Perinatal Opioid Use: Understanding and Aligning Response between Systems

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Maximillian McCormick
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1 Perinatal Opioid Use: Understanding and Aligning Response between Systems Dorothy J. Mandell, PhD Population Health University of Texas System & University of Texas Health Science Center, Tyler

2 The Team Baylor College of Medicine, Public Health Pediatrics Christopher Greeley, MD Beth van Horne, DrPH Nancy Correa, MPH Rachael Keefe, MD Yen Hoang Nong, MPH Meredith Vinez, MPP Suratha Elango, MD Population Health, UT System Administration Dorothy Mandell, PhD Matthew Myers, MPH

3 Background NAS & Infant Drug Exposure Neonatal Abstinence Syndrome (NAS): A clinical diagnosis stemming from a collection of withdrawal symptoms expressed by a newborn Seizures, cardiac issues, gastric issues, temperature instability, hyperirritability, high-pitch uncontrollable cry Primarily associated with prenatal opioid exposure Not all infants exposed to drugs are diagnosed with NAS Drug Exposed: Texas most prevalent drug of threat: Methamphetamines Poly-drug exposures

4 The rising tide The rate of infants affected by drugs in utero has doubled since the mid 2000 s About 35% of prenatal drug exposure cases have a NAS diagnosis Rate per 1,000 Live Births Prenatal Drug Exposure: Hospital Data Estimates

5 Statewide Prenatal Drug Exposure, 2016

6 Differences by County, 2016 No county has more NAS cases and more prenatal drug exposure cases than Bexar County 26.8% of all NAS cases in Texas were in Bexar County 11% of prenatal drug exposure without withdraw cases in Texas were in Bexar County 8% of all births are in Bexar County 47% of prenatal drug exposures have a diagnosis of NAS in Bexar county County Prenatal drug exposure rate NAS Bexar Dallas Tarrant Harris Travis Nueces All prenatal drug exposure

7 Toll of Prenatal Drug Exposure (2015) Non Drug Exposed Drug Exposed w/o Withdraw NAS Low birth weight 6.1% 28.8% 19.1% Length of Stay 3.3 days 9.6 days 21.9 days Medicaid 48.3% 69.8% 70.5% Average cost $3,680 $15,890 $32,910

Mapping Bexar County: Hospital Identification of Infant Prenatal Drug Exposure (2016) 78212 has the highest prenatal

8 Mapping Bexar County: Hospital Identification of Infant Prenatal Drug Exposure (2016) has the highest prenatal drug exposure and NAS rate For Bexar county there is a high correlation between prenatal drug exposure and NAS in communities

9 Infancy, CPS, and Substance Use ~2.5% of all infants in Texas become involved with CPS Half of these become involved in first 2 weeks Drug exposure likely cause of vast majority of these cases FY16, 38.5% of the ~167k completed investigations were drug related* FY17, 90 of the 172 (52%) child fatalities caused by abuse or neglect involved a parent or caregiver actively using a substance and/or under the influence. 11 of the 172 (6%) fatalities, the child had a documented history of prenatal drug or alcohol exposure

10 Aligning Response between Systems: Project goals and approach Goal: To build a cross-sector collaboratives in San Antonio and Houston, with partners from all impacted sectors, to reduce the conflict and confusion arising during the response to perinatal opioid use and improve outcomes for mothers and their children. Through collaboration, we will: Identify and understand the roles and mission of each sector Identify gaps and/or misalignment in response and services Conduct readiness and implementation assessment with key stakeholders Generate pathways (e.g., policy recommendations) to fill the gaps and create alignment Create new connections and build trust and collaboration between agencies

11 GAPS: Obstetrics & Pediatrics Emergency Medicine Gaps in response and services: San Antonio Network

12 Meeting 1 Generate recommendations to fill the gaps and create alignment Goal: introduce project, vet themes from interviews, share and discuss across sectors Meeting 2 & 3 Goal: go through journey mapping process using 2 true stories from women in recovery, share and discuss across sectors Houston San Antonio Meeting 1: Introduction Law Enforcement/Justice 3 14 Healthcare 2 1 Treatment 6 1 CPS 0 2 State 0 0 Community 1 0 Research 0 2 Meeting 2: Journey Mapping Law Enforcement/Justice 4 5 Healthcare 4 3 Treatment 4 1 CPS 1 2 State 1 1 Community 0 3 Research 0 4

