Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants

The opioid epidemic carries with it another epidemic, this one of infants born with neonatal abstinence syndrome (NAS), stemming from in utero exposure to opioids. NAS is characterized by withdrawal symptoms such as tremors, irritability, poor feeding, respiratory distress, and seizures.  In a recent day-long course at Penn sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA), health professionals came together to learn how to screen for, diagnose, and treat pregnant mothers with opioid use disorder (OUD) and infants with NAS.

Held at Penn’s Smilow Center for Translational Research, the course, Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants, was co-hosted by LDI,  the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), and the Helen O. Dickens Center for Women’s Health at the Hospital of the University of Pennsylvania. The diverse audience included social workers, pharmacists, and medical providers with backgrounds in obstetrics, family practice, pediatrics, and infectious disease.

Trina Salva, MD, Medical Director at the Helen O. Dickens Center for Women’s Health, set the stage for the event, saying, “We need to equip ourselves with the tools to help our patients the best we can. More and more we are seeing opioid use disorder not just in our pregnant patients, but their families and our own.”

SAMHSA Region III Administrator Jean Bennett, PhD, moderated the course and emphasized the importance of the interactive curriculum. “You will get great information today, but this is only the beginning of a conversation. Not just with our amazing faculty, but with your neighbors in this room.”

The curriculum included six modules providing up to date information on OUD in pregnant women, pharmacotherapy, prenatal care, preparing for labor and delivery, infant care, and postnatal care.

Co-Facilitator Carrie Malanga, RN, PMHNP-BC, a psychiatric mental health nurse practitioner and Clinical Director for Mothers MATTER, discussed prenatal care, including OUD and Substance Use Disorder (SUD) screening tools. She highlighted that pregnant women should be universally screened for SUD, as early as possible, to get the appropriate care and referrals to specialized treatment. Ideally, Ms. Malanga noted, an individualized treatment plan would be developed through a coordinated team of healthcare professionals including OB/GYNs, SUD treatment specialists, nurses, case managers, peer recovery coaches, and the patient.

Co-Facilitator Stephen Patrick, MD, a practicing neonatologist and Director of the Center for Child Health Policy at Vanderbilt University School of Medicine, discussed the benefits of medications for OUD during pregnancy. Opioid detoxification or withdrawal is not recommended during pregnancy.  Stabilization on medications for OUD minimizes opioid withdrawal, reduces cravings, and high-risk behaviors, such as intravenous drug use.

According to SAMHSA guidelines there is no evidence that buprenorphine and methadone cause an increase in birth defects and these medications likely have minimal long-term neurodevelopmental impact. Prenatal education, smoking cession, and breastfeeding are recommended interventions to manage the incidence and severity of NAS and mitigate long-term risk. Dr. Patrick also explained the importance of adjunct therapies such as behavioral therapy and peer support, which has been shown to increase retention in treatment programs.

In infants, NAS is an expected and treatable condition that often follows prenatal exposure to opioids. The number of mothers with OUD at time of delivery more than quadrupled between 1999–2014 in the United States. Between 50-80% of opioid-exposed infants will develop NAS. Multiple factors contribute to the development of NAS, including the opioid type and polysubstance use. In the US, an infant is born with NAS every 15 minutes.

Course participants learned about validated NAS scoring scales, such as the MOTHER NAS Scale, that can determine NAS severity and guide treatment decisions. They learned that consistency is the key to treating these infants; standard protocols have been associated with a reduced length of opioid exposure and hospital stay for infants with NAS.

As continuing medical education, the course accomplished its objective to present participants with best practices for treating pregnant women with OUD.  But it may have accomplished even more than that: by educating medical providers, it may encourage some to get waivered to prescribe buprenorphine and others to advocate against punitive policies that discourage women from seeking treatment.

Addressing Gaps in Evidence-Based Opioid Policy and Practice

Although evidence from health policy research should inform policymaking, researchers and policymakers don’t always communicate. A conference sponsored by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) – a NIDA-funded Center of Excellence – and hosted by the Leonard Davis Institute of Health Economics (LDI) sought to close this gap… if even for a day.

Substance Use Disorder in America: Research to Practice, and Back Again brought researchers, policymakers, and other stakeholders together to discuss evidence-based approaches to address substance use disorder and the opioid epidemic in America. Specifically, the conference was designed to improve the translation of current research for policy stakeholders and to inform future research so that it can be responsive to policymakers’ needs.

Despite the wide acceptance of evidence-based practice by medical professionals, research is rarely a part of the decisions made by policymakers. Instead, policymakers often rely on intuition, ideology, or conventional wisdom. Noting that policymakers most often credit in-person relationships with researchers as the most influential factor in determining the use of research evidence, the conference stressed the importance of establishing these networks. Early engagement with policymakers can help researchers identify meaningful research questions, and encourage researchers to become a part of the translation from evidence to policy and practice. These relationships can help policymakers consider the evidence as they try to make the best use of scarce resources. Ultimately, personal relationships are key to closing the gap and establishing evidence-based policy and practice, particularly in curbing substance use disorders and the opioid epidemic.

The conference wasted no time putting these connections to the test. Throughout the conference, researchers, policymakers, and clinicians were challenged to work together to come up with feasible strategies to curb the opioid epidemic. In an afternoon exercise, small, mixed groups of attendees reacted to a scenario in which a young patient died of an overdose despite repeated encounters with the health system. The scenario highlighted gaps in treatment, follow-up, and coordination. The groups identified evidence-based strategies for addressing these issues, and came back together to present their ideas to the larger group. In a post-conference survey, attendees ranked the most promising and feasible ideas within four categories, as shown below:

Quality of Treatment 

  1. Tie insurer payment to minimum standards for treatment based on evidence-based practice and continuity of care
  2. Eliminate or reduce the burden of regulations on prescribing buprenorphine
  3. Create an independent accreditation body that rates treatment facilities on meeting standards of care, and provides a publicly-available list of available treatment centers and their quality scores.

Continuity of Care 

  1. Develop in-person or telephone care coordination following discharge, through peer support, or MAT providers
  2. Promote hub-and-spoke models to ensure primary care physicians feel comfortable and supported prescribing MAT
  3. Promote emergency department induction of buprenorphine prior to discharge or hospital admission

Opioid Prescribing / Pain Management

  1. Require insurers to cover alternative pain treatment modalities, so that opioids are not the default pain management
  2. Tie the use and development of prescription guidelines to federal funding
  3. Develop a national state scorecard on opioid prescribing – ranking the states in relation to their goals – and hold governors responsible

Consumer Engagement 

  1. Create a centralized system of treatment facilities and providers where patients can sign up themselves (Airbnb-type model)
  2. Increase family and consumer marketing campaigns
  3. Create a consumer-rating metric of treatment programs
  4. Provide incentives for individuals to seek treatment (starting with research on best incentive programs)

The conference achieved its short-term objective of developing new relationships between researchers and policymakers and demonstrating collaborative work.  Ultimately, its long-term success will depend on the forged connections that will continue to close the communication gaps between researchers and policymakers.

This post originally appeared on the Leonard Davis Institute Health Policy$ense blog on August 29,2017.