Healing Two Generations: Care for Pregnant/Parenting Women with Substance/Opioid Use Disorder

Hello everyone and welcome to today’s
webinar, which is co-sponsored by the Northwest ATTC and the Western States
Node of the NIDA Clinical Trials Network. My name is Meg Brunner and I’m with the
Northwest ATTC and I’m gonna be hosting this thing today for you guys. We’re
gonna get started in a minute but first I just wanted to give you some
information on how this is gonna work. So, first we’ll be posting the slides from
today and also a recording of the webinar on the Northwest ATTC website
later this afternoon — you can see the URL on the bottom of the screen there. You’ll
also get an email after the webinar is over with a link to a survey about it
that we would really like you to complete, and you’ll get a second follow
up survey in 30 days. Your feedback is really important to us so thank you in
advance for filling those out. In about a week or two, you’ll get another email
from us — sorry about that! — that has instructions on how to obtain your CEU
for this session. So if you stay until the end of the webinar you’ll be
eligible for 1.5 NAADAC credits. Please feel free to ask the speakers questions
at any time during the presentation using the chat box and then at the end
I’ll read your questions to them so they can respond. Okay so let’s get started. Our two speakers today are Dr. Hendree Jones and Dr. Carl Seashore. Dr. Jones is
executive director at UNC Horizons and professor at the Department of
Obstetrics and Gynecology at UNC Chapel Hill. She’s an internationally
recognized expert, oops, I was supposed to advance the slide here hold on let me
see if I can actually advance the slide — there we go. There we go. Okay she’s an
internationally recognized expert in the development and examination of both
behavioral and pharmacologic treatments for pregnant women and their children in
risky life situations and has written over 195 peer-reviewed publications and
also authored two books including one on comprehensive care for women who are
pregnant and have substance use disorders. Dr. Seashore is a Professor of
Pediatrics in the Division of General Pediatrics and Adolescent Medicine and
is soon to be the Pediatrician in Residence at UNC Horizons. Very cool. He
is a general academic pediatrician with interest in quality improvement, newborn
care, ambulatory pediatrics and informatics. Dr. Seashore has worked
extensively with the Perinatal Quality Collaborative of North Carolina
relating to newborn care delivery across the state. They’ll be speaking today
about research and clinical perspectives on providing comprehensive care for
pregnant and parenting women with opioid use disorder. So Dr. Jones I’m gonna
transfer control of the screen over to you okay and so just click on the slide
and then see if you can advance the slides. And just a reminder it might take
a second. [Dr. Jones] I’m clicking okay on the screen Just saw the mouse move, so that seems like a good time you know. [Meg] Let me just take a look at that and I think you just did it. [Dr. Jones] Well we just moved the mouse like okay that’s I guess that’s the way
we’re gonna do it. All right okay and I’m now I can’t move back. All right so we’re
just gonna go ahead and start. Sorry about that. Where our disclosures — we
really don’t have any disclosures. I guess we’re not that popular with drug
companies which I guess is a good thing. In terms of the FDA context I think
it’s really important that we at least acknowledge that both methadone and
buprenorphine that we’re gonna be talking about today have historically
been labeled in the… previously the FDA used categories and it was category C,
basically recognizing that there are animal reproduction studies that have
shown adverse effects on animal fetuses and that there weren’t adequate, well
controlled studies in humans so basically use these medications if the
benefits outweigh the risks for pregnant women. And of course now the labels have
been been changing on opioid medications and so it’s important to also note that
as May of 2016 that the FDA is requiring a boxed warning around the risk of
neonatal opioid withdrawal syndrome which we often know as neonatal
abstinence syndrome for a variety of opioid agonist medications including
methadone and buprenorphine. What’s also important on this slide is
that we know that medication assisted treatment in the form of methadone and
buprenorphine are really our first line therapies and if you look at the labels
for both methadone, as well as the single product and combination product, they all
talk about pregnancy and they all talk about lactation and postpartum. So again
use these medications like you would other medications where the benefit
needs to outweigh the risk to the mother and the fetus. And then finally I would
draw your attention to a 2014 paper published with an FDA consultant where
these medications are not to be considered “off-label” use, or in other
words, they’re on label use. Reading the product inserts will be very helpful for
explaining that. Okay so we have four objectives that we’re going to
accomplish with the time that we have. So we want to look at the historical and
current factors; they can help us understand the current opioid crisis
that we have in this country particularly for women. We’ll be looking
at the new SAMHSA recommendations that were published in February of 2018
about how to care for pregnant women and their children. And then we’ll also be
looking at identifying factors that drive neonatal abstinence syndrome, also
known as neonatal opioid withdrawal. And then the final objective that we hope to
accomplish is looking at different elements, at least three elements that
you can name that are common themes around model programs that we know work
to produce positive mother and child outcomes. So taking a historical look,
which I think is really important otherwise history begins to repeat
itself, we know that this isn’t the first time in our country that we’ve had an
opioid crisis. So if you look carefully at the literature, that the first time it
was acknowledged was in the 1800s and the vast majority of people that were
using opioids were women and they were obtaining their opiates from
well-meaning providers that were providing them opiates for
