certified nurse-midwives. INTERVENTION/MEASUREMENTS We created a 16-item questionnaire that identified potential barriers to screening, such as education/resources for providers, screening tools, referral processes, legal implications, patient relations, and infrastructure. RESULTS A majority (n = 8, 66.7%) of participants indicated they had received adequate training regarding substance use during pregnancy and felt comfortable asking pregnant women about their substance use. All (n = 12, 100%) providers indicated that women would feel safe disclosing their substance use but might feel offended if their provider asked them about it. Although most reported screening women for substance use, they did not use a consistent screening tool or process. Participants identified lack of time, legal concerns, and lack of access to resources for referrals as other barriers to screening. CONCLUSION Clinicians perceive barriers to screening for substance use during pregnancy, and they may be unaware of legal implications for patients related to perinatal substance use. Identifying barriers to universal screening may facilitate development of best practices related to counseling patients about substance use during pregnancy.
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22
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Pentecost R, Latendresse G, Smid M. Scoping Review of the Associations Between Perinatal Substance Use and Perinatal Depression and Anxiety. J Obstet Gynecol Neonatal Nurs 2021; 50:382-391. [PMID: 33773955 PMCID: PMC8286297 DOI: 10.1016/j.jogn.2021.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate published literature on the associations between perinatal substance use (PSU), perinatal depression and anxiety (PDA), and known maternal-newborn outcomes. DATA SOURCES We conducted a systematic search of health-related databases, including PubMed, CINAHL, MEDLINE, and Embase. Search terms included maternal mental health, substance use, postpartum, opioid, alcohol, methamphetamine, addiction, dependence, pregnancy, depression, and anxiety. STUDY SELECTION We included English-language, peer-reviewed reports of primary research and systematic reviews that were published between 2010 and 2020 and focused on PSU and PDA. We excluded commentaries, nonsystematic reviews, and articles on maternal mental health other than PDA. Fourteen of 379 articles met the inclusion criteria. DATA EXTRACTION We used the Joanna Briggs Institute Review Guidelines to guide extraction of the following data: author(s), year of publication, type of study, country of origin, study sample, targeted substance(s), mental health, key findings, and recommendation(s). DATA SYNTHESIS In studies of PSU, researchers identified a strong association with PDA. Likewise, researchers investigating PDA found a strong association with PSU. Findings from these articles suggest an increasing risk for PSU with increasing severity of PDA, depending on the specific substances of use. Findings also indicated that women with polysubstance use have greater odds for comorbid perinatal mental health conditions. A relationship between PSU and PDA and adverse newborn outcomes, such as low birth weight, was found. CONCLUSION There is a paucity of published research on co-occurring PSU and PDA. However, polysubstance use appears to be associated with the greatest risk for PDA. It is essential to address PSU and PDA together to better understand the effects on maternal and infant outcomes.
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23
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Washio Y, Wright EN, Davis-Vogel A, Chittams J, Anagnostopulos C, Kilby LM, Teitelman AM. Prior Exposure to Intimate Partner Violence Associated With Less HIV Testing Among Young Women. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:NP2848-NP2867. [PMID: 29651922 PMCID: PMC6204109 DOI: 10.1177/0886260518768564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Low-income minority women are disproportionately represented among those living with HIV in the United States. They are also at risk for the SAVA (substance abuse, violence, and HIV/AIDS) syndemic issues. Women who have recently given birth are at high risk for substance use and intimate partner violence (IPV), and HIV testing is not routinely administered during the postpartum visit. We explored the relationship between substance use, IPV, and HIV testing among low-income young adult women attending Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federally supported nutrition program. A survey assessed substance use, relationships in particular with violence exposure, and HIV testing behavior in the past 6 months among a convenience sample of 100 women aged 18 to 30. The survey was conducted at several WIC offices in an urban setting in the Mid-Atlantic region between June and December 2015. Physical violence was the only IPV variable significantly associated (p = .022) with not being tested for HIV in the past 6 months, remaining significant even after adjusting for demographic and other significant variables (adjusted odds ratio [AOR] = 0.02; 95% confidence interval [CI] = [0.00, 0.41]). Women exposed to physical IPV or psychological IPV in the past year were significantly more likely to have ever used an illicit drug (physical IPV: 34% vs. 59%, p = .052; psychological IPV: 22% vs. 53%. p = .002). These findings between physical IPV and HIV testing history highlight the need to further understand how the context of violence affects HIV testing behaviors. Providing convenient, safe, and accessible HIV testing sites in spaces like WIC may increase HIV testing rates overall and specifically among women experiencing IPV.
