Integrating Reproductive Health Services Into Opioid Treatment Facilities: A Missed Opportunity to Prevent Opioid-exposed Pregnancies and Improve the Health of Women Who Use Drugs

Programs and practices that support pregnant people who use drugs' access to sexual and reproductive health care in Canada: a scoping review

BACKGROUND

Pregnant people who use unregulated drugs (PPWUD) are at high risk of health complications yet experience a range of barriers to sexual and reproductive health care. Given that improving maternal health and access to reproductive health care are key targets underpinning the Sustainable Development Goals (SDG), there is an urgent need to improve access to appropriate supports and services for this population. Little is known about what programs and practices exist to support PPWUD's access to sexual and reproductive health care. This scoping review aimed to identify the available literature on these programs and practices in Canada.

METHODS

A scoping review was conducted using JBI methodology and reported using PRISMA guidelines. Scholarly databases and grey literature sources were searched to identify literature published between 2016-2023 in English or French that discussed, defined, conceptualised, or evaluated programs and practices that support PPWUD's access to sexual and reproductive health care in Canada. Identified literature was screened using Covidence. Data were extracted from included texts, then analysed descriptively. Frequencies and key concepts were reported.

RESULTS

A total of 71 articles were included, most of which were grey literature. Of the total, 46 unique programs were identified, as well as several useful practices. Most programs were in urban centres in Western Canada, and most programs offered holistic 'wrap-around services.' Several programs delivered these services on-site or as 'drop-in' programs with the support of staff with lived/living experience of substance use. Most frequent program outcomes included keeping parents and children together, improving connection to other services, and reducing substance use harms. Noted helpful practices included non-judgmental care and the use of harm-reduction strategies.

CONCLUSIONS

Several programs and practices that support PPWUD exist in Canada, though few focus exclusively on sexual and reproductive health. There remain opportunities to improve access to programs, including expanding geographic availability and range of services. The review has clinical application by providing an overview of available programs that may support clinicians in identifying services for PPWUD. Future research should consider client perspectives and experiences of these programs.

REVIEW REGISTRATION NUMBER

Open Science Framework https://osf.io/5y64j .

Factors associated with contraceptive use among postpartum women with substance use disorder

OBJECTIVE

Rates of unintended pregnancy among women with substance use disorder (SUD) are much higher than the general reproductive-age population, suggesting lower rates of contraceptive use. This study aims to determine the prevalence of contraceptive use in postpartum women with SUD and identify factors associated with its use.

METHODS

This retrospective cohort study using electronic health record data from 2016 to 2019 included postpartum adult women with any SUD who received care at a high-risk pregnancy clinic (n = 353). The primary outcome was contraception utilization as identified using diagnosis and procedure codes. An adjusted multivariate logistic regression was used to evaluate the relationship between postpartum contraceptive use and sample characteristics.

RESULTS

Of the 353 postpartum women with SUD, contraceptive use was found in 128 (36.3%) women. Among the study population, the most commonly reported substance use disorders were nicotine use disorder (70.3%), opioid use disorder (51.3%), and cannabis use disorder (15.0%). Among those with opioid use disorder, 45.3% were found to be using medication for opioid use disorder (MOUD). Women who attended a postpartum visit had 2.23 times the odds of using contraception compared to women who did not (OR: 2.23, 95% CI: 1.20-4.15). Those using MOUD had 3.69 times the odds of using contraception compared to those who were not (OR: 3.69, 95% CI: 1.89-7.19). Overall, women who utilized contraception were more likely to be younger than 25, receiving MOUD, and participating in postpartum care.

CONCLUSIONS

Postpartum women with SUD are not using contraceptive methods and this is associated with a lack of appropriate healthcare interventions in the perinatal period, which can reduce the odds of receiving effective family planning services. Specialized whole-health interventions and policies to increase access to care for women with SUD should be developed.

“We Have to Keep Advocating and Helping and Doing What We Can”: Examining Perinatal Substance Use Services in the Absence of Integrated Treatment Programs

Effective treatment of substance-exposed pregnancies requires gender-responsive care coordinated across agencies and systems. A deeper understanding of the perspectives, experience, and practices of professionals providing these services is needed to improve care. This study examines service provision for perinatal substance use through the perspectives and experiences of healthcare and social service professionals. Using a constructivist grounded theory design, data were collected over a 7-year period. Data collection consisted of interviews and focus groups with professionals as well as observations of professional meetings and workshops where practices and procedures were discussed. A multi-level model of service delivery is described. The role of affect, particularly around issues of custody, is discussed along with structural level actions that develop in the absence of integrated treatment. Structural support both within and across systems of care is crucial to developing coordinated and compassionate care and to increasing engagement in care services.

