1
|
Valentine SE, Godfrey LB, Gellatly R, Paul E, Clark C, Giovannini K, Saia KA, Nillni YI. Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States. SSM Ment Health 2023; 4:100256. [PMID: 38645900 PMCID: PMC11027481 DOI: 10.1016/j.ssmmh.2023.100256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Abstract
Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.
Collapse
Affiliation(s)
- Sarah E. Valentine
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Laura B. Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Resham Gellatly
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Immigrant and Refugee Health Center, Boston Medical Center, Boston, MA, USA
| | - Emilie Paul
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - Caitlin Clark
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA, USA
| | - Karissa Giovannini
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA, USA
| | - Kelley A. Saia
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA, USA
- Department of Obstetrics & Gynecology, Boston University School of Medicine, Boston, MA, USA
| | - Yael I. Nillni
- Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
- National Center for PTSD, Women’s Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
| |
Collapse
|
2
|
Deflorimonte C, Glissendorf V, Hofer J, Cai A, Iannella N, Boateng JO, Carter G, Saia KA, Jones HE, Wachman EM. National Provider Survey: Use of Naltrexone for Pregnant Individuals with Substance Use Disorders. J Addict Med 2023; 17:736-738. [PMID: 37934548 PMCID: PMC10873530 DOI: 10.1097/adm.0000000000001225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVES A national survey evaluated the availability of naltrexone as a treatment for alcohol use disorder and/or opioid use disorder for pregnant individuals. Provider perceptions of barriers to treatment with naltrexone during pregnancy were also examined. METHODS Sites were selected from a national registry of naltrexone prescribers (N = 5208). A 10% sampling of sites within 150 miles of each state's capital was selected (n = 2073). Survey of 11 questions included availability of naltrexone for pregnant individuals, standard practices for treating pregnant individuals already on naltrexone, and barriers to treatment. Survey responses were summarized to identify top barriers and national trends in service availability. RESULTS Of the 236 sites contacted, 78 (33.1%) completed the survey. There was significant geographic variation in number of available sites, with Northeast United States having the most sites. Of the 78 responding sites, only 23 (35.9%) offered naltrexone for pregnant individuals. The most common barriers to prescribing naltrexone included the following: sites without pregnant patients (15.6%), lack of national guidelines in using naltrexone for pregnant patients (14.1%), providers' discomfort with prescribing naltrexone during pregnancy due to safety concerns (9.4%), and providers' discomfort due to inexperience (4.7%). CONCLUSIONS Accessibility of naltrexone and related care for pregnant individuals with alcohol use disorder and opioid use disorder varies greatly across the United States with numerous barriers and educational gaps identified. Additional research and resources are needed to expand naltrexone treatment access for pregnant individuals.
Collapse
Affiliation(s)
- Chloe Deflorimonte
- From the Department of Pediatrics, Boston Medical Center, Boston, MA (CD, NI, JOB, EMW); Boston University School of Public Health, Boston, MA (VG); Boston University Chobanian and Avedisian School of Medicine, Boston, MA (JH, AC); UNC Horizons and Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Carrboro, NC (GC, HEJ); and Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA (KAS)
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Laks J, Walley AY, Bagley SM, Barber CM, Gaeta JM, Neville LA, Peterkin AF, Rosenthal E, Saia KA, Weinstein ZM, Harris MTH. Developing a Women's Health track within addiction medicine fellowship: reflections and inspirations. Addict Sci Clin Pract 2023; 18:3. [PMID: 36617557 PMCID: PMC9827632 DOI: 10.1186/s13722-022-00357-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 12/08/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Women who use drugs face sexism and intersectional stigma that influence their drug use experiences and treatment needs. There is a need to build the capacity of addiction medicine specialists who can deliver gender-responsive services and advance research and policy in women-focused addiction care. We describe the development of a Women's Health track within an addiction medicine fellowship program and reflect on successes, challenges, and future directions. MAIN BODY The Women's Health track was developed in collaboration between program leaders in Addiction Medicine and Obstetrics/Gynecology. Implementing the track led to the development of women-focused rotations and continuity clinics, as well as enrichment of women's health didactic education for all fellows. The fellowship track spurred interdepartmental mentorship and collaboration on research and advocacy projects. CONCLUSION Addiction medicine fellowships can replicate this curriculum model to advance women-focused education, research, and policy. Future curricula should focus on structural sexism in drug use and addiction treatment throughout a woman's life course.