things like menstrual problems, pregnancy problems, anxiety, depression etc etc. It
was really in the 40s and the 50s where we started to see negative and
stigmatizing language used around women who are using opiates. There’s a famous
book called “The Road to H” where they basically describe women that were
using opiates, and who especially became pregnant, as unloving, as selfish, as
self-indulgent, as non-compliant, and those sort of negative words and
negative stereotypes unfortunately have really stuck. So then moving forward to
the 70s with the Vietnam era and we had another rise in opiates in this country
and that’s when the National Institute on Drug Abuse in the early
seventies one of their first initiatives that they focused on was opioids and
pregnancy and there were some really interesting demonstration programs that
happened there that we actually have some long-term outcomes of babies that
were prenatally exposed to opiates including methadone. And then finally of
course in this current time we have the opioid epidemic that again was, in part,
stemmed from a great access to legal prescription opioids. So looking now
where we are, there was a Presidential Commission on combating drug addiction
and the opioid crisis and one of the main tag lines that came out of that was
an acknowledgement that every single day 175 lives are lost in terms of drug
overdose. In general it’s been, it’s different estimates are around but
around 120 individuals every day die attributed to opiate related causes. And
so that’s, you know if you think about this incredibly sobering statistic, it’s
like an airplane every single day falling out of the sky and if an
airplane every single day was falling out of the sky, perhaps, you know, the
response would have been more immediate. The good news of course is that there is
a tremendous amount of state local and national attention being given to this
and a lot of funding is being put towards solutions. And so the last part
of the slide that I’ll draw you to is the numbers of individuals who die
each year and you can see where HIV is going up and then
obviously dramatically gone down in the last decade, whereas car accidents and
guns have remained relatively stable whereas drug overdoses have crept up. And
so when we look at a gendered view of opioid use in the United States, or
misuse in the United States, you can see that in the far left hand, they’re all
the opiates, males — the light red and dark red are males in 2015 and 2016
respectively — so you can see that these are the age adjusted rates of overdose
deaths. So you can see for opiates, all opiates, prescription opiates, as well as
for cocaine and psychostimulants that if you look at sheer numbers males more
often die than women do. What’s not in this number of course is the
sensitivity around, from 1999 to 2017, the death rate from drug overdose among
women aged thirty to sixty-four has dramatically spiked up, 260%. So I think we need to be paying close attention to both genders
and not forgetting women. This triple wave epidemic is something that has been
talked about and I think this slide nicely shows that from the CDC just in
terms of, you know, it used to be that we would have a stimulant epidemic
and that would go down, and then we would have a sedative epidemic, and then that
would go down. Now we’re getting waves that are kind of
tidal waves crashing over us with, you can see the rise in what’s called
painkillers here concurrent with the rise in heroin and then of course
now the fentanyl and fentanyl analogs in terms of death. And so each one of those,
while they’re all opiates, still the context I think in which individuals are
getting these and using these and dying from them do tend to be different and
warrant unique approaches. And particularly for women because this is a
talk focused on women, there’s been an overall 48% rise in death rate in in women and in large part this is
women in rural America and it’s attributed to both suicide and overdoses. So we just really there can’t be enough emphasis placed on the need to really
focus on women and what we can do to help protect them and help them have
better health outcomes. And so when thinking about women and opiates, we know
from the literature that women compared to men are more likely to report chronic
pain, we are more likely to be prescribed prescription pain relievers, kind of like
the 1800s, we’re more likely to be given them in higher doses and for longer
periods of time than our male counterparts and there was also data to
show that we were less likely to receive naloxone for an overdose. And hopefully
that has begun to change with training and first responders. So that
hopefully that gender gap is starting to change. So this is an interactive part of
our webinar with thinking about how you define addiction so if you could take
just a moment to write in the chat box how you all define addiction, I’ll read a
couple of those responses. Two new messages all right, so an illness
that is inherited is one of the answers, use despite negative consequences,
chronically relapsing brain disorder, use despite negative consequences, compulsive
behavior despite negative consequences, loss of control, chronic illness or
condition, pervasive dependence on a substance, dependent on something, and
substance use that impairs functioning in multiple life areas. Fantastic, yes. So
I think all of those responses tell me that you’re very familiar with with the
topic and, you know, also too it also says something about the sort of multimodal
issue that this illness is. If we were to look at the DSM-5 you
know they’ve really — the DSM has changed our language. It used to be abuse and
dependence and now they’ve changed it to be a use disorder that is a
continuum from mild to moderate to severe, and in this wheel you can see you
know that really that loss of control, the loss of being able to fulfill
obligations, the use despite health problems, those urges, the inability to
successfully cut down or stop when we want to, as well as the issues around
tolerance and withdrawal. So I think thank you all so much for for adding to
the discussion and the webinar. So who is at risk for having an opioid use
disorder? Obviously everybody that takes an opiate is not going to develop an