A Comparison of Sex-Specific Reproductive and Sexual Health Needs between Addiction Medicine and Primary Care Treatment Settings

Introduction: Reproductive and sexual health (RSH) is an important component of wellness and recovery for people with substance use disorder (SUD). Evidence to guide better integration of RSH services into SUD treatment is limited. Our objectives were to compare 1) unmet RSH needs; and 2) barriers to RSH service utilization between care settings providing treatment for SUD or other chronic medical conditions. Methods: Participants at two outpatient clinics, addiction medicine (women n = 91, men n = 75) and primary care (women n = 59, men n = 50), completed a one-time electronic survey between July and September 2019. Separately for men and women, comparisons between addiction medicine and primary care groups were made using Pearson χ², Fisher's Exact, and T-tests. Results: Participants were 75.0% Black and aged 49.4 years. Overall, unmet RSH needs were less prevalent among participants at the primary care than the addiction medicine clinic, such as receipt of a past 12-month sexual exam (men: 36.0% vs. 17.3%; women: 55.6% vs. 30.1%). The most common barrier to RSH service receipt was cost (men: 59.4%; women: 52.6%), followed by fear of judgment for drug/alcohol use for SUD participants (men: 33% vs. 12%; women: 26% vs. 7%). Many SUD participants expressed high desire for integrated RSH services into the addiction medicine clinic (men: 51.4%; women: 59.8%). Conclusion/Implications: The integration of RSH into addiction medicine is lagging compared to care settings for people with other chronic medical conditions. Future research should focus on advancing sex- and gender-informed RSH service integration into SUD treatment settings.

Together in care: Lessons learned at the intersection of integrated care, quality improvement, and implementation practice in opioid treatment programs

Background

Integrated care programs that systematically and comprehensively address both behavioral and physical health may improve patient outcomes. However, there are few examples of such programs in addiction treatment settings. This article is a practical implementation report describing the implementation of an integrated care program into two opioid treatment programs (OTPs).

Method

Strategies used to implement integrated care into two OTPs included external facilitation, quality improvement (QI) processes, staff training, and an integrated organizational structure. Service, implementation, and client outcomes were examined using qualitative interviews with program staff (n  =  16), program enrollment data, and client outcome data (n  =  593) on mental health (MH), physical health, and functional indicators.

Results

Staff found the program to generally be acceptable and appropriate, but also noted that the new services added to already busy workflows and more staffing were needed to fully reach the program's potential. The program had a high level of penetration (∼60%-70%), enrolling over 1,200 clients. Staff noted difficulties in connecting clients with some services. Client general functioning and MH symptoms improved, and heavy smoking decreased. The organizational structure and QI activities provided a strong foundation for interactive problem-solving and adaptations that were needed during implementation.

Conclusions

This article highlights an example of the intersection of QI and implementation practice. Simplified QI processes, consistent post-implementation meetings, and change teams and champions facilitated implementation; however, ongoing training and support, especially related to data are needed. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff is necessary.Plain Language Summary: Providing medical and behavioral health treatment services in the same clinic using coordinated treatment teams, also known as integrated care, improves outcomes among those with chronic physical and behavioral health conditions. However, there are few practical examples of implementation of such programs in addiction treatment settings, which are promising, yet underutilized settings for integrated care programs. A multi-sectoral team used quality improvement (QI) and implementation strategies to implement integrated care into two opioid treatment programs (OTPs). The program enrolled over 1,200 clients and client general functioning and mental health (MH) symptoms improved, and heavy smoking decreased. Qualitative interviews provided important information about the barriers, facilitators, and context around implementation of this program. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff, as well as ongoing training and supports for staff, are necessary. This project may help to advance the implementation of integrated care in OTPs by identifying barriers and facilitators to implementation, lessons learned, as well as providing a practical example of potentially useful QI and implementation strategies.

Outcomes of Ottawa, Canada's Managed Opioid Program (MOP) where supervised injectable hydromorphone was paired with assisted housing

BACKGROUND

The Ottawa Inner City Health's Managed Opioid Program is the first, to our knowledge, to pair injectable opioid agonist hydromorphone treatment with assisted housing for people experiencing homelessness with severe opioid use disorder (OUD) and injection drug use. We aimed to describe this program and evaluate retention, health, and social wellbeing outcomes.

METHODS

We retrospectively assessed the first cohort of clients enrolled in the Managed Opioid Program between August 2017-2018. The primary outcome was retention at 12 months. Secondary outcomes included injectable and oral opioid dose titration, non-prescribed opioid use, overdoses, connection with behavioural health services, and social well-being. Descriptive statistics were used to summarize baseline demographics and secondary outcomes. Actuarial survival analysis was used to assess retention among participants.

