Continuing Education Webinar The Pregnancy Opioid Epidemic: An Outpatient Medical Home Approach to Treatment

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1 Continuing Education Webinar The Pregnancy Opioid Epidemic: An Outpatient Medical Home Approach to Treatment This webinar will be recorded and available on the NPIC/QAS website

2 Nurse Planner: Carolyn L. Wood, PhD, RN, Clinical Nurse Consultant Purpose/Goal(s) of this Education Activity: The purpose/goal(s) of this activity is to enable the learner to expand knowledge on the management of addiction in pregnancy. 1.0 Contact Hour: This continuing nursing education activity was approved by the Northeast Multistate Division (NE-MSD), an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. 1.0 AMA PRA Category 1 Credit : Accreditation: Women & Infants Hospital is accredited by the Rhode Island Medical Society to sponsor intrastate continuing education for physicians. Women & Infants Hospital designates this online educational activity for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should only claim credit commensurate with the extent of their participation in the activity.

3 Disclosures and Successful Completion of this Activity No commercial support has been provided for this activity. No one involved in planning or presenting this program has a conflict of interest. There will be no discussion of off-label usage of any products. In order to successfully complete this activity and receive 1.0 Contact Hour(s) or 1.0 AMA PRA Category 1 Credit, you must attend/watch the webinar and return the completed posttest/evaluation to NPIC/QAS.

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5 Pregnancy Recovery Center A Medical Home Model Approach for Pregnant Women Suffering from Substance Use Disorders 11/1/16 National Perinatal Information Center (NPIC) Webinar Dennis English, MD, MMM FACOG Clinical Professor (Emeritus) Obstetrics & Gynecology Department of Obstetrics, Gynecology, and Reproductive Sciences University of Pittsburgh School of Medicine Senior Medical Advisor NPIC

6 DISCLOSURES Currently serve as Senior Medical Director NPIC Continue to work (intermittently) in the Magee-Womens Hospital of UPMC Pregnancy Recovery Center Member Board of Directors Magee Womens Hospital 6

7 OVERVIEW Addiction to Opioid drugs: a major national problem causes impaired health, harmful behaviors creates major economic and social burdens Treatment of drug addiction: Efficacy equivalent to other chronic conditions: hypertension, asthma, diabetes mellitus Treatment during pregnancy effective in decreasing maternal and neonatal adverse effects Options of Methadone and buprenorphine (Medication Assisted Treatment: MAT) Medical Home approach i.e. (Magee Womens of UPMC: Pregnancy Recovery Center) 7

8 Prevalence and Incidence Obstetrical providers and the Nation are facing an increasing number of Drug Addicted Pregnant women The number of past users of heroin has increased from 373,000 in 2007 to 914,000 in 2014 (National Survey on Drug Use and Health: NSDUH) The misuse and abuse of prescription drugs, particularly opioid pain relievers has been called a public epidemic (CDC) Estimated 4.3 million people engaged in non medical use of pain relievers and 1.9 million have a pain reliever disorder includes ~ 4.0% of pregnant women using within the last 30 days (NSDUH) In ,235 drug overdose deaths were related to Prescription opioid and there were 8,257 Heroin deaths (triple from 2010) The CDC estimates that in 2012 providers wrote over 259 MILLION prescriptions for opioids The estimated societal costs of opioid abuse was $55 BILLION in 2007, 45% of which were health care related

9 Prevalence and Incidence Substance use varies among and within different cultural groups Present among all socioeconomic, cultural and ethnic groups White women more likely to abuse prescription drugs than any other race or ethnicity

10 Diagnostic Criteria: Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 1 or more of the following occurring within a 12 month period: 1. Use results in failure to fulfill major role obligations: work: absences, poor performance school: absences, suspensions, expulsions home: neglect of children or household 2. Recurrent use in physically hazardous situations 3. Recurrent substance-related legal problems 4. Continued use despite resulting persistent or recurrent social or interpersonal problems

11 Diagnostic Criteria: Substance Dependence A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period: 1. tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount 2. withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms

12 Substance Dependence (continued) 3. larger amounts of substance taken or over a longer period than was intended 4. persistent desire or unsuccessful efforts to cut down or control use 5. great deal of time spent in activities to obtain, use or recover from the substance s effects 6. important social, occupational and recreational activities given up or reduced because of use 7. continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use

13 Role of Ob/Gyn Physician Screening, identifying and counseling women regarding substance use Routine screening in history taking: no physical symptoms in majority of abusers screen everyone since no predictors (increases identification from 3% to 16%) Screening Tools : 4P s, CRAFFT (ACOG committee opinion #524) Know and Triage to local community resources

14 Screening Questions First, use ubiquity statements: Substance use is so common in our society that I now ask all my patients what, if any, substances they are using? Then, ask direct questions: Have you ever tried...? How old were you when you first used...? How often; what route; how much? How much does your drug habit cost you?