opioid use disorder and so giving guidance to providers about what do we
need to be looking for. And there have been a number of papers that have been
published on this topic. I just picked two to highlight. And so what they found
is among individuals that had an opioid use disorder that were prescribed
opiates they found that the biggest risks for developing an opioid use
disorder was already having another substance use disorder. And you can see
there on the left-hand side that alcohol use disorder was for 41% of patients and
nicotine dependence was 29%. And then there’s also that component of major
depression. When we looked at another study of 4,400 patients entering drug
treatment for an opioid use disorder because they had been initially exposed
by a physician’s prescription to treat pain, again it’s similar data. So we can
see having used a psychoactive substance not medically before or at the same time
of their opioid prescription was a big red flag as was alcohol, tobacco, and
marijuana, and that was true for both women as well as for men. So what’s
really important about this is when opiates are being prescribed, that you’re
having conversations and looking for these red flags to have additional
conversations and understanding and guidelines for patients that might need
these opiates to not develop an opioid use disorder. When we think
about pregnant women, these are data from SAMHSA with a national survey and you
can see data from 2015 in blue, 2016 in green, 2017 in gray, and when we’re
looking at illicit drugs, you can see that’s broken out, and while so much of
our national conversation and is around obvious you can see that opiates, while
they’ve gone up in proportion over 2015 2016 and 2017, it’s still marijuana is
actually the leading illicit substance that is reported by women to they used
during pregnancy, and then of course that’s still smaller than the tobacco
use or alcohol use during pregnancy. And so I hope that opiates doesn’t
overshadow the conversations that we need to be having with women about
tobacco products and alcohol products and particularly with regard to vaping
and there’s other types of inhaled products. So now I’m gonna turn it
over to Carl to talk about neonatal abstinence syndrome. [Dr. Seashore] Great, thank you, Handree, and so as we think about the epidemic, particularly the opioid
epidemic, over the last decade, one of the huge impacts of that and where it’s been
palpable to me as a pediatrician is in the concomitant rise and our seeing of
neonatal abstinence syndrome also called neonatal opioid withdrawal syndrome. So
you’ll see that abbreviations NAS or NOWS. And so to follow the theme of sort
of looking at history here how has that been defined historically? So you’ll see
the first reference there on the bottom of the screen is from 1975 and
that’s really when our modern definition of this came to be, and essentially NAS
results when a pregnant woman is regularly using opioids such as heroin
or oxycodone or medication assisted treatment with methadone or
buprenorphine during the pregnancy and so that the fetus is continually exposed
to that compound or medication in the womb, and then
when they’re born that continuous exposure is cut off when the umbilical
cord is severed and that withdrawal can manifest in lots of different ways. Characteristically we think about it as four different categories. One is central
nervous system withdrawal, in which case you might hear high-pitched crying or
see irritability. If you’ve ever watched a news clip on NAS, it inevitably
involves a screaming baby which is perhaps not the right way to present it
but it’s what we see. They can also have exaggerated reflexes, tremors, and
increased muscle tone or tight muscles. Their sleep patterns are often disrupted,
they also exhibit autonomic nervous system dysfunction, with sweating, fever,
yawning, sneezing, and some of those things can overlap behaviors that we see
in normal babies, non-exposed babies. The gastrointestinal system as you know has
opioid receptors in it and babies can manifest gastrointestinal distress after
exposure in the womb, and this can show up as poor feeding, vomiting, loose stools. Often these babies have a terrible diaper rash after a couple of days if
their stools are loose and then they can also show signs of respiratory distress. And I can recall more than one baby that I’ve been called to the bedside for
evolving respiratory distress and other symptoms, and have been concerned about
sepsis or pneumonia, when in fact it’s neonatal abstinence syndrome from an
unknown exposure during the pregnancy. So really a wide variety of symptoms can
manifest, but it’s important to recognize that neonatal abstinence syndrome is
different than fetal alcohol syndrome, and fetal alcohol syndrome causes
permanent structural brain changes typically with early exposure to high
doses of alcohol in the first trimester, and this has been associated with
long-term behavioral and cognitive and physical outcomes in babies, whereas
opioid exposure during pregnancy has not had those same associations. We also know
how to treat NAS — over the last five to ten years there’s been really
exciting progress in in how we approach treatment for these babies and moms
together. And as far as we know these treatments
don’t have the same sorts of long-term effects as alcohol exposure in the womb
or even nicotine exposure with growth restriction and prematurity and other
consequences of that. So as we think about the rates of NAS in the setting
of our current opioid epidemic, if you look at this slide,
it’s the incidence of NAS per thousand live births looking between 2004 and
2014, and this was from the journal Pediatrics published just last year. And
you can see that the rate of NAS has been climbing just as the rate of opioid
use and prescriptions has been climbing and then the majority of these babies
are covered by Medicaid so the burden for this treatment of NAS typically is
falling to states and the federal government. Another important thing to think about in terms of the background of
approaching women with NAS is that can occur in a host of different types
of presentations. So for me when I was in training 20 years ago it was more
common that I would see this with either drugs of abuse or methadone, and
buprenorphine treatment really wasn’t available. Currently my experience in a
