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Milligan K, Tarasoff LA, Rodrigues ER, Iwajomo T, Gomes T, de Oliveira C, Brown HK, Urbanoski KA. Neonatal outcomes of pregnant women attending integrated and standard substance use treatment programs in Ontario, Canada. Birth 2024; 51:284-294. [PMID: 37983747 DOI: 10.1111/birt.12784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/01/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Substance use in pregnancy raises concern given its potential teratogenic effects. Given the unique needs of parenting people and the potential impact for developing children, specialized substance use treatment programs are increasingly being implemented for this population. Substance use treatment is associated with more positive neonatal outcomes compared with no treatment, however treatment models vary limiting our understanding of key treatment components/modelsFew studies have explored the influence of treatment model type (i.e., integrated treatments designed for pregnant clients compared with standard treatment models) and no studies have examined the influence of treatment model on neonatal outcomes using Canadian data. METHOD We conducted a population-based cohort study of clients who were pregnant when initiating integrated (n = 564) and standard (n = 320) substance use treatment programs in Ontario, Canada. RESULTS Neonatal outcomes did not significantly differ by treatment type (integrated or standard), with rates of adverse neonatal outcomes higher than published rates for the general population, despite receipt of adequate levels of prenatal care. While this suggests no significant impact of treatment, it is notable that as a group, clients engaged in integrated treatment presented with more risk factors for adverse neonatal outcomes than those in standard treatment. While we controlled for these risks in our analyses, this may have obscured their influence in relation to treatment type. CONCLUSION Findings underscore the need for more nuanced research that considers the influence of client factors in interaction with treatment type. Pregnant clients engaged in any form of substance use treatment are at higher risk of having children who experience adverse neonatal outcomes. This underscores the urgent need for further investment in services and research to support maternal and neonatal health before and during pregnancy, as well as long-term service models that support women and children beyond the perinatal and early childhood periods.
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Affiliation(s)
- Karen Milligan
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Lesley A Tarasoff
- Department of Health & Society, University of Toronto Scarborough, Toronto, Ontario, Canada
| | - Erica R Rodrigues
- Department of Psychology, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Tomisin Iwajomo
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Claire de Oliveira
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hilary K Brown
- Department of Health & Society, University of Toronto Scarborough, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Karen A Urbanoski
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada
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McNamara KA, Murnion B, Fotheringham P, Terplan M, Lintzeris N, Oei JL, Bond DM, Nassar N, Black KI. Interconnections between unintended pregnancy, alcohol and other drug use, and pregnancy, birth, infant, childhood and socioeconomic outcomes: a scoping review. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024:bmjsrh-2023-202140. [PMID: 38471787 DOI: 10.1136/bmjsrh-2023-202140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Unintended pregnancy (UIP) and substance use disorder share underlying root causes with similar impacts for women and their offspring in pregnancy, birth and beyond. Furthermore, intoxication with alcohol and other drugs (AOD) increases the risk of UIP. OBJECTIVES To assess the available evidence on associations between UIP and health, social and economic outcomes, in women who use AOD. SEARCH STRATEGY The review utilised the Joanna Briggs Institute Methodology for Scoping Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. The search was conducted across multiple databases, including Scopus and Medline, and limited to studies published between January 2000 to June 2023. SELECTION CRITERIA Studies reporting on interactions between AOD use and UIP, and pregnancy, birth, infant, childhood, social or economic outcomes. All patterns and types of AOD use, except isolated use of tobacco, were included. Studies were available in English and conducted in high-income countries. DATA COLLECTION AND ANALYSIS Selected articles were reviewed, and data collected by two independent reviewers using a standardised data extraction sheet. Findings were summarised and reported descriptively. MAIN RESULTS A total of 2536 titles and abstracts were screened, 97 full texts were reviewed, and three studies were selected for inclusion in the scoping review. There was heterogeneity in types and patterns of AOD use, differences in study design and tools to assess pregnancy intention, and each focused on disparate outcomes. No study assessed or reported on birth outcomes. CONCLUSION There is a paucity of data examining the intersection between AOD use and UIP and further research is needed.