13 Ideas for the Ideal Future State by Touchpoint Overall/General Schools and communities provide more support for at-risk kids/families. Better identification and support services Public campaign to decrease stigma and increase awareness of disease and services Targeted outreach in places women go regularly (gas stations, grocery stores, corner stores ) to know services exist, where to go, All sectors trained on addiction and services Recovery coach/case manager to follow through ENTIRE process, engagement at all touchpoints, and beyond to sustain recovery Early warning system to monitor spikes and identify locations for needed outreach Child welfare and prevention Support services engaging with women early in pregnancy Specialized CPS workers and CPS liaisons to coordinate with other sectors Clear expectations and process outlined to assist other sectors preparing mom/ensuring child safety Pre & Post natal Comprehensive use of SBIRT in OB offices (including screening for IPV, depression/anxiety, substance use). OB office with integrated social work to address additional needs (food insecurity, trauma, etc) Done with compassion and understanding. Education and referrals using warm hand-off Birth control/family planning discussed during prenatal visits and given at delivery Safety planning and CPS preparation prior to birth Medical coverage (including treatment) continues for mom to address ALL of her mental and physical health needs (healthy mom=healthy baby) Warm and supportive delivery/postpartum care experience Hospitals able to care for women in active treatment (MAT) Treatment/Recovery Treatment options are available to fit needs Treatment facilities support pregnant mom, partners, and other children Pregnant women and partners are prioritized for treatment Comprehensive, integrated care delivered onsite to treat whole person Safety planning and CPS preparation prior to transitioning Linked into supportive community services prior to transitioning Safe and sober housing with support services available to help sustain recovery Justice System Addiction addressed throughout incarceration using best practices (men, women, and pregnant women) Linked into supportive community services upon release Specialized courts and probation officers used to fullest extent Sealing/expunging criminal records so that minor offenses are not impeding on employment

Overall feeling is that medical providers are not always identifying women who need intervention Strong opinions both for and

14 Screening Issues Source: Children and Family Futures Substance use screening/testing protocols are not always written down. Much is left up to the discretion of the provider causing inconsistencies and screening/testing to appears to be arbitrary Overall feeling is that medical providers are not always identifying women who need intervention Strong opinions both for and against universal drug testing during pregnancy and at delivery Medical staff have had limited training on opioid addiction and MAT

15 SBIRT: Screening, Brief Intervention, and Referral to Treatment SBIRT is an early intervention approach that targets those with nondependent substance use to provide effective strategies for intervention prior to the need for more extensive or specialized treatment Overview of SBIRT: Example toolkit for implementing: toolkit.pdf

Clinical Guides https://www.store.samhsa.

16 Clinical Guides Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their- Infants/SMA

17 All Sectors Trained on Addiction and Services... negative attitudes of health professionals towards patients with substance use disorders are common and contribute to suboptimal health care for these patients.

18 All Sectors Trained on Addiction and Services Every door is the right door to treatment Everyone is a touchpoint for identification Everyone should have knowledge for treatment referral

19 Data Sharing: Early warning system Rapid ascertainment of overdoses & reversals Where should community outreach be targeted Rapid shift in resources Opioid Involved Deaths of Women of Childbearing Age MAT Clinics

20 Texas Compared to the Nation National Average Pacific Mountian Texas West South Central East South Central South Atlantic West North Central East North Central Middle Atlantic New England Drug Exposed NAS As of 2015, Texas has the lowest rates of NAS and pre-natal drug exposure without withdraw The gift of time: Identify, Coordinate, & Prevent But not much time: Seizures of Fentanyl increasing /Obstetric-Care-for-Women-with- Opioid-Use-Disorder-Bundle.aspx

21 Thank you! Contacts: Beth van Horne: Dorothy Mandell:

Texas Strategies to Address the Opioid Crisis and Neonatal Abstinence Syndrome

Texas Strategies to Address the Opioid Crisis and Neonatal Abstinence Syndrome 1 Learning Objectives Become familiar with how the opioid epidemic is impacting Texas women Become familiar with Neonatal