RESULTS

The study sample included 26 participants: median age was 36 years, 14 were female, 22 were White, eight had alcohol use disorders, 25 had stimulant use disorders, and all had a history of concurrent psychiatric illness. Retention at 12 months was 77% (95% CI 62-95). Throughout the first-year participants' opioid treatment doses increased. The median daily dose of injectable hydromorphone was 36 mg [17-54 mg] and 156 mg [108-188 mg] at enrollment and one year respectively. The median daily dose of oral opioid treatment was 120-milligram morphine equivalents [83-180 mg morphine equivalents] and 330-milligram morphine equivalents [285-428 mg morphine equivalents] at enrollment and one year respectively. Over half had no overdoses and there were no deaths among participants who remained enrolled. At one year, 45% stopped non-prescribed opioid use, 96% connected to behavioral health services, 73% reconnected with estranged families, and 31% started work or vocational programs.

CONCLUSION

Individuals with severe OUD engaged in injectable hydromorphone treatment and housing showed high retention in care and substantive improvements in patient-centered health and social well-being outcomes.

Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder

BACKGROUND

Unintended pregnancies are prevalent among women with opioid use disorder (OUD). The Sex and Female Empowerment (SAFE) project developed a social-cognitive, theory-driven intervention to increase acceptance of and adherence to contraceptive practices among women receiving medication for OUD (MOUD). This study evaluated the feasibility and acceptability of two SAFE interventions (Face-to-face and Computer-adapted) compared to usual care as well as their efficacy to improve contraception utilization.

METHODS

This pilot randomized trial enrolled 90 heterosexual, non-pregnant, reproductive-age women receiving MOUD. Participants were randomized into either a: SAFE Face-to-face intervention, SAFE Computer-adapted intervention, or usual care (UC) condition (n = 30 each) and followed for 6 months. Outcome measures included intervention completion, intervention satisfaction, attendance at a contraception consultation appointment, and long-acting reversible contraceptive (LARC) method receipt. A generalized linear model was used for inferential testing and to estimate least squares means (predicted probabilities for binary outcomes) and their standard errors.

RESULTS

Compared to the UC condition, both the SAFE Face-to-face and the SAFE Computer-adapted intervention had higher intervention completion [Means (Standard Errors) = 0.97 (.03) and 0.97 (.03), respectively, vs. 0.53 (.09); ps<.001], higher intervention satisfaction [Ms (SEs) = 3.7 (.11) and 3.8 (.11), respectively, vs. 3.1 (.11); ps<0.001), higher contraception consultation visit attendance [Ms(SEs) = 0.80 (.07) and 0.73 (.08) vs. 0.33 (.09); p < .001], and greater LARC receipt [Ms(SEs) = 0.77 (.08) and 0.73 (.08) vs. 0.23 (.08); p < .001).

CONCLUSIONS

SAFE appears feasible and efficacious for supporting women in contraception decision-making. Integrating SAFE into women's comprehensive OUD treatment services holds promise to increase contraceptive decision-making and initiation of a chosen method.

Contraceptive Knowledge among Females and Males Receiving Medication Treatment for Opioid Use Disorder Compared to Those Seeking Primary Care

BACKGROUND

Rates of unintended pregnancy among women receiving medication treatment for opioid use disorder (mOUD) are high, likely due in part to low rates of contraceptive use. Lack of knowledge about contraception may be contributing to inadequate contraceptive use. Objectives: To compare contraceptive knowledge among women and men receiving mOUD relative to a comparison group seeking primary care. Methods: We surveyed 332 reproductive-age women and men receiving mOUD or primary care with the recently validated 25-item Contraceptive Knowledge Assessment. We examined overall differences between patient groups and between females and males using two-way analyses of variance; individual item differences were tested using logistic regression. Results: The mean percent of total correct responses was lower among individuals receiving mOUD (n = 167) relative to the comparison group (n = 165), 47.7% vs. 53.8%, respectively (p < .001), and higher among females (n = 169) relative to males (n = 163), 56.1% vs. 45.2%, respectively (p < .001). Individual item analyses revealed patient group and sex differences primarily in the areas of contraceptive efficacy, attributes of contraceptive methods, and fertility awareness. Conclusion: While there were modest differences between patient groups and sexes, the results suggest a deficit in contraceptive knowledge across all groups. Substance use disorder treatment clinics could be an opportunistic setting in which to provide accurate information about contraception to patients with OUD and other substance use disorders.