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Affiliation(s)
- Kelly A McNamara
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Bridin Murnion
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Penelope Fotheringham
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- MotherSafe Counselling Service, The Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Mishka Terplan
- Friends Research Institute Inc, Baltimore, Maryland, USA
| | - Nicholas Lintzeris
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Kogarah, New South Wales, Australia
| | - Ju Lee Oei
- Faculty of Medicine & Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Diana M Bond
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Natasha Nassar
- Child Population and Translational Health Research, Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten I Black
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Jilani SM, Davis JM, Grossman M, Jones HE, Terplan M, Jansson LM. A Dyadic Framework of Care for Opioid-exposed Birthing Persons and Their Infants and Children. J Pediatr 2024; 266:113893. [PMID: 38142930 DOI: 10.1016/j.jpeds.2023.113893] [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: 07/20/2023] [Revised: 12/07/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE To develop a dyadic-centered framework focused on clinical care, surveillance, and research for birthing persons with opioid use disorder (OUD) and their infants and children. STUDY DESIGN Between February and March 2023, an analysis was conducted within the US Department of Health and Human Services (HHS) of activities directed at opioid-exposed birthing persons and their infants and children (the dyad) to identify: 1) number of activities, stratified by type and 2) characteristics across health and supportive activities that serve the dyad vs birthing persons or infants and children individually. Descriptive and thematic analyses were used to assess quantity and characteristics of fiscal year 2023-2024 activities aggregated across eleven HHS agencies. RESULTS Of 181 activities examined, 75 met inclusion criteria specific to serving birthing persons with OUD and opioid-exposed infants and children. Sixty-two percent of activities were dyad focused. Five categories of dyadic activities were identified: research (45%), education and training (28%), health and supportive services (21%), surveillance (4%), and quality improvement (2%). Eight specific characteristics were key to dyadic activities: a life course and generational approach, emphasis on relationship, dyadic outcomes, service wraparound, payment structures supporting dyadic care, data linkage, and social determinants of health. CONCLUSIONS This analysis of HHS activities directed at birthing persons with OUD and opioid-exposed infants and children showed that most programs had a dyadic focus. Synthesizing elements identified from activities serving the dyad facilitated the development of a dyadic framework integrating clinical care, public health surveillance, and research.
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Affiliation(s)
- Shahla M Jilani
- Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, Washington, DC.
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Medical Center, Boston, MA and The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Lauren M Jansson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Johnson A, Swenson KS, Dillner E, Klie KA, Duncan R, Brandspigel S, Breen K. Addressing Perinatal Substance Use: A Triad Approach Led by the Colorado Perinatal Care Quality Collaborative. J Midwifery Womens Health 2024. [PMID: 38339840 DOI: 10.1111/jmwh.13615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/06/2023] [Indexed: 02/12/2024]
Abstract
Unintentional overdose is a leading driver of maternal death in Colorado. The high volume of maternal deaths from preventable causes lends questions to failures in our clinical and community-based care for pregnant and postpartum people. The Colorado Maternal Mortality Review Committee identified 3 main contributors including stigma in the community and health care system, fragmentation of the health care system, and the need for more clinician training. The Colorado Perinatal Care Quality Collaborative led a 3-pronged intervention to address these challenges and improve perinatal care. The first intervention, the Colorado Alliance for Innovation on Maternal Health Substance Use Disorder quality improvement initiative, partnered with birthing hospitals statewide to institute universal screening and timely referral for individuals at risk of substance use disorder (SUD) and perinatal mood and anxiety disorders. The second intervention, the Improve Perinatal Access, Coordination, and Treatment for Behavioral Health initiative, established a perinatal support network within communities. This program assists individuals with SUD, perinatal mood and anxiety disorders, or social needs to navigate the perinatal period. The third intervention, the Colorado Maternal Overdose Matters Plus program, has enhanced in-hospital access to pharmacotherapy for pregnant and postpartum individuals with SUD through training and technical support. These collaborative initiatives aim to minimize barriers to care by integrating inpatient screening, treatment referrals, pharmacotherapy access, and community care support to mitigate maternal mortality in Colorado.