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Affiliation(s)
- Yukiko Washio
- Christiana Care Health Services, Newark, DE, USA
- University of Delaware, Newark, USA
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24
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Abstract
OBJECTIVES To engage community members with opioid use disorder (OUD) and case managers working with pregnant and parenting individuals with OUD in a priority setting process to identify the key priorities for research, policy, and care improvement during pregnancy, birth, and postpartum. METHODS We conducted focus groups across Washington State with pregnant and parenting people with OUD and with case managers working with this community as part of research priority setting using the validated Research Prioritization by Affected Communities protocol. Priorities for research, policy, and service improvement were developed during each focus group by the participants. RESULTS Three focus groups with pregnant and parenting people with OUD and 2 focus groups with case managers were conducted (total N = 24 and 16, respectively). Both prioritized topics such as stigma and bias, housing, access to treatment, and steps toward successful recovery. The community and case manager groups shared similar, complementary strategies for each priority, with differences reflecting their perspectives in relation to OUD. CONCLUSIONS Community-engaged priority setting among those with OUD was an effective and meaningful way to guide future research, policy, and care improvement efforts.
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Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: Practical Applications and Clinical Impact. Obstet Gynecol Surv 2020; 75:175-189. [PMID: 32232496 DOI: 10.1097/ogx.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Opioid use disorder is increasingly common in the United States and affects many pregnancies. Given the rise in pregnancies complicated by opioid use, providers should understand the diagnosis and management of opioid use disorder in pregnancy. Objective This article focuses on screening for opioid misuse, selecting appropriate treatment for patients, initiating medication-assisted treatment in the inpatient setting, and providing appropriate peripartum care. Evidence Acquisition A PubMed search was undertaken using the following search terms: "opioid use disorder", "pregnancy," "medication assisted treatment," "buprenorphine," "methadone," "heroin," "addiction," "neonatal abstinence syndrome," and "detoxification." The search was limited to the English language publications, with most being published after 2000. Results All women should be screened for opioid use disorder during pregnancy. Opioid use has profound effects on the mother and infant. Medication-assisted treatment is the standard of care for pregnant women with opioid use disorder. Patients will require a multidisciplinary approach to management in the intrapartum and postpartum period. Conclusions Conclusions Opioid use disorder is a common, chronic condition with significant implications during pregnancy. Recognition and appropriate treatment of this disorder can optimize maternal and fetal outcomes. Conclusions Obstetricians are increasingly being challenged to manage pregnancies complicated by opioid use disorder and should be proficient in providing safe and effective care.
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Smid MC, Schauberger CW, Terplan M, Wright TE. Early lessons from maternal mortality review committees on drug-related deaths-time for obstetrical providers to take the lead in addressing addiction. Am J Obstet Gynecol MFM 2020; 2:100177. [PMID: 33345905 PMCID: PMC7753059 DOI: 10.1016/j.ajogmf.2020.100177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/17/2022]
Abstract
Problem: In the United States, maternal mortality review committees (MMRC) are providing compelling data that drug-related deaths are emerging as a leading cause of pregnancy-associated death (death during pregnancy or up to a year postpartum). Recommendations from the MMRC consistently highlight screening all pregnant and postpartum women for drug use and improving access to evidence-based substance use disorder and mental health treatment. Unfortunately, many providers lack the confidence, skills and necessary resources to screen for substance use, provide basic behavioral health services or facilitate referral to high-quality services in their clinical settings. Our profession’s collective lack of response to a leading cause of maternal death represents a missed opportunity for potentially life-saving interventions. A Solution: We call on our fellow obstetrician gynecologists to incorporate the lessons learned from MMRC and integrate addiction assessment and treatment into prenatal and postpartum care. Provider level integration of behavioral health services is, however, insufficient to fully address the magnitude of drug-related maternal deaths in the US. We, therefore, ask colleagues to address the structural/systemic barriers to care identified in MMRC. By doing so, we can prevent drug-related maternal deaths.
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Affiliation(s)
- Marcela C Smid
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and the Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.
