PROJECT ECHO OPIOID USE DISORDER IN PREGNANT WOMEN 1 OPIOID USE - - PowerPoint PPT Presentation

PROJECT ECHO OPIOID USE DISORDER IN PREGNANT WOMEN

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OPIOID USE DISORDER IN WOMEN

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

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RECOGNITION & PREVENTION

DEEPA N AGAR, M D AN DRI A PET ERSON , PH ARM D

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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

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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
• r 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.

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WHAT IS THE SCOPE OF THIS PROBLEM IN NEVADA?

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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

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2015-2016 CDC OPIOID PRESCRIPTION RATES BY COUNTY

Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42

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EPIDEMIOLOGY

• Nevada High Intensity Drug Trafficking Areas (HIDTA)

Report: 2018 Threat Assessment

• Prescription painkillers prescribed per 100,000 patients
• 2nd highest state in US for hydrocodone & oxycodone
• 4th highest state in US for methadone
• 7th highest state in US for codeine
• Prescription drug overdose mortality rate
• 4th 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

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OVERDOSE DEATHS PER 100,000 RESIDENTS

Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42

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WHAT IS THE SCOPE OF THE PROBLEM IN PREGNANT WOMEN?

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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.

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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

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NEVADA PRENATAL SUBSTANCE ABUSE

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DIGNITY HEALTH DATA

Methadone Clinic: Maternal Toxicology Data

2015 2016 P Value Overall (2015-2016) # of mothers in a methadone clinic 13/42 (31%) 30/59 (51%) P < 0.001 43/101 (43%) Non-Compliance Rate 6/13 (46%) 16/30 (53%) P = 0.221 22/43 (51%)

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DIGNITY HEALTH DATA

Methadone Clinic: Infant Toxicology Data

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

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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%)

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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 20/42 (48%) 43/59 (73%) P =0.01 63/101 (62%) Infants positive for a controlled substance 22/42 (52%) 39/59 (66%) P =0.165 61/101 (60%) Infants positive for > 1 substance (polysubstance use) 23/42 (55%) 48/59 (81%) P =0.015 71/101 (70%)

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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%)

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DIGNITY HEALTH DATA

Prenatal Care/Discharge Information

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

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UNDERSTANDING BARRIERS TO TREATMENT FOR PREGNANT WOMEN…

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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.

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BARRIERS TO TREATMENT DURING PREGNANCY

• Multiple policies exist on screening, treatment, reporting
• f 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.

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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.

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

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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 1st 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.

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HOW DO I SCREEN?

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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.

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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.

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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.

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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) Alcohol & substances 3 Paper & pencil No Prenatal clinic Tolerance, Annoyed, Cut-down, Eye-opener (T-ACE) Alcohol 4 Paper & pencil No Prenatal clinic Tolerance, worried, eye-

• pener, amnesia,

K(c)ut-down (TWEAK) Alcohol 5 Paper & pencil No Prenatal clinic

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.

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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.

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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.

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COMMON SCREENING QUESTIONS: LENGTH OF TIME DRUGS CAN BE DETECTED IN URINE

Drug Time 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 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

Moeller, K. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76.

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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 Tricyclic antidepressants Carbamazepine Cyclobenzaprine Cyproheptadine Diphenhydramine Hydroxyzine Quetiapine

Moeller, K. Urine drug screening: practical guide for clinicians. Mayo Clin Proc. 2008;83(1):66-76.

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

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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
• ut 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.

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WHERE CAN I REFER MY PATIENT AFTER A BRIEF INTERVENTION?

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REFERRAL OPTIONS

• Tune in August 28th 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/

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DIGNITY HEALTH EMPOWERED PROGRAM

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WHAT ABOUT INFANT TOXICOLOGY?

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INFANT TOXICOLOGY

Matrix Benefits Drawbacks Urine

• Sample can be difficult to

collect

• Results are readily available
• 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 Cord Tissue

• Sample is easily collected
• Accurate results
• Exempt from maternal

consent procedures

• Collection
• Storage
• Policy must be in place

Meconium

• Sample is easily collected
• Relatively wide collection

range

• Exempt from maternal

consent 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

Hair

• Sample is easily collected
• Exempt from maternal

procedures

• Fetal hair only reflects exposure during 3rd 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.

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WHAT IS NEONATAL ABSTINENCE SYNDROME (NAS)?

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NEONATAL ABSTINENCE SYNDROME (NAS)

• Tune in September 11th at 8am to

learn more!!!

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QUESTIONS???

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