PROJECT DOVE Improving Maternal and Neonatal Health Through Safer Opioid Prescribing
PARTNERS SUPPORT Bureau of Justice Assistance, Department of Justice
Rhode Island Opportunity Non-medical prescription opioid use above national average High rates of opioid dispensing to women of childbearing age Growing number of opioid agonist treatment opportunities Small state, geographically manageable for populationlevel intervention
Project Goal Project Dove aims to improve healthcare quality, access, and maternal and fetal quality of life by: Utilizing PDMP data to improve neonatal & maternal outcomes Promoting implementation of evidence-based medical practice for safe opioid prescribing during pregnancy
Project Aims Create a CME and academic detailing materials that address screening, PDMP use, and treating women at risk of delivering an NAS newborn. Promote CME statewide; use PDMP to identify target communities for academic detailing and CME. Conduct an evaluation comparing intervention and control communities on clinical outcomes, e.g., knowledge, self-efficacy, opioid prescribing, perceptions of MAT in pregnancy, NAS rates.
Project Activities Phase 1 Data gathering to assess needs Use PDMP data to select high-risk intervention communities Create multimedia CME course Record simulated patient videos Develop academic detailing materials Phase 2 Live CME and academic detailing in high-risk communities Examine PDMP registration, usage data, and NAS rates by community CME available online for providers in high-risk communities Phase 3 Analyze maternal and neonatal outcomes to measure impact of interventions CME available online for providers statewide
Data Gathering Review of content by national experts Meetings with local multidisciplinary advisors Partnership with RI Neonatal Abstinence Syndrome Task Force Interviews with stakeholders (including peer recovery support specialists) at the Office of Women s Health Region 1 Women and Opioids Symposium Environmental scan of RI hospitals, NAS rounds Statewide prescriber survey
Prescriber Survey Assessed needs and understanding related to opioid prescribing, opioid use disorder, and treatment in pregnant women; and PDMP use/preparedness Oversampled prescribers practicing in/caring for patients residing in intervention community Inclusion criteria: Medical provider with prescribing capabilities Primary practice location is in Rhode Island Most patients of the provider live in Rhode Island Exclusion criteria: Veterinarians
Prescriber Survey Results Reached 69% of response goal, as of March 16 th Data will inform academic detailing development, including how providers can use the PDMP to enhance patient care Survey Responses as of: March 16th Responses 347 0 100 200 300 400 500 GOAL
Selection of Intervention Communities Examined opioid prescriptions (excluding buprenorphine products for OUD) by city/town of residence, filled during the first six months of 2016 to women of child bearing age (15-44 yo): date of birth of 1/1/1972 through 1/1/2001. Compared rates per 1,000 women by city/town of residence using 2010 U.S. Census data (2016 census estimates by city/town and age/sex were not available). Ranked rates by county Selected highest ranking community in each county
Crude Rate per 1000 Women Community Selection Results 400 Six Month Opioid Prescribing Rates Among Women 15-44 Years in County and Intervention Community 350 300 250 200 150 100 50 0 Bristol Kent Newport Providence Washington County Rate Intervention Community Rate
CME Development Status CME content and design drafted Patient video scripts developed Patient and clinician actors recruited Female patients played by: Actor, peer recovery support specialist, research assistant and overdose prevention trainer Clinicians played by: practicing OB/GYN, family medicine, social worker Videographer contracted Prior collaboration on other safer prescribing, naloxone CMEs (Scope of Pain) Online CME developer/host selected
Project Dove Academic Detailing Targeted, one-on-one conversations with providers, clinic staff in intervention communities after live CME Key take-homes, talking points from CME Social marketing materials Q & A, resource provision, practice Use current PDMP academic detailing initiative design, infrastructure Ongoing detailing by health department PDMP just added proactive clinical alerts for high MME, opioid-benzo combinations, and multiple prescriber episodes
Academic Detailing on Safer Prescribing Customized Prescriber Profile Report on prescriber patient that meet 5 pharmacy, 5 prescriber, over 6 month period threshold Prescriber PDMP Search Request History (over six month period) What do you do if you see a positive prescription monitoring report What do you do, when a patient violates a pain agreement? Reference guide to making a patient request in the PDMP
Academic Detailing on Safer Prescribing
CME Learning Objectives Help patients on opioid therapy understand its implications for pregnancy Identify and respond to opioid use disorder among pregnant patients Provide care for pregnant women with opioid use disorder
CME Modules 1 Understanding the Effects of Opioids in Pregnancy 2 Identifying Issues, Developing a Treatment Plan 3 Treatment Plan Adjustment and Perinatal Care
Three Patient Cases
Goals of Patient Case Carol Shared decision-making Pregnancy as an opportunity to reassess opioids for chronic pain Takes opioids for chronic back pain PDMP and records show no signs of misuse
Sarah Goals of Patient Case Comfort in describing reasons to maintain methadone Team coordination with methadone provider and neonatal clinician Supporting patient in recovery Takes methadone for heroin use disorder Concerned about fetal/neonatal effects of methadone
Angela Shows signs of prescription opioid use disorder Goals of Patient Case Identifying and responding to opioid use disorder Understanding legal/ethical considerations Finding medication-assisted treatment and other resources
Sample Patient Video Dialogue Dr. Jones is an OB/GYN. Angela was referred to Dr. Jones by her primary care provider. Angela called Dr. Jones office to request an oxycodone prescription but agreed to an appointment. Prior to the patient visit with Angela, Dr. Jones reviewed Angela s records and the PDMP report placed in the records by Dr. Jones Medical Assistant. Angela s urine screen confirmed her pregnancy. [Visit 1 dialogue demonstration]
Medication-Assisted Treatment Key challenge: Overcoming misperceptions about MAT in pregnancy MAT is recommended for pregnant women with opioid use disorder: Detox associated with high illicit opioid relapse rates MAT improves retention in treatment Neonatal Abstinence Syndrome following MAT is an expected and treatable condition
Supplemental Resources Collecting or developing resource materials to provide in electronic form to CME participants, for example: Screening tools Provider checklists Buprenorphine induction sample protocol for pregnant patients Labor pain medication management table Sample hospital NAS policy Patient/family brochures Local and national resource lists
CME Challenges Fentanyl and how to address Difficulty gaining clarity about mandatory reporting and child welfare agency response State policies related to substance use in pregnancy are vague Limited access to buprenorphine for pregnant women General provider shortage and reluctance to serve pregnant women CME tension between modeling best practices and showing realworld limitations Emerging models of care (Center of Excellence in MAT) but unclear how pregnant women will fit in Need for specification of hospital protocols related to NAS
Questions/Comments? Traci Green: Traci.c.green@gmail.com Gillian Leichtling: gleichtling@rmcres.com Nicole Robertson: Nicole.robertson@bmc.org