PROJECT ECHO OPIOID USE DISORDER IN PREGNANT WOMEN

PROJECT ECHO OPIOID USE DISORDER IN PREGNANT WOMEN 1

OPIOID USE DISORDER IN WOMEN Recognition & Prevention Date: August 14 th, Time: 8 am Presenters: Deepa Nagar MD, Andria Peterson PharmD Maternal Treatment Options Date: August 28 th, Time: 8 am Presenters: Brian Iriye MD, Farzad Kamyar MD, MDA Infant Treatment Options Date: September 11 th, Time: 8 am Presenters: Deepa Nagar MD, Andria Peterson PharmD Reporting & Follow-up Date: September 25 th, Time: 8 am Presenters: Hayley Jarolimek, Kevin Schiller 2

RECOGNITION & PREVENTION DEEPA NAGAR, MD ANDRIA PETERSON, PHARMD 3

ABBREVIATIONS OUD = Opioid use disorder NAS = Neonatal abstinence syndrome SUD = Substance use disorder MAT = Medication assisted treatment SBIRT = Screening, brief intervention & referral for treatment CPS = Child protective services PDMP = Prescription drug monitoring program 4

BACKGROUND The United States continues to face an opioid epidemic Compromises the health of individuals, families & communities >27 million people reported concurrent use of an illicit drug or misuse of a prescription drug in past 30 days in 2015 Women continue to be a high risk population Prescription misuse & illicit drug use during pregnancy results in very poor consequences on the mother-infant dyad Infants are at risk for withdrawal, also known as neonatal abstinence syndrome (NAS) Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 5

WHAT IS THE SCOPE OF THIS PROBLEM IN NEVADA? 6

EPIDEMIOLOGY Nevada High Intensity Drug Trafficking Areas (HIDTA) Report: 2018 Threat Assessment US opioid prescription rate 66.5 per 100 residents Nevada opioid prescription rates 2013: 78.1 per 100 residents 2016: 87.5 per 100 residents Opioid prescription rates by select counties Clark: 84.3 per 100 residents Nye: 155.6 per 100 residents Equates to more than one prescription per person!!! Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 7

2015-2016 CDC OPIOID PRESCRIPTION RATES BY COUNTY Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 8

EPIDEMIOLOGY Nevada High Intensity Drug Trafficking Areas (HIDTA) Report: 2018 Threat Assessment Prescription painkillers prescribed per 100,000 patients 2 nd highest state in US for hydrocodone & oxycodone 4 th highest state in US for methadone 7 th highest state in US for codeine Prescription drug overdose mortality rate 4 th highest state in US 3 out of 4 heroin users starts with prescription drugs Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 9

OVERDOSE DEATHS PER 100,000 RESIDENTS Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 10

WHAT IS THE SCOPE OF THE PROBLEM IN PREGNANT WOMEN? 11

EPIDEMIOLOGY 1998-2011: Prevalence of OUD during pregnancy doubled Increased to 4 per 1,000 deliveries 2008-2012: # of reproductive age women filling an opioid prescription each year according to pay source 33% enrolled in Medicaid >25% enrolled with private insurance 2011-2012: 31% increase in women of childbearing age (15-44 year old) reported past-month use of heroin 3 out of 4 heroin users start with Opioid prescriptions Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 12

EPIDEMIOLOGY Epstein RA, Bobo WV, Martin PR, Morrow JA, Wang W, Chandrasekhar R, et al. Increasing pregnancy-related use of prescribed opioid analgesics. Ann Epidemiol. 2013;23(8):498-503 13

NEVADA PRENATAL SUBSTANCE ABUSE 14

DIGNITY HEALTH DATA Methadone Clinic: Maternal Toxicology Data 2015 2016 P Value Overall (2015-2016) # of mothers in a methadone clinic Non-Compliance Rate 13/42 (31%) 30/59 (51%) P < 0.001 43/101 (43%) 6/13 (46%) 16/30 (53%) P = 0.221 22/43 (51%) 15

DIGNITY HEALTH DATA Methadone Clinic: Infant Toxicology Data 2015 2016 P Value Overall (2015-2016) # of infants with mothers in a methadone clinic Non-Compliance Rate 13/42 (31%) 30/59 (51%) P < 0.001 43/101 (43%) 11/13 (85%) 22/30 (73%) P = 0.394 33/43 (77%) 16

DIGNITY HEALTH DATA Infant Toxicology Data of Mothers in a Methadone Clinic: Illicit vs Controlled vs Polysubstance Use 2015 2016 P Value Overall (2015-2016) Infants of mothers in a methadone clinic positive for > 1 substance (polysubstance use) 11/13 (85%) 22/30 (73%) P = 0.938 33/43 (77%) 17

DIGNITY HEALTH DATA Infant Toxicology Data: Illicit vs Controlled vs Polysubstance Use 2015 2016 P Value Overall (2015-2016) Infants positive for an illicit substance Infants positive for a controlled substance Infants positive for > 1 substance (polysubstance use) 20/42 (48%) 43/59 (73%) P =0.01 63/101 (62%) 22/42 (52%) 39/59 (66%) P =0.165 61/101 (60%) 23/42 (55%) 48/59 (81%) P =0.015 71/101 (70%) 18