typical week in the nursery is that if I am concerned about NAS it’s in a woman
who’s engaged in treatment through our Horizons program and is taking
buprenorphine in a medically assisted treatment type program, although we
certainly still do see illicit use as well as prescribed medications for
chronic pain. So we can have a host of different scenarios where a woman is
taking oxycodone because she had a pelvic fracture during her second
trimester and she has pain from that — that’s a real case — with women who are in
MAT and receiving medication like methadone or buprenorphine under medical supervision, also women are using street drugs such as heroin and others
illicitly but also women who are perhaps finding their way to some
buprenorphine or methadone illicitly. So it’s not always cut and dry and it’s
really important to dig into the history of a pregnancy to understand the scope
of risk because the the stability of the mother-baby dyad depends tremendously on
whether or not the mother is in treatment or otherwise stable in her
receipt of these opioid medications during pregnancy, and that’s really
important for management decisions moving forward. The pathophysiology of
neonatal abstinence syndrome is really rooted in this deprivation of opioids
for chronically stimulated receptors. This stimulates a whole cascade of
neurotransmitter synthesis and redistribution that ultimately increases
noradrenaline corticotropin and receptor activity peripherally, as well as
acetylcholine, while decreasing serotonin and dopamine. So basically you’re getting
a surge of all the stress hormones and suppression of all the “chill” hormones to
put it in lay terms and so you can imagine that would make a baby feel
pretty out of sorts when they’re acutely deprived of these substances that they
were exposed to in utero. Another key point that I think is really important
to reinforce with ourselves and our colleagues, but also with the mothers and
and family members of these babies, is that newborns aren’t addicted to these
medications, right, they are simply physically dependent because they were
exposed during pregnancy. But as Hendree’s interactive exercise pointed out just a
few slides ago, we really think about addiction as a behavioral disease and
babies are not behaving in erratic ways to seek their next dose of medication,
they’re simply having a physiologic response to the withdrawal, and so it’s
really important to talk about that it’s dependence rather than
addiction, and as a physiologic process that we can understand and know how to
treat, rather than thinking of these babies as being addicted. And again,
if you’ve read any of these articles in the lay press it’s not at all uncommon
for the headline to read something like “addicted babies: what do we do about it”
or something like that, and so I’ve written many letters to the editor to
get those changed and I would encourage you all to do the same if you see that. As far as the substances that might be implicated in NAS, again, the historical
definition was really built around heroin in the 70s but in fact we’ve seen
now over the ensuing decades that the physiologic expression of NAS can occur
with other non-opioid drugs as well as the newer synthetic opioids that we’re
seeing both in prescription and MAT applications today, as well as on the
street. But we also see it with SSRIs and tricyclics or methamphetamine and other
inhaled drugs, and so again, a very good history of the mother’s exposures during
pregnancy is critical and if we take that, as folks involved with care of
newborns, from a vantage point of being able to help their baby as as best as
possible, then we’ll be more successful in understanding exactly what those
exposures may be and how we therefore need to treat them. There are some other
factors that none of us can control that relate to NAS manifestations in
severity. One is genetics; differential metabolism of opioids can lead to
differential experiences physiologically. The most notable change about this
recently is the removal of the recommendation of any codeine products
in pregnant and breastfeeding women and more careful thought given to
ultra-rapid metabolizers and potential secondary exposure to baby in moms
receiving those medications. So for the OB folks in the room definitely looking
at ACOG resources about prescribing during pregnancy
and breastfeeding is something I’d encourage you to do. And then the other
things that sometimes we can control are concomitant substance exposure, and the
secondary data analysis from the mother study that showed NAS presenting more
severely in babies who are concomitantly tobacco exposed illustrates this well. So when you’re working with the mom especially prenatally being able to
counsel her about things she can do to help her baby have the best possible
outcome, perhaps, although it’s not easy, the most impactful thing she could do
while remaining in treatment and on medicated medication assisted treatment
is to cut down or eliminate her tobacco exposure, and just last week I had a mom
who did this by picking up vaping instead of smoking with the
misunderstanding that the vaping products didn’t include nicotine, and so
being really attentive to that in the prenatal period is important. But we
do know that babies who are born to moms in MAT are more likely to go to term
and have a healthy birth weight and so that is definitely the preferred
treatment course and it’s important also to know that the dose of methadone or
buprenorphine doesn’t seem to relate to the severity of NAS so the mother
should be on the dose that’s right to treat her symptoms without a concern
that a higher dose might put the baby at increased risk. So what can we do? And I
saw in the chat box someone was eager to hear about treatment, so thanks for
hearing about background, and we’ll jump into that now. There’s lots of things
that we can do short of pharmacotherapy that can really improve the outcomes, andn
the literature over the last five years has been rich with papers demonstrating
very specific projects that have have shown success here. So one and the one
we’ve known for the longest is simply having a protocol —
getting the people together, before you’re looking at a baby, who are going