| | - Charles W Schauberger
- Department of Obstetrics and Gynecology and Behavioral Health, Gundersen Health System, La Crosse, WI
| | | | - Tricia E Wright
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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27
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Paris R, Herriott AL, Maru M, Hacking SE, Sommer AR. Secrecy Versus Disclosure: Women with Substance Use Disorders Share Experiences in Help Seeking During Pregnancy. Matern Child Health J 2020; 24:1396-1403. [PMID: 33025236 DOI: 10.1007/s10995-020-03006-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Substance misuse during pregnancy can be harmful to the health of both mothers and infants. Existing recovery services or prenatal care for pregnant women with substance use disorders (SUD) in the U.S. and other countries typically fall short in providing the necessary specialized care women with SUDs need. Disclosure of substance misuse is one key factor in gaining access to specialized prenatal care; yet, barriers such as social stigma and internal shame and guilt lead many women to under-report any substance misuse during their pregnancy. This study sought to understand the process of how and why pregnant women with SUDs choose to disclose or not disclose their substance misuse to their providers when seeking prenatal care. METHODS Data were collected through interviews with N = 21 women with SUDs in the northeast U.S. whose young children had been exposed to opioids, cocaine, or MAT in utero. Thematic, inductive analysis using line-by-line coding was conducted to understand the perspectives of the women. RESULTS The women's narratives suggested a clear tension regarding whether to disclose their substance misuse to any providers during their pregnancy. Four themes describing the process of disclosure or non-disclosure were found, including reasons for and ways of being secret or choosing to disclose their substance misuse during pregnancy. CONCLUSIONS FOR PRACTICE The centrality of shame, guilt, and stigma regarding substance misuse must be addressed by medical and mental health providers in order to increase disclosure and improve access to care for women with SUDs.
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Affiliation(s)
- Ruth Paris
- Boston University School of Social Work, 264 Bay State Road, Boston, MA, 02215, USA.
| | - Anna L Herriott
- School of Social Service Administration, University of Chicago, Chapin Hall, Hyde Park Campus, Chicago, IL, 60637, USA
| | - Mihoko Maru
- Boston University School of Social Work, 264 Bay State Road, Boston, MA, 02215, USA
| | - Sarah E Hacking
- The Home for Little Wanderers, Preschool Outreach Program, 780 American Legion Highway, Roslindale, MA, 02131, USA
| | - Amy R Sommer
- Jewish Family & Children's Service, 1430 Main St., Waltham, MA, 02451, USA
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Byatt N, Masters GA, Bergman AL, Moore Simas TA. Screening for Mental Health and Substance Use Disorders in Obstetric Settings. Curr Psychiatry Rep 2020; 22:62. [PMID: 32936340 DOI: 10.1007/s11920-020-01182-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW The objective of this review is to describe the extent to which (1) obstetric settings are currently screening for mental health and substance use disorders and social determinants of health (SDoH), and (2) screening is followed by systematic approaches for ensuring an adequate response to positive screens. Additionally, clinical and policy implications of current screening practices and recommendations are discussed. RECENT FINDINGS Screening for perinatal depression in obstetric settings has increased. Despite their prevalence and negative impact, screening for other mental health and substance use disorders and SDoH is much less common and professional society recommendations are either nonexistent, less consistent, or less prescriptive. To truly address maternal mental health, we need to move beyond focusing solely on depression and address other mental health and substance use disorders and the contextual social determinants in which they occur.
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Affiliation(s)
- Nancy Byatt
- University of Massachusetts Medical School and UMass Memorial Health Care, 55 Lake Ave North, Worcester, MA, 01655, USA.
| | - Grace A Masters
- University of Massachusetts Medical School and UMass Memorial Health Care, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - Aaron L Bergman
- University of Massachusetts Medical School and UMass Memorial Health Care, 55 Lake Ave North, Worcester, MA, 01655, USA
| | - Tiffany A Moore Simas
- University of Massachusetts Medical School and UMass Memorial Health Care, 55 Lake Ave North, Worcester, MA, 01655, USA
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29
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Knittel AK, Zarnick S, Thorp JM, Amos E, Jones HE. Medications for opioid use disorder in pregnancy in a state women's prison facility. Drug Alcohol Depend 2020; 214:108159. [PMID: 32683223 PMCID: PMC7977476 DOI: 10.1016/j.drugalcdep.2020.108159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) improves both maternal and neonatal outcomes for pregnant women with opioid use disorder (OUD). Although correctional policies often state that incarcerated pregnant women with OUD should receive MOUD, implementation data is scant. Our aims were to 1) quantify the extent to which pregnant women in a Southeastern prison received MOUD during their incarceration; 2) to describe the medications and doses used during incarceration and frequency of MOUD referral after incarceration; and 3) identify associations between maternal characteristics and receipt of MOUD in order to identify points of intervention for clinical policy change. METHODS We conducted a retrospective chart review of pregnant women with OUD in a North Carolina state women's prison from 2016-2018. We collected MOUD, demographic, custody, pregnancy, and pre-incarceration substance use data. We used descriptive statistics, chi square tests, and logistic regression. RESULTS There were 179 pregnant women with OUD. During incarceration, 11.7 % received buprenorphine, 17.8 % methadone, 22.8 % oxycodone, and 47.8 % did not receive any opioid medications. Of those who received buprenorphine, methadone, and no MOUD, respectively, 65 %, 51.2 %, and 3.2 % were referred for community MOUD. Women were more likely to receive MOUD during incarceration if they had received MOUD pre-incarceration. CONCLUSIONS There was significant unmet need for MOUD and MOUD referral among pregnant women imprisoned in North Carolina from 2016-2018. Our findings suggest that the initial assessment for MOUD and referral to a community MOUD provider may represent opportunities to improve MOUD access for this population.