DIGNITY HEALTH DATA Infant Toxicology Results: Specific Substances 2015 2016 P Value Overall (2015-2016) Opiates 20/42 (48%) 34/59 (58%) P = 0.320 54/101 (54%) Benzodiazepines 3/42 (7%) 13/59 (22%) P = 0.043 16/101 (16%) Methamphetamine 14/42 (33%) 31/59 (53%) P = 0.056 45/101 (45%) Marijuana 11/42 (26%) 18/59 (31%) P = 0.636 29/101 (29%) Cocaine 0/42 (0%) 2/59 (3%) P = 0.228 2/101 (2%) 19

DIGNITY HEALTH DATA Prenatal Care/Discharge Information 2015 2016 Overall (2015-2016) Infants admitted for NAS with no prenatal care Infants discharged with someone other then parents 11/42 (26%) 11/59 (19%) 22/101 (22%) 12/42 (29%) 22/59 (37%) 34/101 (34%) 20

UNDERSTANDING BARRIERS TO TREATMENT FOR PREGNANT WOMEN 21

BARRIERS TO TREATMENT DURING PREGNANCY Shame Misinformation Legal consequences implemented by several states Goal: Protect the infant from opioid exposure Consequence: Drives women away from seeking or continuing care leading to worse outcomes for infant & the mother Healthcare professionals & systems are often reluctant to provide care Typically due to misunderstanding & lack of experience in treating pregnant women Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 22

BARRIERS TO TREATMENT DURING PREGNANCY Multiple policies exist on screening, treatment, reporting of substance use during pregnancy/postpartum period & involvement of child protective services (CPS) which can be confusing American Academy of Addiction Psychiatry American Society of Addiction Medicine Committee on Healthcare for Underserved Women American College of Obstetricians & Gynecologists American Academy of Pediatrics Substance Abuse & Mental Health Services Administration Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 23

BARRIERS TO TREATMENT DURING PREGNANCY Take home point: Without treatment, pregnant women with OUD face increased risks of preterm delivery, low infant birth weight & have an increased risk for transmitting HIV to their infants Effective interventions, including medication-assisted treatment (MAT), can lead to healthy outcomes for mother & infant Requires recognition by health care professionals!!!! Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 24

WHAT WOMEN SHOULD I SCREEN FOR SUBSTANCE USE DISORDER (SUD)? 25

RECOGNITION World Health Organization (WHO) recommendations Who? Healthcare professionals should ask ALL pregnant women about their use of alcohol & other substances Universal screening Ask about past, present, prescribed, licit & illicit use How often? As early as possible in pregnancy & at every follow-up visit 2017 American College of Obstetricians & Gynecologists (ACOG) recommendations: Screening for SUD should be part of comprehensive OB care & should be done at the 1 st prenatal visit Screening based only on factors, such as poor adherence to prenatal care or prior adverse pregnancy outcome, can lead to missed cases & may add to stereotyping/stigma It is ESSENTIAL that screening be UNIVERSAL Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 26

HOW DO I SCREEN? 27

WHAT IS SBIRT? SBIRT: Screening, Brief Intervention, & Referral for Treatment Evidence-based practice to identify, reduce & prevent problematic use, abuse & dependence on alcohol & illicit drugs 3 major components Screening Brief intervention Referral to treatment Substance abuse and mental health services administration. Integration.samhsa.gov. Accessed August 9, 2018. 28

SCREENING SBIRT: Screening A healthcare professional assesses a patient for risky substance use behaviors using standardized tools Screening can occur in any healthcare setting Tools for screening: Prescription Drug Monitoring Program (PDMP) Interviews & instruments Toxicology Substance abuse and mental health services administration. Integration.samhsa.gov. Accessed August 9, 2018. 29

SCREENING State-based PDMPs Collects data from pharmacies on prescriptions of controlled substances Confirms patients seeing multiple physicians for controlled prescriptions Also helpful in identifying use of any other prescription medications that can be harmful during pregnancy Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 30

Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. SCREENING Interviews & instruments A complete history is essential to establishing a safe & appropriate treatment plan Measure Problem Screened # of items Method Training necessary? Validation Sample 4P s Plus & Integrated 5Ps Violence, mental health, tobacco, alcohol, illicit substances 5 Paper & pencil No Inpatient/ Outpatient Substance Use Risk Profile-Pregnancy (SURP-P) Tolerance, Annoyed, Cut-down, Eye-opener (T-ACE) Tolerance, worried, eyeopener, amnesia, K(c)ut-down (TWEAK) Alcohol & substances 3 Paper & pencil No Prenatal clinic Alcohol 4 Paper & pencil No Prenatal clinic Alcohol 5 Paper & pencil No Prenatal clinic 31