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Affiliation(s)
- Amber Johnson
- Colorado Perinatal Care Quality Collaborative, Denver, Colorado
| | - Karli S Swenson
- Colorado Perinatal Care Quality Collaborative, Denver, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elena Dillner
- Colorado Perinatal Care Quality Collaborative, Denver, Colorado
| | - Kaylin A Klie
- The Naloxone Project, Denver, Colorado
- Departments of Family Medicine and Psychiatry, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Katie Breen
- Colorado Perinatal Care Quality Collaborative, Denver, Colorado
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Apsley HB, Brant K, Brothers S, Harrison E, Skogseth E, Schwartz RP, Jones AA. Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057231224181. [PMID: 38362719 PMCID: PMC10874161 DOI: 10.1177/17455057231224181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/14/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Women face unique barriers when seeking treatment for substance use disorders, often related to pregnancy and parenting. OBJECTIVES This study adds to the extant literature by elucidating the pregnancy- and parenting-related barriers women face when initiating or continuing medication for opioid use disorder, specifically. DESIGN This study is based on qualitative semi-structured interviews. METHODS Three subgroups participated in semi-structured interviews regarding their experiences (N = 42): women with current or past opioid use disorders who have used or were presently using medication for opioid use disorder, professionals working in substance use disorder treatment programs, and criminal justice professionals. RESULTS Three parenting-related subthemes were identified: (1) insufficient access to childcare to navigate appointments and meetings, (2) fear of losing custody of, or access to, one's children, and (3) prioritizing one's children's needs before one's own. Three subthemes were identified with regard to pregnancy as a barrier: (1) hesitancy among physicians to prescribe medication for opioid use disorder for pregnant patients, (2) limited access to resources in rural areas, and (3) difficulty navigating a complex, decentralized health system. CONCLUSION Systemic changes are needed to reduce pregnant and parenting women's barriers to seeking medication for opioid use disorder. These include improved childcare support at both in-patient and outpatient treatment programs, which would assuage women's barriers related to childcare, as well as their fears of losing access to their children if they spend time away from their children for treatment. An additional systemic improvement that may reduce barriers for these women is access to comprehensive, integrated care for their prenatal care, postpartum care, pediatric appointments, and appropriate substance use disorder treatment.
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Affiliation(s)
- Hannah B Apsley
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Kristina Brant
- Department of Agricultural Economics, Sociology, and Education, The Pennsylvania State University, University Park, PA, USA
| | - Sarah Brothers
- Department of Sociology and Criminology, The Pennsylvania State University, University Park, PA, USA
| | - Eric Harrison
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Emma Skogseth
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | | | - Abenaa A Jones
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Townsel C, Irani S, Buis C, Lasser S, Menke N, Preston Y, Kountanis JA, Skoczylas M, Menke R, Getty B, Stout M, Muzik M. Partnering for the future clinic: A multidisciplinary perinatal substance use program. Gen Hosp Psychiatry 2023; 85:220-228. [PMID: 37992465 DOI: 10.1016/j.genhosppsych.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/29/2023] [Accepted: 10/13/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes. METHODS We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed. RESULTS Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched. CONCLUSIONS Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.
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Affiliation(s)
- Courtney Townsel
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Sanaya Irani
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America; University of Michigan Medical School, United States of America
| | - Carol Buis
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Sheryl Lasser
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Nathan Menke
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America
| | - Yolanda Preston
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America
| | - Joanna A Kountanis
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States of America
| | - Maria Skoczylas
- University of Michigan Medical School, United States of America; Department of Pediatrics, University of Michigan, Ann Arbor, MI, United States of America
| | - Rena Menke
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America
| | - Barbara Getty
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Molly Stout
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
| | - Maria Muzik
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America; Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States of America.
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Mazel S, Alexander K, Cioffi C, Terplan M. Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls. Subst Abuse Rehabil 2023; 14:49-59. [PMID: 37424702 PMCID: PMC10327918 DOI: 10.2147/sar.s375652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 06/27/2023] [Indexed: 07/11/2023] Open
Abstract
There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.