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Affiliation(s)
- Andrea K. Knittel
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | - John M. Thorp
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Elton Amos
- North Carolina Department of Public Safety, Raleigh, NC
| | - Hendree E. Jones
- UNC Horizons, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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30
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Preis H, Garry DJ, Herrera K, Garretto DJ, Lobel M. Improving Assessment, Treatment, and Understanding of Pregnant Women With Opioid Use Disorder: The Importance of Life Context. ACTA ACUST UNITED AC 2020. [DOI: 10.1080/23293691.2020.1780395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Heidi Preis
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
| | - David J. Garry
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Kimberly Herrera
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Diana J. Garretto
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Marci Lobel
- Department of Psychology, Stony Brook University, Stony Brook, New York, USA
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31
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Zanardo V, Parotto M, Manghina V, Giliberti L, Volpe F, Severino L, Straface G. Pain and stress after vaginal delivery: characteristics at hospital discharge and associations with parity. J OBSTET GYNAECOL 2020; 40:808-812. [PMID: 31814477 DOI: 10.1080/01443615.2019.1672140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The objective of this study was to characterise pre-discharge maternal pain and stress severity after vaginal delivery and associations with parity. This is a descriptive analysis with 148 women in the early post-partum period (84 primiparae and 64 secondiparae) after vaginal delivery. Pain and stress were measured by McGill Pain Questionnaire (MGPQ) and by the Psychological Stress Measure (PSM). Vaginal delivery in primiparae women was associated with MGPQ, significantly higher pain scores. Sensorial, affective and mixed pain descriptive categories were also significantly higher. Pain location involved lower abdomen, vagina and perianal area. In addition, their PSM showed a significantly higher 'Sense of effort and confusion' subscale scores. In conclusion, this study provides important information on the quality of care implications of hospital-to-home discharge practices in puerperae after vaginal delivery, a critical time characterised by qualitatively and quantitatively high pain and stress in primiparae.Impact statementWhat is already known on this subject? Pain and fatigue are the most common problems reported by women in the early postpartum period.What the results of this study add? Primiparae who delivered vaginally presented at the time of hospital-to-home discharge significantly higher pain and stress, as compared to secondiparae. Pain involved lower abdomen, vagina and perianal area, whereas the stress was quantitatively higher in the 'sense of effort and confusion'.What the implications are of these findings for clinical practice and/or further research? Awareness of problematic pain and stress associations with parity may offer the opportunity to better support puerperae to develop maternal orientation and adjust to motherhood.
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Affiliation(s)
- Vincenzo Zanardo
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Matteo Parotto
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Valeria Manghina
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Lara Giliberti
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Francesca Volpe
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Lorenzo Severino
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
| | - Gianluca Straface
- Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy.,Department of Anesthesia, University of Toronto, Toronto, Canada
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32
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Faherty LJ, Stein BD, Terplan M. Consensus Guidelines and State Policies: The Gap Between Principle and Practice at the Intersection of Substance Use and Pregnancy. Am J Obstet Gynecol MFM 2020; 2:100137. [PMID: 33089133 DOI: 10.1016/j.ajogmf.2020.100137] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The opioid crisis has had a substantial effect on women who are pregnant and parenting, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. There is overwhelming consensus on the principle of a non-punitive approach towards substance use in pregnancy. Experts universally endorse supportive policies, which reduce barriers to care, and oppose punitive policies, which can increase the fear of legal penalties, discouraging women from seeking prenatal care and addiction treatment during pregnancy. We review the change over time in state-level policy environments around substance use in pregnancy and contrast the policy response with the principles and guidance from professional societies and federal agencies. Between 2000 and 2015, more states adopted punitive policies than supportive policies, in direct contrast with guidance from professional societies and federal agencies. The increase in punitive policies over the past two decades suggests that the gap between principles and practice is widening. Furthermore, the increase in punitive policies is occurring in the context of significant structural barriers to comprehensive health care across the woman's entire life course, a growing awareness of racial and ethnic inequities in maternal morbidity and mortality, and increasing restrictions at the state level on abortion access. Women with substance use disorder (SUD) need comprehensive, coordinated, evidence-based, trauma-informed, family-centered care. This care should be delivered in a compassionate and non-punitive environment, and clinicians, policymakers, and public health officials all have a role to play in achieving this goal.
