Screening Pregnant and Postpartum Women for Substance Use Disorder. MPQC Fall Summit November 14, 2018

Transcription

1 Screening Pregnant and Postpartum Women for Substance Use Disorder MPQC Fall Summit November 14, 2018

2 Disclosures No relevant financial or non-financial relafonships

3 Screening Pregnant and Postpartum Women for Substance Use Disorder Screening vs. TesFng Screening for Substance Use Disorder (SUD) as Part of RouFne Prenatal Care Fentanyl: a Local Update

4 AddicFon is a Disease AddicFon is TREATABLE

5 Screening for SUD in Pregnancy

6 Substance Use in Pregnancy 5% pregnant women use illicit substances 10% drink alcohol 15% use tobacco More common than: GDM (6-8%) Preeclampsia (5%) WrightT et al The role of screen, brief intervenfon and referral to treatment in the perinatal period AJOG Nov 2016

7 Worcester Area: Substance Use in Pregnancy 5% pregnant women use illicit substances 10% drink alcohol 15% use tobacco 9.8% use illicit substances 0.9% drink alcohol 14.3% use tobacco 112 New Ob PaFents in CWC Jan 2017 April 2017 Denied Tobacco EtOH "Drugs"

8 How should do we screen? Screening for substance abuse is a part of complete obstetric care and should be done in partnership with the pregnant woman Rou%ne screening should rely on validated screening tools ACOG CO Number 711, August 2017 (Replaces Commi.ee Opinion Number 524, May 2012)

9 Isn t informal screening good enough? Do we all ask the same way? Relying on self-report underesfmates the frequency and severity of use in pregnant women 40-60% of cases missed when later compared to objecfve laboratory results Garg M, Garrison L, Leeman L, Hamidovic A, Borrego M, Rayburn WF, Bakhireva L. Validity of Self-Reported Drug Use InformaFon Among Pregnant Women. Matern Child Health J Jan;20(1):41-7

10 Isn t informal screening good enough? 127 new pafents over 6 mos period 117 were asked about SUD at IOB 27 were screened for SUD using a standard tool 7 of the 27 (25.9%) screened posifve for substance use 1 pafent screened posifve and was not asked at first visit 3 of the 6 pafents (50%) screened in by the NIDA Quick Screen denied substance use during the informal screen.

11 Screening for SUD IntervenFon: moving screen from nursing intake to first Ob visit, training residents in SBIRT Pre Post % screened by NIDA 19.3% 63.4% % of NIDA screening posifve 25.9% 36.2% % screened by informal means 90% 88.2% % informal screening posifve 21.4% 17.3%

12 Universal Screening SUD occurs in every socioeconomic class, and racial and ethnic group Recommended by: ACOG - AMA AAP - CDC Screen at the first prenatal visit (at least) ACOG CO Number 711, August 2017 WrightT et al The role of screen, brief intervenfon and referral to treatment in the perinatal period AJOG Nov 2016

13 Why not Universal TESTING? False posifves are a real thing ParFcularly immunoassays Long-term maternal effects: Medical Legal Familial Substance Abuse and Mental Health Services AdministraFon, PrevenFon of substance abuse and mental illness SAMHSA.gov/prevenFon

14 Biological Samples: Screening vs Urine Drug Screen aka Immunoassays Rapid, Cheap, Automated Results as posifve or negafve Can be POCT High rate of false posifves PosiFves should be followed with confirmatory tesfng TesFng GMahajan Role of Urine Drug TesFng in the Current Opioid Epidemic Anesthesia and Analgesia December 2017 Volume 125 Number 6

15 UDS - Immunoassays: Common False PosiFves Substance Amphetamines Benzodiazepines Buprenorphine Methadone Opiates Buproprion Chlorpromazine FluoxiFne Labetolol Menormin Efavirenz Sertraline Codeine Morphine Methadone Tramadol Diphenhydramine QueFapine Verapamil Dextromethorphone Diphenhydramine Fluoroquinalones Poppy seeds Possible cross-reac%ng drugs Ofloxacin Promethazine Pseudoephedrine Trazadone Quinine Rifampin Verapamil MahajanG (2017). Role of Urine Drug tesfng in the Current Opioid Epidemic. Anesthesia & Analgesia. December 2017 Volume 125 Number 6 p SaitmanA, ParkHD, FitzgeraldR (2014). False-PosiFve Interferences of Common Urine Drug Screen Immunoassays: A Review. Journal of AnalyFcal Toxicology, Volume 38, Issue 7, 1 September 2014, p

16 UDT Confirmatory Urine Drug Tests Gas or liquid chromatography mass spectrometry Cost of tesfng related to number of substances tested $250-$1400 SFll has risk of false posifve or false negafve results Can enhance pafent care Confirm compliance Detect non-compliance Inform use MahajanG (2017). Role of Urine Drug tesfng in the Current Opioid Epidemic. Anesthesia & Analgesia. December 2017 Volume 125 Number 6 p SaitmanA, ParkHD, FitzgeraldR (2014).