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Affiliation(s)
- Shayna Mazel
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | | | - Camille Cioffi
- Center on Parenting and Opioids, Prevention Science Institute, University of Oregon, Eugene, OR, USA
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Charron E, Yu Z, Lundahl B, Silipigni J, Okifuji A, Gordon AJ, Baylis JD, White A, Carlston K, Abdullah W, Haaland B, Krans EE, Smid MC, Cochran G. Cluster analysis to identify patient profiles and substance use patterns among pregnant persons with opioid use disorder. Addict Behav Rep 2023; 17:100484. [PMID: 36844693 PMCID: PMC9950438 DOI: 10.1016/j.abrep.2023.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/23/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The study objective was to identify distinct profiles of pregnant persons with opioid use disorder (PP-OUD) using cluster analysis and examine difference in substance use patterns between profiles. We examined data from 104 PP-OUD ≤ 32 weeks of gestation who were recruited into a behavioral health clinical trial at two academic medical centers. We used Partitioning Around Medoids analysis to identify clusters and explored patterns of substance use and substance use treatment between clusters using bivariate statistical tests and regression methods. We identified two distinct clusters of participants, including 'Group A' (n = 68; 65.4 %) and 'Group B' (n = 36; 34.6 %). Group A had fewer members who were not employed (38 % vs 58 %) and incarcerated (3 % vs 8 %) compared to Group B. Group A compared with Group B included more members with: a history of overdose (72 % vs 50 %); anxiety (85 % vs 25 %); ≥moderate pain (76 % vs 22 %); ≥moderate depression (75 % vs 36 %); ≥moderate drug use severity (94 % vs 78 %); and, more days of cannabis (mean: 6.2 vs 2.3 days), stimulant (mean: 4.5 vs 1.3 days), and injection heroin (mean: 1.3 vs 0 days) use in the past 30 days (P < 0.05 for all comparisons). Clusters of PP-OUD differed with respect to sociodemographic characteristics, mental health conditions, and substance use patterns. More research is needed to confirm identified profiles and assess treatment outcomes associated with cluster membership.
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Affiliation(s)
- Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma, Schusterman Center, Tulsa, OK, United States
- Program of 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, United States
| | - Ziji Yu
- Program of 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, United States
| | - Brad Lundahl
- College of Social Work, University of Utah, Salt Lake City, UT, United States
| | - John Silipigni
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Akiko Okifuji
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Adam J. Gordon
- Program of 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, United States
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Jacob D. Baylis
- Program of 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, United States
| | - Ashley White
- Program of 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, United States
| | - Kristi Carlston
- Program of 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, United States
| | - Walitta Abdullah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Elizabeth E. Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions (Magee CARES), Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Marcela C. Smid
- Program of 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, United States
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, United States
| | - Gerald Cochran
- Program of 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, United States
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Kropp FB, Smid MC, Lofwall MR, Wachman EM, Martin PR, Murphy SM, Wilder CM, Winhusen TJ. Collaborative care programs for pregnant and postpartum individuals with opioid use disorder: Organizational characteristics of sites participating in the NIDA CTN0080 MOMs study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209030. [PMID: 37023858 DOI: 10.1016/j.josat.2023.209030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/17/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
INTRODUCTION Pregnant individuals with substance use disorders face complex issues that may serve as barriers to treatment entry and retention. Several professional organizations have established recommendations on comprehensive, collaborative approaches to treatment to meet the needs of this population, but information on real-world application is lacking. Sites participating in the NIDA CTN0080 "Medication treatment for Opioid use disorder in expectant Mothers (MOMs)"-a randomized clinical trial of extended release compared to sublingual buprenorphine among pregnant and postpartum individuals (PPI)-were selected, in part, because they have a collaborative approach to treating PPI with opioid use disorder (OUD). However, organizational differences among sites and how they implement expert recommendations for collaborative care could impact study outcomes. METHODS Prior to study launch at each of the 13 MOMs sites, investigators used the Pregnancy and Addiction Services Assessment (PAASA) to collect information about organizational factors. Input from a team of addiction, perinatal, and economic evaluation experts guided the development of the PAASA. Investigators programmed the PAASA into a web-based data system and summarized the resultant site data using descriptive statistics. RESULTS Study sites represented four US census regions. Most sites were specialty obstetrics & gynecology (OB/GYN) programs providing OUD services (n = 9, 69.2 %), were affiliated with an academic institution (n = 11, 84.6 %), and prescribed buprenorphine in an ambulatory/outpatient setting (n = 11, 84.6 %); all sites offered access to naloxone. Sites reported that their population was primarily White, utilized public insurance, and faced numerous psychosocial barriers to treatment. Although all sites offered many services recommended by expert consensus groups, they varied in how they coordinated these services. CONCLUSIONS By providing the organizational characteristics of sites participating in the MOMs study, this report assists in filling the current gap in knowledge regarding similar programs providing services to PPI with OUD. Collaborative care programs such as those participating in MOMs are uniquely positioned to participate in research to determine the most effective models of care and to determine how research can be integrated into those clinical care settings.