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Affiliation(s)
- Laura J Faherty
- Boston, MA, RAND Corporation and Boston University School of Medicine Department of Pediatrics
| | - Bradley D Stein
- Pittsburgh, PA, RAND Corporation and University of Pittsburgh School of Medicine
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Moreland A, Hartley C, DelMas S, McRae-Clark A. Examining Stressors and Available Parenting Resources for Opioid-Using Mothers: Qualitative Findings from an Inpatient Substance Use Treatment Program. Community Ment Health J 2020; 56:426-434. [PMID: 31630288 PMCID: PMC7885178 DOI: 10.1007/s10597-019-00478-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 09/24/2019] [Indexed: 11/28/2022]
Abstract
Given the alarming opioid epidemic, high prevalence of parents involved in substance use treatment programs for opioid use disorder, and critical role that parenting stress plays on opioid use and relapse, the current study examines stressors experienced by mothers enrolled in substance use treatment. Specifically, interviews were conducted with mothers with opioid use disorder (OUD) enrolled in an inpatient substance use treatment program, to identify common themes and develop recommendations related to interventions targeting common stressors among this population. A significant number of parent-related, substance use-related, and other stressors were present prior to and during substance use treatment; with more stressors reported during treatment than prior to treatment. Mothers with OUD reported that they would be interested in receiving parenting services, but that relevant parenting resources were not offered during substance use treatment.
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Affiliation(s)
- A Moreland
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, 29425, USA.
| | - C Hartley
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - S DelMas
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - A McRae-Clark
- National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC, 29425, USA
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National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder. Obstet Gynecol 2020; 134:365-375. [PMID: 31306323 DOI: 10.1097/aog.0000000000003381] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.
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35
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Ko JY, Tong VT, Haight SC, Terplan M, Stark L, Snead C, Schulkin J. Obstetrician-gynecologists' practices and attitudes on substance use screening during pregnancy. J Perinatol 2020; 40:422-432. [PMID: 31666646 PMCID: PMC7047638 DOI: 10.1038/s41372-019-0542-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/29/2019] [Accepted: 10/20/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To describe obstetrician-gynecologists' practices and attitudes related to substance use screening in pregnant patients. STUDY DESIGN A 2017 cross-sectional survey assessed US obstetrician-gynecologists' (n = 462; response rate = 34%) practices (substance use screening frequency and methods) and attitudes (practice priority of screening, confidence in treating, and responsibility statements). Chi-squared tests and adjusted modified Poisson regression were used to estimate associations between practices and attitudes. RESULTS Of 353 respondents with screening information, 79% frequently screen for substance use and 11% used a validated instrument. Confidence was the highest for treating pregnant patients using tobacco (81%). Respondents whose practices make it a high priority to screen for all substances were 1.2 times as likely to frequently screen as their counterparts (95% CI: 1.1-1.3). CONCLUSIONS Four out of five obstetricians-gynecologists reported a high frequency of substance use screening in pregnant patients. Findings highlight the importance of increasing priority of substance use screening by obstetrician-gynecologists.
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Affiliation(s)
- Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S107-2, Atlanta, GA, 30341, USA.
- United States Public Health Service, Commissioned Corps, Rockville, MD, 20857, USA.
| | - Van T Tong
- Division of Congenital and Developmental Disorders, National Center for Birth Defects and Developmental Disorders, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S106-3, Atlanta, GA, 30341, USA
| | - Sarah C Haight
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S107-2, Atlanta, GA, 30341, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave Suite 103, Baltimore, MD, 21201, USA
| | - Lauren Stark
- Research Department, American College of Obstetricians and Gynecologists (ACOG), 409 12th Street SW, Washington, DC, 20024, USA
| | - Carrie Snead
- Research Department, American College of Obstetricians and Gynecologists (ACOG), 409 12th Street SW, Washington, DC, 20024, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Box 356460, Seattle, WA, 98195, USA
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36
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Meinhofer A, Hinde JM, Ali MM. Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings. J Subst Abuse Treat 2019; 110:9-17. [PMID: 31952630 DOI: 10.1016/j.jsat.2019.12.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/28/2019] [Accepted: 12/05/2019] [Indexed: 12/22/2022]
Abstract
The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.
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Affiliation(s)
- Angélica Meinhofer
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America.
| | - Jesse M Hinde
- RTI International, Behavioral Health Research Division, Research Triangle Park, NC, United States of America
| | - Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health & Human Services, Washington, DC, United States of America
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37
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Martin CE, Terplan M, Krans EE. Pain, Opioids, and Pregnancy: Historical Context and Medical Management. Clin Perinatol 2019; 46:833-847. [PMID: 31653311 DOI: 10.1016/j.clp.2019.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, 1250 East Marshall Street, Richmond, VA 23298-0268, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave, Suite 103, Baltimore MD 21202, USA.