Collapse
Affiliation(s)
- Jordana Laks
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA ,grid.427661.00000 0000 9549 973XBoston Health Care for the Homeless Program, Boston, MA USA
| | - Alexander Y. Walley
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA
| | - Sarah M. Bagley
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA ,grid.189504.10000 0004 1936 7558Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, MA USA
| | - Cecily M. Barber
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA ,grid.189504.10000 0004 1936 7558Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Jessie M. Gaeta
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA ,grid.427661.00000 0000 9549 973XBoston Health Care for the Homeless Program, Boston, MA USA
| | - Linda A. Neville
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA
| | - Alyssa F. Peterkin
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA
| | - Emily Rosenthal
- grid.189504.10000 0004 1936 7558Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Kelley A. Saia
- grid.189504.10000 0004 1936 7558Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Zoe M. Weinstein
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA
| | - Miriam T. H. Harris
- Grayken Center for Addiction, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University School of Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118 USA
| |
Collapse
|
4
|
Epstein RL, Sabharwal V, Wachman EM, Saia KA, Vellozzi C, Hariri S, Linas BP. Perinatal Transmission of Hepatitis C Virus: Defining the Cascade of Care. J Pediatr 2018; 203:34-40.e1. [PMID: 30170857 PMCID: PMC6252153 DOI: 10.1016/j.jpeds.2018.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/27/2018] [Accepted: 07/02/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The US National Viral Hepatitis Action Plan calls for major efforts to expand hepatitis C virus (HCV) diagnosis and treatment; prenatal care settings are potential venues for expanding HCV testing. We aimed to characterize the HCV diagnostic cascade for women and infants and investigate factors associated with linkage and follow-up. STUDY DESIGN We used electronic health records for a 10-year cohort of 879 women with opioid use disorder from an obstetric clinic serving women with substance use disorders. RESULTS Altogether, 744 women (85%) were screened for HCV; 510 (68%) were seropositive, of whom 369 (72%) had nucleic acid testing performed and of these 261 (71%) were viremic. Of 404 infants born to HCV-seropositive women, 273 (68%) were tested at least once for HCV, 180 (45%) completed the American Academy of Pediatrics-recommended perinatal HCV screening, and 5 (2.8%) were diagnosed with HCV infection and linked to care. More recent delivery date (2014-2015) was associated with maternal linkage to care (aOR, 2.5; 95% CI, 1.4-4.7). Maternal coinfection with HIV (aOR, 9.0; 95% CI, 1.1-72.8) and methadone maintenance therapy, compared with buprenorphine (aOR, 1.5; 95% CI, 0.9-2.5), were associated with higher rates of infant HCV testing. CONCLUSIONS HCV prevalence among pregnant women with opioid use is high and infant HCV screening is imperfect. Programmatic changes to improve both mother and infant follow-up may help to bridge identified gaps in the cascade to cure.
Collapse
Affiliation(s)
- Rachel L Epstein
- Department of Pediatrics, Section of Infectious Diseases, Boston Medical Center, Boston, MA; Department of Internal Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA.
| | - Vishakha Sabharwal
- Department of Pediatrics, Section of Infectious Diseases, Boston Medical Center, Boston, MA
| | - Elisha M Wachman
- Department of Pediatrics, Division of Neonatology, Boston Medical Center, Boston, MA
| | - Kelley A Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA
| | - Claudia Vellozzi
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Susan Hariri
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Benjamin P Linas
- Department of Internal Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA
| |
Collapse
|
5
|
Saia KA, Schiff D, Wachman EM, Mehta P, Vilkins A, Sia M, Price J, Samura T, DeAngelis J, Jackson CV, Emmer SF, Shaw D, Bagley S. Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment. Curr Obstet Gynecol Rep 2016; 5:257-263. [PMID: 27563497 PMCID: PMC4981621 DOI: 10.1007/s13669-016-0168-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF THE REVIEW Opioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population. RECENT FINDINGS We review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal ("detoxification") is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad. SUMMARY Further research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.
Collapse
Affiliation(s)
- Kelley A. Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | - Davida Schiff
- Department of Pediatrics, Boston Medical Center, Boston, USA
| | | | - Pooja Mehta
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | - Annmarie Vilkins
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | - Michelle Sia
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | - Jordana Price
- Department of Family Medicine, Boston Medical Center, Boston, USA
| | - Tirah Samura
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | - Justin DeAngelis
- Department of Obstetrics and Gynecology, Boston Medical Center, 85 East Concord Street, 6th Floor, Boston, MA 02118 USA
| | | | | | - Daniel Shaw
- Department of Psychiatry, Boston Medical Center, Boston, USA
| | - Sarah Bagley
- Department of Internal Medicine, Boston Medical Center, Boston, USA
| |
Collapse
|
6
|
Brogly SB, Saia KA, Walley AY, Du HM, Sebastiani P. Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis. Am J Epidemiol 2014; 180:673-86. [PMID: 25150272 DOI: 10.1093/aje/kwu190] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices.
Collapse
|