17 UDT Confirmatory Urine Drug Tests Drug Toxicology Monitoring 1 with Confirma%on, Urine Amphetamines, Benzodiazepines, Buprenorphine, Cocaine Metabolite, Heroin Metabolite, Marijuana Metabolite 20, Methadone Metabolite, Opiates, Oxycodone Drug Toxicology Monitoring 2 with Confirma%on, Urine Amphetamines, Barbiturates, Benzodiazepines, Buprenorphine, Cocaine Metabolite, Heroin Metabolite, Marijuana Metabolite 20, Methadone Metabolite, Opiates, Oxycodone Drug Toxicology Monitoring 6 with Confirma%on, Urine Amphetamines, Barbiturates, Benzodiazepines, Cocaine Metabolite, Marijuana Metabolite 20, Methadone Metabolite, Opiates, Oxycodone, Phencyclidine Drug Toxicology Monitoring 9 with Confirma%on, Urine Amphetamines, Barbiturates, Benzodiazepines, Buprenorphine, Cocaine Metabolite, Heroin Metabolite, Marijuana Metabolite 20, MDMA/MDA, Methadone Metabolite, Opiates, Oxycodone, Phencyclidine MahajanG (2017). Role of Urine Drug tesfng in the Current Opioid Epidemic. Anesthesia & Analgesia. December 2017 Volume 125 Number 6 p SaitmanA, ParkHD, FitzgeraldR (2014).

18 Screening Tools NIDA Quick Screen 4Ps TWEAK CRAFFT ACOG CO Number 711, August 2017 WrightT et al The role of screen, brief intervenfon and referral to treatment in the perinatal period AJOG Nov 2016

19 Screening Tools NIDA Quick Screen 4Ps Parents, Partner, Past, Pregnancy TWEAK CRAFFT ACOG CO Number 711, August 2017

20 Screening Tools NIDA Quick Screen 4Ps Parents, Partner, Past, Present / Pregnancy TWEAK CRAFFT 1. Have you ever used drugs or alcohol during Pregnancy? 2. Have you had a problem with drugs or alcohol in the Past? 3. Does your Partner have a problem with drugs or alcohol? 4. Do you consider one of your Parents to be an addict or alcoholic? HEwing A PracFcal Guide to IntervenFon in Health and Social Services with Pregnanct and Postpartum Addicts and Alcoholics: theorefcal framework, brief screening tool, key interview quesfons, and strategies for recovery resources Born Free Project, Contra Costa County DPH

21 Screening Tools NIDA Quick Screen 4Ps TWEAK Developed for alcohol use in pregnancy CRAFFT T Tolerance How many drinks can you hold? W Worried Have close friends or relafves worried or complained about your drinking in the past year? E Eye-opener Do you somefmes take a drink in the morning when you first get up? A Amnesia stands for blackouts Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? K K/Cut Down Do you somefmes feel the need to cut down on your drinking? ACOG CO Number 711, August 2017 WrightT et al The role of screen, brief intervenfon and referral to treatment in the perinatal period AJOG Nov 2016

22 Screening Tools NIDA Quick Screen 4Ps TWEAK CRAFFT Developed for adolescents Car, Relax, Alone, Forget, Family/Friends, Trouble ACOG CO Number 711, August 2017

23 So I screened now what? Screening Brief Interven%on Referral to Treatment Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G6 Creanga AA. The role of screening, brief intervenfon, and referral to treatment in the perinatal period. Am J Obstet Gynecol Nov;215(5):

24 So I screened now what? Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G6 Creanga AA. The role of screening, brief intervenfon, and referral to treatment in the perinatal period. Am J Obstet Gynecol Nov;215(5):

25 OUD in Worcester

26 OUD in Worcester 2017: Statewide trend of decreasing numbers of death by opioid overdose Statewide, deaths from overdose down 8.2% Increase in awareness, Narcan prescribing

27 OUD in Worcester 2017: Statewide trend of decreasing numbers of death by opioid overdose Worcester County deaths confnue to increase Opioid Related Deaths

28 OUD in Worcester 2017: Statewide trend of decreasing numbers of death by opioid overdose Worcester County deaths confnue to increase May be due to increasing amounts of Fentanyl MA OD Deaths 2017 Fentanyl Non-Fentanyl

29 OUD in Worcester 2017: Statewide trend of decreasing numbers of death by opioid overdose Worcester County deaths confnue to increase May be due to increasing amounts of Fentanyl MA OD Deaths 2017 UMASS Non-fatal ODs 2017 Fentanyl Non-Fentanyl Fentanyl Non-Fentanyl

30 OUD in Worcester 2017: Statewide trend of decreasing numbers of death by opioid overdose Worcester County deaths confnue to increase May be due to increasing amounts of Fentanyl

31 Street opioid trade in Worcester dominated by fentanyl Heroin now used to cut fentanyl Reports of carfentanil BSAS June 2018 advisory: Fentanyl + cocaine in 43% of ODs BSAS June 2016 advisory: Fentanyl + cocaine pressed to look like Perc 30s. OUD in Worcester DRUG ENFORCEMENT ADMIN Dea.gov

32 OUD in Worcester Green Clinic Urine Tox - Sept 2018: 10/42 Urine Tox PosiFve Sept /10 posi%ve, posi%ve for fentanyl 2/10 posifve, posifve for heroin metabolite Urine Toxicologies in Green Clinic September 2018 Neg Pos Fentanyl Other

33 OUD in Worcester Opioid related deaths confnue to increase in Worcester Street level opioid now dominated by FENTANYL Majority of high-risk populafon tests posifve for FENTANYL and not other opioids FENTANYL *MAY NOT* BE INCLUDED IN URINE DRUG TEST PANELS

34 In Conclusion Please Screen for SUD with a Standardized Tool Know your tests FENTANYL is on the rise THANK YOU!