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213, USA
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Abstract
PURPOSE OF REVIEW Perinatal opioid use is a major public health problem and is associated with a number of deleterious maternal and fetal effects. We review recent evidence of perinatal outcomes and treatment of opioid use disorder (OUD) during pregnancy. RECENT FINDINGS Opioid exposure in pregnancy is associated with multiple obstetric and neonatal adverse outcomes, with the most common being neonatal opioid withdrawal syndrome (NOWS). Treatment with buprenorphine or methadone is associated with NOWS, but neither medication appears to have significant adverse effects on early childhood development. Buprenorphine appears to be superior to methadone in terms of incidence and severity of NOWS in exposed infants. The long-term effects of opioid exposure in utero have been inconclusive, but recent longitudinal studies point to potential differences in brain morphology that may increase vulnerability to future stressors. Maintenance therapy with methadone or buprenorphine remains the standard of care for pregnant women with OUD given its consistent superiority to placebo in terms of rates of illicit drug use and pregnancy outcomes. New non-pharmacologic management options for NOWS appear promising. Future research is needed to further evaluate the effects of opioid exposure in utero and determine the optimal delivery model for maintenance therapy.
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Affiliation(s)
- Amalia Londono Tobon
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Erin Habecker
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA.
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Care and Treatment Recommendations for Pregnant Women with Opioid Use Disorder. MCN Am J Matern Child Nurs 2019; 44:212-218. [DOI: 10.1097/nmc.0000000000000538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Krans EE, Kim JY, James AE, Kelley D, Jarlenski MP. Medication-Assisted Treatment Use Among Pregnant Women With Opioid Use Disorder. Obstet Gynecol 2019; 133:943-951. [PMID: 30969219 PMCID: PMC6483844 DOI: 10.1097/aog.0000000000003231] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate temporal trends in medication-assisted treatment use among pregnant women with opioid use disorder. METHODS We conducted a retrospective cohort study using Pennsylvania Medicaid administrative data. Trends in medication-assisted treatment use, opioid pharmacotherapy (methadone and buprenorphine) and behavioral health counselling, were calculated using pharmacy records and procedure codes. Cochrane-Armitage tests evaluated linear trends in characteristics of pregnant women using methadone compared with buprenorphine. RESULTS In total, we evaluated 12,587 pregnancies among 10,741 women with opioid use disorder who had a live birth between 2009 and 2015. Across all years, 44.1% of pregnant women received no opioid pharmacotherapy, 27.1% used buprenorphine, and 28.8% methadone. Fewer than half of women had any behavioral health counseling during pregnancy. The adjusted prevalence of methadone use declined from 31.6% (95% CI 29.3-33.9%) in 2009 to 25.2% (95% CI 23.3-27.1%) in 2015, whereas the adjusted prevalence of buprenorphine use increased from 15.8% (95% CI 13.9-17.8%) to 30.9% (95% CI 28.8-33.0%). Greater increases in buprenorphine use were found in geographic regions with large metropolitan centers, such as the Southwest (plus 24.9%) and the Southeast (plus 12.0%), compared with largely rural regions, such as the New West (plus 5.2%). In 2015, the adjusted number of behavioral health counseling visits during pregnancy was 3.4 (95% CI 2.6-4.1) among women using buprenorphine, 4.0 (95% CI 3.3-4.7) among women who did not use pharmacotherapy, and 6.4 (95% CI 4.9-7.9) among women using methadone. CONCLUSION Buprenorphine use among Medicaid-enrolled pregnant women with opioid use disorder increased significantly over time, with a small concurrent decline in methadone use. Behavioral health counseling use was low, but highest among women using methadone.
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Affiliation(s)
- Elizabeth E Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, and the Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, and the Pennsylvania Department of Human Services, Harrisburg, Pennsylvania
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Abstract
Pregnancy presents a window of opportunity for effecting positive change in the lives of women with opioid use disorder (OUD). Care should be empathetic and nonjudgmental with a focus on counseling for initiation and maintenance of beneficial health behaviors as well as development of a strong patient-provider relationship.1 These include adherence to treatment of OUD through pharmacotherapy and behavioral counseling, smoking cessation, healthy nutrition, treatment of coexisting medical and psychosocial conditions, as well as preparation for the postpartum period through breastfeeding education and antenatal discussion of contraception. Women will also benefit from anticipatory guidance with regard to neonatal abstinence syndrome (see Chapter 7). This may include a consultation with pediatric or neonatal providers who will be caring for their infants. In the absence of other obstetric indications, minimal additional fetal assessment outside that of standard prenatal care is recommended for OUD.