to be involved from OB and anesthesia, midwifery, pediatrics, family medicine,
social workers, nursing staff, lactation consultants, really everybody who’s going
to be interacting with that family that dyad and creating a protocol where you
talk about non-judgmental language as was mentioned
earlier, where we talk about what the assessment mode is going to be for these
babies, what the room environment is going to look like, where can they be
cared for, does your hospital require these babies to be admitted to an
intensive care setting for their NAS or can you provide the same level of care
on the mother-baby unit where rooming in has been shown to improve outcomes
exceptionally well. What assessment tool are you using, are you using the original
Finnegan, a modified version of the Finnegan, one of the other opioid
withdrawal assessment tools that’s out there, or one of the newer tools such as
the eat sleep and console approach that was recently published out of Yale and
has subsequently been validated or at least our restudied at BU and in New
Hampshire. Other things is what criteria do you use to initiate and wean
pharmacotherapy when you start it? What is your policy around breastfeeding in
women who otherwise don’t have a contraindication to breastfeeding, such
as HIV infection, and then what about separation of mother and baby especially
as the baby’s length of stay goes longer than the mother’s postpartum stay and
the baby may need a longer period of observation?And so thinking about all of
those factors are things we can control as as pediatric providers that can
improve babies outcomes. So here’s a paper from Yale. This is Matt Grossman’s
work. This was a cohort of 50 consecutive methadone-exposed infants managed in
their inpatient unit. Their Finnegan scores were recorded per historical
routine, but they were managed using this eat sleep and console assessment
approach which, if you’ve not heard of that, essentially is instead of measuring
the 28 items in giving a numerical score to those and adding those numbers up and
making a treatment based on those numbers, instead it
encourages focusing on functional outcomes in the baby, ie,
can they eat an appropriate amount for their for their age, can they sleep for
at least one hour uninterrupted without waking, and if
they’re fussy or irritable can they be easily consoled, either by the mother or
other family members who are present or with additional interventions
recommended by hospital staff. That might be something as simple as dimming the
lights or turning off the television, it might be finding the right swaddling
technique, or using a pacifier, it might be increasing the caloric density if the
baby’s not breastfeeding of their formula to make eating a bit more
efficient. These are measured objectively as greater than or equal to an ounce if
they’re bottle feeding, again undisturbed sleep for an hour, and console if they’re
crying within 10 minutes. So what Dr. Grossman and his team then looked at was
the treatment decisions that were made using their ESC approach and they
compared those with the predicted treatment directions, had the FNASS
scores been used. And using the ESC approach, they had six infants who were
treated with morphine compared to thirty one, so 12 percent versus 62
percent of the babies in this particular cohort were treated using this novel
approach and they had no readmissions or other adverse events reported with this
cohort. So a really provocative but also encouraging study validating this novel
ESC approach. And speaking from our own experience here in Chapel Hill, we’ve
been using this approach for about 18 months now and much, very similar to Matt’s published work and and ours is in press, we have substantially reduced the amount
of opioid used in treating NAS and then the improved length of stay again with
no observed adverse outcomes. [Dr. Jones] And so just to add on to that,
just to think about this, a number of papers that have been published looking
at which type of opioid medication is better to treat NAS and it seems
like, my take on the literature, and Carl you can correct me if I’m wrong,
is that methadone seems like it’s got a bit of an edge and winning out in terms
of medication. So I didn’t know if you wanted to say anything more about that. [Dr. Seashore] Yeah, like I said,
there’s been a lot that’s come out in the last five to ten years, and we’ve
seen studies looking at buprenorphine, that was a New England Journal paper
suggesting non-inferiority at least if not better. Methadone does seem to be edging out morphine from a safety perspective, but
morphine still remains the most commonly used medication simply because of its
ease of titration and availability, but I think that’s an area where we’re going
to see some change in the coming years and we should be paying attention to the
literature to see what else comes out that might give a more clear guidance on
what to use for both primary and secondly medications for babies with
more severe NAS. [Dr. Jones] Awesome thank you. So let’s take a step back now and let’s
really talk about what happens when women who are using substances get
pregnant, because that’s the most common reality that you see, is that you have a
woman she’s using different types of substances and then she becomes pregnant, and for some women they continue to use and for others they don’t, and you can
actually see this in the national data if you’re looking at non-pregnant in the
dark green through first, second, and third trimester for alcohol, for
cigarettes, as well as for illicit substances, at least women are telling us
that they are reducing their, the proportion of women are reducing their
substance use once they become pregnant and then throughout their pregnancy
which I think is encouraging. But for some women who are using substances
become pregnant, they’re not able to stop and really, you know, I don’t think I’ve
ever met a woman who didn’t want to have a healthy birth outcome, and so for those
women who aren’t able to reduce or stop they likely by
nature of that substance use disorder definition that we looked at before they
likely have some type of substance use disorder. So we want to be, because it’s
that sort of salient feature of continuing to use in spite of adverse
consequences, so we need to be able to respond to them in an empathetic and
