4/19/2018. Opioid Use Disorder in Pregnancy OBJECTIVES ANTENATAL TESTING

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1 Opioid Use Disorder in Pregnancy 2017 Recommendations from ACOG and The Pew Charitable Trust KATHY D. HARTKE, MD, LEGISLATIVE CO-CHAIR AND IMMEDIATE PAST CHAIR, WISCONSIN SECTION OF THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS, BROOKFIELD, WI DISCLOSURES No financial disclosures Expert witness in the in the United States District Court for the Western District of Wisconsin Tamara M. Loertscherv. Eloise Anderson, Brad Schimel, Taylor County Testified in Racine County Court 1996 Opioid Addiction Resources - OBJECTIVES March 16, 2018 Drug Enforcement Administration Review key points on Obstetric Care for Women With Opioid Use (Patient Safety Bundle) Discuss research on safer opioid prescribing Present 2018 ACOG and Pew Charitable Trust policy recommendations U.S. Centers for Disease Control and Prevention (CDC) - 63,632 drug overdose deaths in the United States in deaths per day - One death every 8.28 minutes - 42,249 (66.4%) of those deaths were due to opioids. ANTENATAL TESTING Lack of evidence for OUD alone Only if other clinical indications eg. growth restriction Perform at least 4-6 hours after daily maintenance methadone dose Anatomy Ultrasound screening at week Serial fetal growth assessment Vol 130, No. 1, July 2017 Obstetrics and Gynecology 1

2 Multidisciplinary Care KEY GAPS IN KNOWLEDGE Training of health care providers in a manner that fosters multidisciplinary care and crosses specialty area boundaries is needed to provide optimal care COMMUNICATE WITH MAT PROVIDER NEONATOLOGY OBSTETRIC Optimal screening, treatment and care throughout pregnancy and pp Elective medically supervised withdrawal during pregnancy NEONATAL New scoring tool, incorporates neurobehavioral assessment Optimal approaches to nonpharmacologic and pharmacologic rx ANESTHESIOLOGY GENETICS Inherited genetic variations in opioid action and metabolism ACOG COMMITTEE OPINION #711 August 2017 Opioid Use and Opioid Use Disorder in Pregnancy Early universal screening, brief intervention and referral for treatment Use validated screening tools For chronic pain minimize opioids. Use alternatives such as exercise, PT, behavioral approaches and nonopioid pharmacologic treatments Opioid agonist pharmacotherapy is recommended over medically supervised withdrawal. ACOG Committee Opinion POSTPARTUM PSYCHOSOCIAL SUPPORT ONGOING SUD TREATMENT MENTAL HEALTH SCREENING AND SUPPORT FOURTH TRIMESTER FIRST POSTPARUM VISIT AT 1 WEEK Breastfeeding should be encouraged CONTRACEPTION Contraception Counseling and access to contraceptive services should be available to all women of reproductive age Should be a routine part of substance use disorder treatment Offer Immediate Post Partum (IPP) contraception 86% of pregnancies in women with OUD unintended 29% of women report 6 or more pregnancies 6% report 10 or more pregnancies 25-75% of women with OUD report no contraceptive use 2/3 of women who use contraception using condoms 2

3 MULTIDISCIPLINARY APPROACH COMMUNICATE WITH MAT PROVIDER NEONATOLOGY ANESTHESIA Opioid Epidemic: Original Research Patterns of Opioid Prescription and Use After Cesarean Delivery Brian Bateman et al. Massachusetts General, Harvard Medical School VOL. 130, NO. 1, JULY 2017 OBSTETRICS & GYNECOLOGY 720 women enrolled 615 (85.4%) filled an opioid prescription Median Number of pills dispensed 40 (interquartile range 30-40) Median Number of pills consumed 20 (interquartile range 8-30) Median Number of leftover pills 15 (interquartile range 3-26) Of those with leftovers pills 95% had not disposed of them at 2 weeks post-op Patterns of Opioid Prescription and Use After Cesarean Delivery Correlation between the larger of number pills dispensed and larger number consumed independent of patient characteristics # of pills dispensed did NOT correlate with patient satisfaction, pain control or need to refill prescription SHARED DECISION MAKING Leftover opioids from legitimate prescriptions represent a primary source of misused or diverted opioids. A shared decision-making approach to opioid prescribing after cesarean delivery was associated with approximately a 50% decrease in the number of opioids prescribed postoperatively in this cohort compared with our institutional standard prescription. This approach is a promising strategy to reduce the amount of leftover opioid medication after treatment of acute post cesarean pain. A Shared Decision-Making Intervention to Guide Opioid Prescribing After Cesarean Delivery ObstetGynecol 2017;130:42 6 3

4 RESPONSIBLE PRESCRIBING Cesarean Delivery is the most commonly performed inpatient surgical procedure in the United States Shared Decision Making - A Promising Strategy - 10 minutes, one day before discharge - Expected use - Patterns of pain - 50% decrease in number of opioids - Low refill rate - Risks and beneftis of opioid and non-opioid analgesics - Information on opioid disposal and access to refills CONTRACEPTION One Key Question All women age are asked One Key Question as a routine part of primary care: Would you like to become pregnant in the next year? Proactively address the root causes of poor birth outcomes and disparities in maternal and infant health. Oregon Foundation for Reproductive Health thenationalcampaign.org BREASTFEEDING Should be encouraged if no contraindications May reduce NAS symptoms Counsel about the need to suspend breastfeeding if relapse 4

5 OPIOID TASK FORCE REPRESENTATIVE JOHN NYGREN H.O.P.E. Heroin & Opioid Prevention and Education 2017 Special Session July 17, 2017 Governor Scott Walker signed into law 11 special session bills that are part of the Heroin, Opiate Prevention and Education (H.O.P.E.) Agenda. The bills were recommended by the Governor s Task Force on Opioid Abuse. Due to the leadership of Rep John Nygren, almost all bills were passed unanimously by both the State Senate and the Assembly Co-Chairs Report to Governor Cocaine Mom Law Jan 2018 Wisconsin s statute governing pregnant moms struggling with substance abuse needs to be revisited. This statute currently affects a number of stakeholders, and we intend to engage them in the coming months as we work towards a revised statute that maintains its core principles but improves its operation based on what we have learned in twenty years of experience and medical advances. Incarcerated Mothers Senate Bill 393 Stop Shackling of Pregnant Women Provide MAT Provide STI Screening and Treatment Provide Timely Prenatal Care Provide Doula Care *AWHONN POSITION STATEMENT March

6 References Opioid Use and Opioid Use Disorder in Pregnancy. Practice Bulletin 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;;130: Malavika Prabhu, MD, Emily McQuaid-Hanson, MD, Stephanie Hopp, MHS, MS, Sara M. Burns, MS, Lisa R. Leffert, MD, Ruth Landau, MD, Julie C. Lauffenburger, PharmD, PhD, NiteeshK. Choudhry, MD, PhD, Anjali Kaimal, MD, MAS, and Brian T. Bateman, MD, MScA Shared Decision-Making Intervention to Guide Opioid Prescribing After Cesarean Delivery Obstet Gynecol 2017;130:42 6. Uma M. Reddy, MD, MPH, Jonathan M. Davis, MD, ZhaoxiaRen, MD, PhD, and Michael F. Greene, MD, for the Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes Workshop Invited Speakers*. Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, andchildhoodoutcomes Executive Summary. Obstet Gynecol 2017;130: Pew Charitable Trust Presentation to the Governor s Task Force 6