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Affiliation(s)
- Emily W Rosenthal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, 833 Chestnut Street, Philadelphia, PA, United States.
| | - Jason K Baxter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, 833 Chestnut Street, Philadelphia, PA, United States
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Patton BP, Krans EE, Kim JY, Jarlenski M. The impact of Medicaid expansion on postpartum health care utilization among pregnant women with opioid use disorder. Subst Abus 2019; 40:371-377. [PMID: 30908175 DOI: 10.1080/08897077.2019.1573209] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Opioid use disorder (OUD) during pregnancy has increased dramatically over the past decade, as have associated adverse maternal health outcomes. Although Medicaid has long been the largest payer for deliveries in the United States, states' decisions to expand Medicaid eligibility to low-income adults has the potential to increase access to care for women in the postpartum period. This study aimed to determine the impact of the 2015 Pennsylvania Medicaid expansion on postpartum insurance coverage and preventive care utilization among pregnant women with opioid use disorder (OUD). Methods: In 2017, we conducted a retrospective cohort study using 2013-2015 administrative Medicaid data provided by the Pennsylvania Department of Human Services. We identified 1562 women with opioid use disorder who had a live birth delivery in a pre-Medicaid expansion or post-expansion study period. We compared length of continuous enrollment in Medicaid following delivery, postpartum visit attendance, and contraception initiation between groups. Results: More women in the post-expansion group remained enrolled in Medicaid at 300 days postpartum, relative to the pre-expansion group (87% vs. 81%). Medicaid expansion was not associated with differences in postpartum visit attendance or contraceptive use. However, women who remained enrolled in Medicaid for at least 300 days post delivery had an increased odds of postpartum visit attendance (odds ratio [OR]: 1.6, 95% confidence interval [CI]: 1.04, 2.4). Conclusion: The rate of continuous Medicaid enrollment among postpartum women with OUD was significantly higher after expansion, whereas rates of preventive care utilization were unaffected. Although improving insurance coverage for women with OUD is an important step to improve access to recommended preventive care, additional efforts are needed to ensure utilization of such care.
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Affiliation(s)
- Briana P Patton
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Joo Yeon Kim
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Health Policy Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Gressler LE, Shah S, Shaya FT. Association of Criminal Statutes for Opioid Use Disorder With Prevalence and Treatment Among Pregnant Women With Commercial Insurance in the United States. JAMA Netw Open 2019; 2:e190338. [PMID: 30848807 PMCID: PMC6484651 DOI: 10.1001/jamanetworkopen.2019.0338] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Inadequate treatment of opioid use disorder (OUD) in pregnant women increases the risk of life-threatening consequences on maternal and fetal outcomes. Untreated OUD during pregnancy is associated with higher rates of adverse outcomes among newborns. OBJECTIVE To examine the variation in the prevalence of OUD and the use of medication-assisted treatment among commercially insured pregnant women according to region and state legislature. DESIGN, SETTING, AND PARTICIPANTS Cohort study in which the patient cohort used was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus adjudicated claims and enrollment database from 2007 to 2015. The database consists of a 10% random sample of private health insurance recipients in the United States and contains claims and enrollment data that are representative of the commercially insured US population. The cohort comprised women (n = 110 285) between 18 and 45 years of age with a code indicating a delivery and continuous insurance enrollment 9 months before and 12 months after delivery. Data analysis was performed from December 2017 to May 2018. EXPOSURES Based on their state of residence, the women were classified into 4 different regions: South, Midwest, West, and Northeast. Those residing in states with statutes that imposed civil or criminal penalties for OUD diagnosis during pregnancy were placed in a separate population from those residing in states without these statutes. MAIN OUTCOMES AND MEASURES Diagnosis of OUD in the 9 months before delivery and the receipt of medication-assisted treatment in the 9 months before or 12 months after delivery. RESULTS The 110 285 pregnant women included in the analysis had a mean (SD) age of 30.26 (5.59) years, with most (67 771 [61.5%]) falling within the 26- to 35-year age range. Of this cohort, 277 women (0.25%) had a diagnosis of OUD and 312 (0.28%) received treatment. Among the 277 women with OUD, 127 (45.9%) received treatment. The prevalence of an OUD diagnosis and receipt of treatment within regions was statistically significant (OUD diagnosis by region: Midwest, 0.05%; North, 0.09%; South, 0.06%; West, 0.06%; χ23 = 45.1148 [P < .001]; OUD treatment by region: Midwest, 0.05%; North, 0.08%; South, 0.10%; West, 0.05%; χ23 = 26.5654 [P < .001]). The prevalence of OUD diagnosis was also statistically significant when comparing women residing in states with statutes with those in states without statutes (OUD diagnosis by criminal statutes: criminalization, 0.07%; no criminalization, 0.18%; χ21 = 14.6456 [P < .001]; OUD treatment by criminal statutes: criminalization, 0.12%; no criminalization, 0.17%; χ21 = 0.0895); the receipt of treatment was not statistically significant (P = .76). CONCLUSIONS AND RELEVANCE These results appeared to show significant variations in the patterns of OUD diagnosis and receipt of medication-assisted treatment among pregnant women, suggesting the need to further explore the source of these variations.