SCREENING Maternal toxicology What can be used? Urine, blood or saliva Do I need informed consent? Oral informed consent may be used, but a signed paper or electronic form is preferred Ask the pregnant woman what, if anything, she expects might be detected in the test Give her an opportunity to describe her substance use patterns & behavior Toxicology testing should still be obtained when there is self-reported use Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 32

SCREENING Maternal toxicology Additional laboratory tests to order in women with SUD: HIV Hepatitis B & C Sexually transmitted infections (STIs) Liver enzymes & serum bilirubin Detection for liver disease Serum creatinine Detection for silent renal disease Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 33

Moeller, K. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76. COMMON SCREENING QUESTIONS: LENGTH OF TIME DRUGS CAN BE DETECTED IN URINE Drug Alcohol Methamphetamine Barbiturates Short-acting (pentobarbital) Long-acting (phenobarbital) Benzodiazepines Short-acting (lorazepam) Long-acting (diazepam) Cocaine metabolites Marijuana Single user Moderate user (4 times/wk) Daily user Long-term heavy smoker Opioids Codeine Heroin (morphine) Hydromorphone Methadone Morphine Oxycodone Propoxyphene Phencyclidine Time 7-12 h 48 h 24 h 3 wk 3 d 30d 2-4d 3 d 5-7 d 10-15 d 30 d 48 h 48 h 2-4 d 3 d 48-72 h 2-4 d 6-48 h 8 d 34

COMMON SCREENING QUESTIONS: AGENTS CONTRIBUTING TO FALSE POSITIVES Substance Potential agent causing false-positive result Substance Potential agent causing false-positive result Alcohol Short-chain alcohols (isopropyl alcohol) Cocaine Coca leaf tea Topical anesthetics containing cocaine Amphetamines Amantadine Buproprion Chlorpromazine Desipramine Dextroamphetamine Ephedrine Isometheptene Labetalol Methylphenidate Phentermine Phenylephrine Promethazine Pseudoephedrine Ranitidine Trazodone Opioids & heroin Dextromethorphan Diphenhydramine Poppy seeds Rifampin Verapamil Benzodiazepines Oxprazosin Sertraline Phencyclidine Dextromethorphan Diphenhydramine Doxylamine Ibuprofen Imipramine Ketamine Meperidine Thioridazine Tramadol Venlafaxine Cannabinoids Dronabinol Efavirenz NSAIDS Proton pump inhibitors Moeller, K. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76. Tricyclic antidepressants Carbamazepine Cyclobenzaprine Cyproheptadine Diphenhydramine Hydroxyzine Quetiapine 35

MY PATIENT HAS A POSITIVE TOXICOLOGY RESULT. NOW WHAT DO I DO? 36

BRIEF INTERVENTION SBIRT: Brief intervention Pregnancy is a time of great potential for positive change A woman with OUD may be motivated to enter treatment out of concern for herself & health of the fetus She can envision a different future for herself & her child 5 basic steps to intervention: 1) Feedback is given to the mother about risks 2) Responsibility of change is placed on the mother 3) Advise to change is given by the provider 4) Menu of treatment options are offered 5) Empathic style is used in counseling 6) Self-efficacy or optimistic empowerment provided to the mother Substance abuse and mental health services administration. Integration.samhsa.gov. Accessed August 9, 2018. 37

WHERE CAN I REFER MY PATIENT AFTER A BRIEF INTERVENTION? 38

REFERRAL OPTIONS Tune in August 28 th at 8am for detailed information regarding maternal treatment options Nevada Division of Public & Behavioral Health (DPBH) certified providers http://dpbh.nv.gov/programs/clinicalsapta/dta/providers/ SAPTAProviders/ 39

DIGNITY HEALTH EMPOWERED PROGRAM 40

WHAT ABOUT INFANT TOXICOLOGY? 41

INFANT TOXICOLOGY Matrix Benefits Drawbacks Urine Cord Tissue -Sample can be difficult to collect -Results are readily available -Exempt from maternal consent procedures -Sample is easily collected -Accurate results -Exempt from maternal consent procedures -Only reflects recent exposure *Not completing confirmatory urine testing can be disastrous, as false positive results may lead to loss of custody & legal prosecution -Collection -Storage -Policy must be in place Meconium Hair -Sample is easily collected -Relatively wide collection range -Exempt from maternal consent procedures -Sample is easily collected -Exempt from maternal procedures -Sample appears to form at 12 weeks. Volume of meconium increases throughout gestation, with most being produced in the last 2 months of gestation, focusing detection on last 2 months in utero. -Sample may be contaminated by urine -Does not reflect periods of abstinence -Fetal hair only reflects exposure during 3 rd trimester -Accuracy is limited by chemical composition of hair (dark hair vs light) Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 42

WHAT IS NEONATAL ABSTINENCE SYNDROME (NAS)? 43

NEONATAL ABSTINENCE SYNDROME (NAS) Tune in September 11 th at 8am to learn more!!! 44

QUESTIONS??? 45