helpful and non-judgmental way. And so how do we do that. So SAMHSA has published guidelines, as I said, in February of 2018. This is a super
user-friendly document and there are different fact sheets that can be pulled
out and I believe they’re even more fact sheets now that have been coming out and
so you can google them, you can download them, and they’re, the audience is for
providers, as well as for laypeople and the five main recommendations that came
out was, one is that we should not be using medication-assisted withdrawal
also known as detox as recommended during pregnancy, and we’ll talk a bit
more about that. Secondly that both buprenorphine and methadone are safest
medications for managing opioid use disorder among pregnant women. But
if women already are on one of those medications you release wouldn’t be
switching them so please don’t switch women that are well maintained on
methadone to buprenorphine or the reverse. If the medication is working for
a women don’t change it, keep her stable because you don’t want to create a
period of vulnerability. A fourth recommendation was that breastfeeding is
recommended for women who are stabilized on buprenorphine and methadone, and that
seems to be a challenge, we need to keep continuing to repeat this message
because there’s still a lot of misinformation out there. And then
finally around the neonatal abstinence syndrome, there was a recommendation for
not treating with diluted tincture of opium, given the amount of alcohol that’s
in that medication. Then so more about the medication supervised withdrawal not
being recommended, so there’s concern not so much around spontaneous
abortion or fetal demise or premature labor as was originally written a long
time ago now, really there’ve been a number of papers to show that it is
possible to withdraw women safely from these medications in terms of
pregnancy outcomes, but really what the concern is is around the return to
substance use, and so from, in non- pregnant adults, we know that
detoxification doesn’t work very well as a long-term solution for opioid use
disorder, so why would we think it would work any differently in pregnant women? That said there should never be a blanket one-size-fits-all, everybody has
to do this, so if there is a decision to withdraw because, for example, a woman
says I’m not going to come to treatment unless I’m withdrawn from all substances
and you want to keep her in care, then that needs to be a case-to-case decision. And so some guidance around doing that would be, you know, using a controlled
setting, having a really good social support and overall recovery support
system and care plan, having a contract talking through what that’s going to be,
what that’s going to look like for her, and making sure there’s a continuous
conversation during that withdrawal, if it’s going to be done, that the benefits
are outweighing those risks. So in terms of what ACOG is seeing around treating
women with opioid use disorders during pregnancy we want to be doing universal
screening and when we see universal screening, that is a verbal tool, it is
not looking for a urine or using some other type of biological matrices,
it’s having a good conversation with a woman so that she will trust you and
she’ll understand what happens if she does say yes, she has been using a
substance. So giving that brief intervention and referral to treatment. And I see a lot of times that the brief intervention is sort of passed over, that
it’s just she screens positive and immediately there’s a referral, when
providers have such a powerful opportunity to talk to women and give
them some really good advice and to use some motivational interviewing, a
readiness ruler, those types of things can be great interventions in this brief
way. And then also just thinking about multidisciplinary long-term follow-up. So
I’m going to talk more about the postpartum period, but really it
shouldn’t just be a truly medicalised approach, we need to have
social supports on board, we need to be thinking about developmental aspects for
the babies, as well as social aspects for mom, and then
comprehensive medical care for both mom and for baby. And this slide just talks
more about how screening really differs from testing, because I see a lot of that
gets confused in the literature and in talks that I see, and so screening you
know it’s a cheap way of doing things, we want tools that are going to be more
sensitive and not miss potential people and then rule them out later with
a later assessment, and screening should be really quick and easy to use and
should be well accepted by both patients and staff. And in turn maternal urine
testing is much more of — it needs to be done very carefully, there needs to be
consent with mothers, there is a cost to it so you really need to think about
how much does this, how much of the benefit are you’re going to get for the
cost, and there’s also how you’re gonna do it because if it’s just quick tests,
there’s a lot of false positives and these can have damaging negative
consequences that radiate for both the mother and for the child if it’s not
confirmed testing. So when we ask have you been using substances, how much have you been using, when we ask in a non-judgmental and more normalized way
each time we are seeing all women, we need to understand that if we pair that
with a urine drug testing, that there are many limitations to a urine drug test,
and just getting a urine drug test is not a diagnosis for a substance use
disorder. We could have women that are using that
don’t test positive because there’s a short detection window for her substance. It might not capture those sort of more intermittent binge
stop/starts. It’s really bad for detecting alcohol use, unless they’ve
used a lot right before they come in, and then for prescription drugs and
opiates, we have to be really careful because depending on the type of panel
and the testing that’s used it doesn’t capture all of the different types of
substances that could be used. And when thinking about doing this type of urine
testing we really also need to be thinking about the ethical issues, and
there’s two different cases, one in 1962, addiction was finally
recognized as an illness by the Supreme Court, as
well is in Ferguson vs.the city of Charleston in 2001, women couldn’t be