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Affiliation(s)
- Laura E Gressler
- Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
| | - Savyasachi Shah
- Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
| | - Fadia T Shaya
- Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore
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Hodgins FE, Lang JM, Malseptic GG, Melby LH, Connolly KA. Coordinating Outpatient Care for Pregnant and Postpartum Women with Opioid Use Disorder: Implications from the COACHH Program. Matern Child Health J 2019; 23:585-591. [DOI: 10.1007/s10995-018-2683-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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McGlothen KS, Cleveland LM. The Right to Mother's Milk: A Call for Social Justice That Encourages Breastfeeding for Women Receiving Medication-Assisted Treatment for Opioid Use Disorder. J Hum Lact 2018; 34:799-803. [PMID: 30040908 DOI: 10.1177/0890334418789401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kelly S McGlothen
- 1 School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Lisa M Cleveland
- 1 School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Tan KZ, Cunningham AM, Joshi A, Oei JL, Ward MC. Expression of kappa opioid receptors in developing rat brain - Implications for perinatal buprenorphine exposure. Reprod Toxicol 2018; 78:81-89. [PMID: 29635048 DOI: 10.1016/j.reprotox.2018.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/03/2018] [Accepted: 04/06/2018] [Indexed: 12/19/2022]
Abstract
Buprenorphine, a mu opioid receptor partial agonist and kappa opioid receptor (KOR) antagonist, is an emerging therapeutic agent for maternal opioid dependence in pregnancy and neonatal abstinence syndrome. However, the endogenous opioid system plays a critical role in modulating neurodevelopment and perinatal buprenorphine exposure may detrimentally influence this. To identify aspects of neurodevelopment vulnerable to perinatal buprenorphine exposure, we defined KOR protein expression and its cellular associations in normal rat brain from embryonic day 16 to postnatal day 23 with double-labelling immunohistochemistry. KOR was expressed on neural stem and progenitor cells (NSPCs), choroid plexus epithelium, subpopulations of cortical neurones and oligodendrocytes, and NSPCs and subpopulations of neurones in postnatal hippocampus. These distinct patterns of KOR expression suggest several pathways vulnerable to perinatal buprenorphine exposure, including proliferation, neurogenesis and neurotransmission. We thus suggest the cautious use of buprenorphine in both mothers and infants until its impact on neurodevelopment is better defined.
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Affiliation(s)
- Kathleen Z Tan
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia
| | - Anne M Cunningham
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia; Westfield Research Laboratories, Sydney Children's Hospital, High Street, Randwick, NSW 2031, Australia.
| | - Anjali Joshi
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia; Westfield Research Laboratories, Sydney Children's Hospital, High Street, Randwick, NSW 2031, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia; The Royal Hospital for Women, Barker Street, Randwick, NSW 2031, Australia
| | - Meredith C Ward
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia; The Royal Hospital for Women, Barker Street, Randwick, NSW 2031, Australia; Westfield Research Laboratories, Sydney Children's Hospital, High Street, Randwick, NSW 2031, Australia.
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Abstract
Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.
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Affiliation(s)
- Amanda J Johnson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Cresta W Jones
- Department of Obstetrics, Gynecology and Women's Health, Division of Maternal-Fetal Medicine, University of Minnesota Medical School, 606 24th Avenue S, Suite 400, Minneapolis, MN 55455, USA.
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Mental Health of Mothers of Infants with Neonatal Abstinence Syndrome and Prenatal Opioid Exposure. Matern Child Health J 2018; 22:841-848. [DOI: 10.1007/s10995-018-2457-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med 2018; 11:178-190. [PMID: 28406856 PMCID: PMC5457836 DOI: 10.1097/adm.0000000000000308] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children. METHODS Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized. RESULTS Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports. CONCLUSIONS Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.
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Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (SLK); JBS International, Inc., North Bethesda, MD (KI, AL, JP, SH, JV); Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD (MC); UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (HEJ); Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD (HEJ)
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