15 History: Red Flags Maternal chaotic lifestyle: psychosocial stresses spouse/partner of an alcoholic or drug abuser domestic violence, physical and sexual Psychiatric diagnosis: depressions, psychosis, anxiety, PTSD lack of functional coping skills unexplained mood swings, personality changes Late or no prenatal care: missed appointments and compliance problems STDs, sexual promiscuity

16 Physical Examination Nothing unusual is the most frequent finding Nothing users unusual of illicit is the most drugs. frequent finding in users of illicit drugs.

17 Toxicology Testing: Principles Random checks without clinical suspicion: many consider this unethical (ACOG only with informed consent) may be illegal in some locales Nonemergency and competent patient: verbally inform prior to testing document permission in medical record First Line Screening urine: major route of excretion and concentration inexpensive and quick Confirmatory tests: gas chromatography, mass spectrometry

18 Toxicology Drug Screen: Urine Time frame for drug or metabolite to be present: marijuana, acute use 3 days marijuana, chronic use 30 days cocaine 1 3 days heroin 1 day methadone 3 days

19 Pregnancy: Generic Issues Educate patient about adverse outcome effects Screen for domestic violence Screen for STDs, hepatitis B and C, TB Co-manage or refer to multispecialty clinic Refer to drug counseling program Monitor with urine toxicology Sequential antepartum assessment of growth Refer newborn to pediatrics Close postpartum follow up

20 Treatment: Principles Pregnancy offers a Golden moment to intervene Drug addiction is a treatable disease No single treatment is appropriate for all individuals (Methadone, Buprenorphine, Inpatient Drug rehabilitation) Recovery from drug addiction is a long-term process: multiple treatment episodes with relapses Effectiveness is dependent on remaining in treatment for a dedicated period of time Matching multiple needs is critical: medical, psychological, social, legal, vocational

21 Magee Pregnancy Recovery Program: History 2002: After the loss of the only treatment center for addicted pregnant women in the region, Magee developed an Inpatient Methadone conversion center and averages conversion/year 2010 NEJM article: Medical Home approach with the use of Buprenorphine for the treatment of opioid addiction in pregnancy demonstrated shorter withdrawal phase for infants who s mothers were converted to Subutex compared to methadone in pregnant patients In 2013, Magee did 343 inpatient Methadone conversions of addict (average 3 day inpatient stay) and had 250 NAS (neonatal abstinence syndrome) babies withdrawing from Methadone with an average NICU LOS of 15+ days Increasing (and unknown) # of patients are delivering at Magee on Suboxone (mostly from illicit sources) 21

22 Magee Pregnancy Recovery Program: History 2014: Magee, and 4 local Medicaid insurers develop a shared savings approach to establish a Pregnancy Recovery Program (Medical Home Approach) at Magee Womens Hospital 4 OB/GYNs complete (Data 2000 waiver) training to become Buprenorphine prescribers ( Magee PRC opens July 24, 2014 Thru July 2016, 210 pregnant patients have been evaluated and treated in the PRC 2016: Magee receives a $500,000 grant to expand their program to other sites in Pennsylvania 22

23 Magee Pregnancy Recovery Program The Pregnancy Recovery Center s goal is to offer comprehensive care for women suffering from opiate addiction by providing Medical Assisted Treatment (MAT) to prevent withdrawal during pregnancy, minimizing fetal exposure to illicit substances and engaging the mother as a leader in her recovery. Pregnancy Recovery Center operates as an outpatient program and provides consistent, collaborative care throughout the patient s pregnancy. Treating pregnant patients with buprenorphine is a relatively new practice. Early research suggests babies born to mothers taking it instead of undergoing methadone treatment recover more quickly after birth.

24 Pregnant Women with Substance Use Disorder Pregnant women with SUD are often judged negatively by caregivers, especially women addicted to alcohol or drugs. As a result pregnant women with SUD are often reluctant to disclose their problems to caregivers and may be reluctant to seek timely prenatal care. Recent advances in brief screening techniques and improved therapies for SUD emphasize taking a nonjudgmental, empathic stance. Research strongly suggests that increased integration and coordination of services improves clinical outcomes and reduces costs during pregnancy.