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Affiliation(s)
- Frankie B Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA.
| | - Marcela C Smid
- University of Utah, 50 N. Medical Drive, Salt Lake City, UT 84132, USA.
| | - Michelle R Lofwall
- Departments of Behavioral Science and Psychiatry, University of Kentucky College of Medicine, 845 Angliana Avenue, Lexington, KY 40508, USA.
| | - Elisha M Wachman
- Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA.
| | - Peter R Martin
- Vanderbilt Psychiatric Hospital, Vanderbilt University Medical Center, 1601 23rd Avenue South, Suite 3035, Nashville, TN 372124, USA.
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA.
| | - Christine M Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
| | - T John Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH 45267, USA.
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Frew JR. Reducing the stigma of perinatal substance use disorders: the time is now. Arch Womens Ment Health 2023; 26:411-413. [PMID: 37103582 DOI: 10.1007/s00737-023-01322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 04/28/2023]
Affiliation(s)
- Julia R Frew
- Department of Psychiatry, Dartmouth Health/Geisel School of Medicine at Dartmouth, One Medical Center Drive, Lebanon, NH, 03756, USA.
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13
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Levander XA, Foot CA, Magnusson SL, Cook RR, Ezell JM, Feinberg J, Go VF, Lancaster KE, Salisbury-Afshar E, Smith GS, Westergaard RP, Young AM, Tsui JI, Korthuis PT. Contraception and Healthcare Utilization by Reproductive-Age Women Who Use Drugs in Rural Communities: a Cross-Sectional Survey. J Gen Intern Med 2023; 38:98-106. [PMID: 35731368 PMCID: PMC9849531 DOI: 10.1007/s11606-022-07558-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/30/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services. OBJECTIVE We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use. DESIGN Rural Opioids Initiative (ROI) - cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018-March 2020); National Survey on Family Growth (NSFG) - nationally-representative U.S. household reproductive health survey (2017-2019). PARTICIPANTS Women aged 18-49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses. MAIN MEASURES Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations. KEY RESULTS Of 855 women in the ROI, 36.8% (95% CI 33.7-40.1, unweighted) and 38.6% (95% CI 30.7-47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08-2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95-1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96-1.82]) that did not meet the threshold for statistical significance. CONCLUSION WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.