tested without their knowledge or consent, because that was a violation of
the Fourth Amendment, and I can tell you there are hospitals out there that are
continuing to do this, and that’s really dangerous for both the mother as well as
for for the child. I also hear continuously about a lot of punitive
measures and if punitive measures were able to really be a good a way to
address the opioid crisis that we have, we wouldn’t have an opioid crisis
problem. So punitive responses really don’t decrease drug use in pregnancy, in
some places they can actually increase it with women being scared to seek
treatment, being scared to seek prenatal care. It can create unnecessary child
welfare involvement and concerns around that, it can disrupt this really critical
period of time of attachment for mom and for baby, and then certainly there
long term consequences for women being convicted of a drug-related crime: they
can’t get housing, they can’t get a job, they can’t get financial aid, they can’t
get help with educational opportunities. So we really need to be treating this as
a health issue and putting those supports in place rather than punitive
issues. In terms of capacity and treatment in this country, again,
piggybacking on this punitive approach, a lot of times we’ll see a punitive
approach with not one single dollar increase for treatment, and we know that
already, still to this day we have underfunding of treatment centers. And
this is a study that Stephen Patrick and colleagues wrote that said that only 15%
of treatment centers offer specialized services for pregnant women. And this
could be even worse in rural and poor areas so we really need to be doing a
much better job with how to get treatment to the right people. And it
shouldn’t just be prenatal care or substance use disorder treatment in and
of itself, it really needs to be integration of care and so for example
at Horizons we have a model of care where pregnant women and postpartum
women come in, they see their provider for physical health care and for their
medication assisted treatment, if they have an opiate use disorder, and they
also see a peer support specialist and a therapist, all in one bundled visit,
and that we’ve seen creates only a 5% low birth weight and 5% prematurity rate at Horizons for at least the last six years running, which is pretty remarkable
in a high-risk population of women. What does our World Health Organization say
about recommendations in their guidelines? These were published in 2014. There are a total of 18 guidelines. The one that I will point you to is the one
that talks about, #11, that pregnant patients with opioid dependence
should be advised to either continue with opioid maintenance therapy, either
methadone or buprenorphine, and this is really the first guideline that ever
came out to say that buprenorphine or methadone can be used, and it wasn’t one
over the other in terms of the medications that we have available to us. If you look at the product inserts that are approved by the FDA to go with the
medications, you will see that methadone, buprenorphine alone, as well as the
combination product all talk about pregnancy postpartum and lactation so
they all can be used during pregnancy, and we’ve been getting a lot more data
on the combination product that I’m not going to go over, but I’m happy to have
conversations with people about that in terms of, and I’m sorry the bullets kind
of drifted down the slide here, but really you know both methadone and
buprenorphine have advantages and disadvantages. The advantage that buprenorphine seems to have over methadone is in terms of lower risk of overdose
deaths. We have fewer drug interactions and it’s also easier to get
in terms of an office-based treatment. There are also disadvantages,
and so certainly around induction, that that can take some time to do with
methadone as well as with buprenorphine, and then the other piece the guidance
did talk about was in terms of buprenorphine and methadone might not be right
for each individual patient and so it really needs to be an individualized
patient discussion to see what their preference is and which fits best for them. These were data that Carl already alluded to with the idea that in looking
across women who have been treated with methadone or buprenorphine and
looking at NAS, what a driving factor of the NAS was not the medication they
were on during pregnancy but how much they were smoking, and so you can see in
these graphs that categorizing women by non-smoking, below average, average or
above average smoking, there’s a really clear dose relationship between worse
outcomes with women — the more they smoke, the worst outcomes they had in
terms of more morphine to treat the NAS that their babies had, the baby
stayed in the hospital for a longer period of time with the more cigarettes
smoked, and their birth weight was actually was lower too, with the more
cigarettes that they smoked. I think it’s important that we talk more about this
fourth trimester or postpartum. It’s such a critical period for mom and for baby
and oftentimes this is when treatment ends. I hear so often that six weeks postpartum and all of the care and support the women have been
receiving it just kind of drops off to nothing very quickly, when actually this
is the most critical time. Babies are not sleeping through the night, they’re going
through feeding growth spurts, and so we really need to be doing more for mom and
more for baby. And there’s a lot of issues around insurance being lost at
this time too. And I think this is in part what driving this maternal mortality
that we see that’s increasing on our national basis. If you look in 2000 we
had 18.8 per 100,000 live births whereas maternal mortality was happening
and that’s continued to eke up to 23.8 per 100,000 live births and this is this is
a really concerning issue. And there were multiple driving factors for this
including overdose, including suicide. I think the loss of Medicaid coverage by
six weeks postpartum might be a possible driver of this as well as sort of the
way that most, some people are being treated during pregnancy for their
opioid use disorder with detoxification. So this study was published in 2014. I
think it’s really startling. They looked at data from 98 to 2009 and