25 Plan of Care Establish a supportive relationship Educate the patient: ask the patient to describe her understanding of the situation and correct misunderstandings link substance use to patient s signs & symptoms describe the importance of stopping or cutting down explain consequences of continued use Refer to specialists for assessment and initiation of a treatment plan (Pregnancy Recovery Center)

26 Medication Assisted Treatment (MAT) : Critical Components Induction and Stabilization/Maintenance (Methadone is full agonist, Buprenorphine is partial MU agonist) Counseling/Behavioral therapies: skill-building, problem-solving to prevent relapse Assess for and treat coexisting conditions: mental disorders infectious diseases family planning

27 Babies of the Substance Use Disorder Patients Babies born to pregnant women with Substance Use Disorders (SUD) are at increased risk for: Neonatal Abstinence Syndrome (NAS) Prematurity (late pre-term), low birth weight, perinatal death Cognitive, behavioral and physical problems during childhood, high rates of child abuse and neglect, involvement in the foster care system, challenges in maternal-infant attachment and developmental delays

28 Magee s Medical Home Approach

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34 Heroin/Opioid: Withdrawal Syndrome Symptoms: drug craving anorexia, nausea, abdominal cramping increased sensitivity to pain Signs: hypertension, hyperventilation, tachycardia lacrimation, mydriasis, rhinorrhea yawning, sweating vomiting, diarrhea chills, flushing, muscle spasms restlessness, tremors, and irritability Piloerection The abrupt withdrawal of opioids is associated with an increase risk of fetal loss.

35 Dosing Pregnant Women with Buprenorphine General Medical dosing levels established in men or non pregnant women: Max dosing 16mg/day (all MU receptors are bound at that level) No literature for dosing of Pregnant women PRC dosed based on COWS scores and patient symptoms Doses range from 4mg to 32 mg Pharmaceutics study at Magee demonstrated therapeutic levels changed with gestational age and are different than non pregnant subjects 35

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37 Buprenorphine Daily Dose Of the current active patients: 9 patients are prescribed less than 16mg daily 17 patients are prescribed 16mg daily 10 patients are prescribed greater than 16mg daily 3% 28% 25% <16mg 36% 36% First Trimester 47% 16mg >16mg 25% Second Trimester Third Trimester Postpartum 72% of active patients are on 16mg daily or less

38 Graduates vs. Discharges 210 Patients that completed induction (active patients) 36 Active patients 83 Graduates to Community 17% Recovery 91 Unsuccessful Discharges 43% 40% Active Participants Graduates Average Age: 29 years old Unsuccessful Discharges Average length of use: 7 years Success rate 57%

39 39 Gestational Age on Admission First Trimester (Earliest admissions: between 5-7 weeks) Third Trimester (Latest admission: 39 weeks) Active PRC Patients 5% 45% 50% First Trimester Second Trimester Third Trimester

40 Opioid Use History Comparison includes initial opioid used and opioid using when entering PRC Data includes all inductions into PRC Non-Prescribed is defined by illicit prescription medication (i.e. Percocet) 1% First Opioid Use Entering the PRC 5% 23% 8% 42% Non-Prescribed Prescribed 50% 37% 34% Heroin Buprenorphine 76% of first opioid contact is with a prescription medication (either prescribed or illicit) 50% enter the PRC on a buprenorphine product 40

41 NAS Treatment 93 Deliveries 57 newborns did not require medication for NAS (62%) 36 newborns required medication for NAS treatment 7 deliveries took place outside of Magee-Womens Hospital Data was collected from delivering facility 39% 61% No NAS Treatment Treated for NAS

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43 Median Charges: $50,114 $21,431 $17,804 78% of babies had charges of $50,000 or less

44 Breastfeeding vs. Bottle feeding 93 Deliveries 50 mothers are breast feeding 43 are bottle feeding only 46% 54% Breastfeeding Bottlefeeding

45 SUMMARY Opioid addiction is a growing problem in the US and pregnant women are affected similarly to the US population Opioid addiction is a chronic health problem and should be treated as such A non judgmental, empathic holistic approach by Health Care providers can improve treatment results for mothers and babies Treatment team should be multidisciplinary Pregnant women may require higher doses of Buprenorphine as opposed to non pregnant patients A Medical Home approach can improve outcomes and save health care dollars 45

46 Resources & Acknowledgements Substance Abuse and Mental Health Services Administration ( Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. ( ACOG Committee Opinion #524 (Opioid Abuse, Dependence and Addiction in Pregnancy) ACOG Committee Opinion #538 (Nonmedical use of Prescription Drugs) ACOG Committee Opinion #473 (Substance Abuse Reporting and Pregnancy: The Role of the OB/GYN) American Society of Addiction Medicine National Survey on Drug Use and Health Michael England MD, Elizabeth Krans MD,Stephanie Bobby RN CARN (Magee Womens Hospital of UPMC Pregnancy Recovery Center) 46

47 Questions & Comments Participants are encouraged to ask questions and share comments. Please use the chat box for questions or comments. Questions and comments are visible only to presenters. Questions will be answered in the order in which they are submitted. Should there not be enough time to address your question(s), please so we may follow-up with you.

48 Thank You for Attending! ATTENTION: For 1.0 Contact Hour or 1.0 AMA PRA Category 1 Credit *DO NOT CLOSE YOUR BROWSER WINDOW* POST-TEST WILL AUTOMATICALLY APPEAR WHEN THE WEBINAR HAS ENDED Please complete the post-test within 24 hours Certificates of Attendance & Completion will be ed within 14 business days

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