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Affiliation(s)
- Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Canyon A Foot
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Ryan R Cook
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jerel M Ezell
- Africana Studies and Research Center, Cornell Center for Health Equity, Cornell University, Ithaca, NY, USA
| | - Judith Feinberg
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
- Department of Medicine Section of Infectious Diseases, West Virginia University, Morgantown, WV, USA
| | - Vivian F Go
- Department of Health Behavior, School of Global Public Health, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Kathryn E Lancaster
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | | | - Gordon S Smith
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Ryan P Westergaard
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - April M Young
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - Judith I Tsui
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - P Todd Korthuis
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Shadowen H, Violante S, Gataric A, Goulding AN, Martin CE. Psychiatric comorbidities and their treatment predict buprenorphine continuation among postpartum people with opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100121. [PMID: 36644222 PMCID: PMC9835555 DOI: 10.1016/j.dadr.2022.100121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Opioid use disorder (OUD) is a growing crisis among pregnant and postpartum people. Psychiatric comorbidities are common, yet how they impact OUD treatment outcomes is not well characterized. The aim of this study was to assess the association of psychiatric comorbidities and receipt of psychiatric treatment with buprenorphine continuation through one year postpartum among a sample of people with OUD. Methods A subsample was identified from a larger retrospective cohort of patients receiving buprenorphine for OUD at the time of delivery from an academic medical center between 2017 and 2020. Medical record abstractions were conducted during pregnancy through one year postpartum. Independent variables included any psychiatric diagnosis and postpartum receipt of psychiatric treatment (medication or behavioral health). The primary outcome was week of buprenorphine discontinuation. Cox Proportional Hazard models were used. Results Of 138 patients, 71.8% had a psychiatric condition and 35.5% continued buprenorphine for a full year postpartum. Postpartum buprenorphine continuation was associated with (a) Psychiatric co-morbidity (buprenorphine discontinuation HR 0.49; 95% CI 0.29, 0.82), (b) Receipt of psychiatric medications in weeks 39-52 postpartum (buprenorphine discontinuation HR 0.21; 95% CI 0.06, 0.83), and (c) Receipt of behavioral health therapy in weeks 9-38 postpartum (buprenorphine discontinuation HR 0.40; 95% CI 0.18, 0.90). Conclusion Our work suggests a dynamic relationship between OUD treatment outcomes, psychiatric comorbidities and receipt of psychiatric treatments through the highly vulnerable postpartum period. Clinicians and researchers alike should work to advance patient-centered engagement in integrated care models tailored for this unique population.
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Affiliation(s)
- Hannah Shadowen
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephanie Violante
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Andrea Gataric
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Alison N. Goulding
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Caitlin E. Martin
- Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA USA,Department of Obstetrics and Gynecology, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA,Corresponding author at: 1250 E. Marshall St., Box #980034, Richmond, VA 23298, USA., (C.E. Martin)
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Redefining Child Protection: Addressing the Harms of Structural Racism and Punitive Approaches for Birthing People, Dyads, and Families Affected by Substance Use. Obstet Gynecol 2022; 140:167-173. [PMID: 35852265 DOI: 10.1097/aog.0000000000004786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/24/2022] [Indexed: 11/27/2022]
Abstract
There has been growing attention on the effect of substance use, including opioid use disorder, on pregnant and birthing people and their infants. Although effective medication treatment for opioid use disorder is the standard of care, racial disparities are evident in access during pregnancy. Structural racism affects treatment access and approaches to reporting to child welfare services. Black people and their newborns are more likely to be drug tested in medical settings, and Black newborns are more likely to be reported to child welfare services. Child welfare models often focus on substance use as being the dominant issue that drives risk for abuse or neglect of a child, and current reporting practices, which vary by state, contribute to these disparities. This commentary proposes an alternate way of thinking about family-based support. We suggest changes to law, institutional policy, clinical care, and ideology. Specifically, we propose realigning around shared goals of supporting the birthing person-infant dyad and recognizing that substance use is not synonymous with abuse or neglect; creating an anonymous notification process outside of the child welfare system to meet federal data-collection requirements; limiting perinatal drug testing and requiring written, informed consent for parental and neonatal testing; and developing integrated care teams and hospital settings and policies that support dyadic care.
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Developments in Nursing Practice to Address Substance Use in the Perinatal Period. J Obstet Gynecol Neonatal Nurs 2022; 51:361-376. [PMID: 35568096 DOI: 10.1016/j.jogn.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/30/2022] Open
Abstract
Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.
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Duska M, Goodman D. Implementation of a Prenatal Naloxone Distribution Program to Decrease Maternal Mortality from Opioid Overdose. Matern Child Health J 2022; 26:985-993. [PMID: 35029805 PMCID: PMC8759060 DOI: 10.1007/s10995-021-03307-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH. METHODS Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation. RESULTS The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups. DISCUSSION The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.
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Affiliation(s)
- M Duska
- The Dartmouth Institute for Health Policy and Clinical Practice, 74 College St, Hanover, NH, 03755, USA.
| | - D Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, 74 College St, Hanover, NH, 03755, USA
- Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH, 03766, USA
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