found that women who used opiates during pregnancy had higher rates of depression,
anxiety, and chronic medical conditions compared to those that didn’t use, but
most concerning was that this last line down here with women using opiates were
four times more likely to have a prolonged hospital stay and almost four
times more likely to die in the hospital before discharge. So this just really
tells us that we have to have better protocols to help our medical facilities
be able to engage women who are using opiates or in treatment for opioids or
in active addiction, how to get them the help that they need and how to
be able to best respond to them to keep them safe. More about pregnancy
associated deaths due to drugs these data are from Texas Maryland Alaska
Georgia and Virginia and you can just see that the overdoses are playing a
concerning role. Looking again nationally across the data in terms of the
divergent paths, so from 1990 to 2015, the number of maternal deaths for 100,000,
you can see here this is even more recent data, and to 2015, which is it’s
eked up now to 26.4 and you can see that we’re going up as many
other countries that you would think we would be equivalent to you are going
down. When looking at the different states you can see that California has
done a really great job actually of reducing the maternal death rate and in
part that’s because of the more comprehensive care that they are
providing to patients. So now that we’ve talked about sort of that fourth trimester,
let’s think about what are the long-term outcomes of children that are prenatally
exposed to opiates because that’s something that we get a lot of questions
about. And I think that the literature is still very much out there. There’s a lot
of, so we don’t have any type of firm conclusion. We have a lot of data from
the 70s and we’re getting some more emerging data now and there have been a
number of NIH calls for proposals so hopefully in the next five years we’ll
have even better answers than we have now. But when you’re looking at the
literature, these this is a guideline of what to be looking for. So there’s a lot of
papers out there that do a very poor job of defining who has been actually
prenatally exposed and prenatally exposed to what. There’s a lot of over-attribution just to opiates, when there’s a tremendous amount of background benzodiazepine and alcohol use and exposure. What type of comparison group
are we looking at? Were the assessments masked, and this is a critical important
point because if you have assessors that know the background of
the children there is bias inherent in the way the assessments are done. And
there’s lots of matching and statistical and inferential issues that we could
talk a lot about. So just be very cautious and thoughtful when you’re
looking at this literature. And the data that we have that were blinded
assessments comparing methadone and buprenorphine outcomes up to 36 months
were published by the MOTHER group of which I was a co-author, and we had 96
children and we looked at: did it matter of methadone versus buprenorphine
exposure, what were the cognitive behavioral differences, developmental
differences compared to the normative, norms that we have on the test that we
look at. We looked at this data inside out, upside down, backwards, and we really
didn’t find any patterns of differences between medications or between the
children compared to the norms, so I think that’s somewhat reassuring,
although we need more data. And so I really think that it’s important as
we’re looking at this and focused so much on long-term outcomes, that we’ve
really remembered the past. And Deborah Frank rent a beautiful article in JAMA
in 2001 that looked at cocaine use and prenatal exposure and she did a very
thoughtful review of the literature and I just think that this quote here from
her is really important, that you know with all of the media hype around cocaine
and exposure she really didn’t find these toxic developmental long lasting
effects six years out and so I think we just
need to be very careful and thoughtful because this label of being prenatal
opiate exposed or an “NAS baby,” which I don’t like that term, has radiating,
damaging long-term effects for the children as they go through life. And I’m
going to turn this over to Carl. [Dr. Seashore] Great, thanks again. So in thinking about the
factors that mold long-term outcome in in these babies,
many of whom are exposed not only to opiates but other substances in utero, is
what is that postnatal period looks like when growth and development are
occurring at such a rapid pace in the first months and years of life. And so
one way to think about that is through understanding attachment and
understanding that securely attached infants really are going to have a
better baseline capability to self-regulate and find safety when they
need it. So a child who has a secure attachment to their mother will
think, “I’m hurt, I’m gonna go go get my mommy and she’s gonna make me feel
better,” right?And the flip side of that is
children who’ve had insecure attachment developed what’s called this internal
working model where they fear or know or concern that a caregiver will be
unavailable or non-responsive when the child needs help, and that can create
sort of a vicious cycle of maladaptive stress response systems in children. And
so, much more so than potentially the actual substance exposure during
prenatal brain development, is what’s going on in postnatal brain development
and what can we be doing to support the optimal mother-child dyad relationship
to take advantage of the neuroplasticity of the of the brain
and early childhood and and help foster those secure attachment and
healthy adaptive behavior systems. And when we think about non secure
attachment and substance abuse there’s a lot of threads that go through that sort
of situation that I think highlight some of the behavioral and other problems we
can see in kids who’ve grown up either in an environment where substance use is
occurring or who are potentially exposed in utero. And
so we know that having been abused as a child yourself is an important risk
factor for whether or not you might abuse your own children. And people
older than I are more likely, probably, to have been spanked as children but that’s
something that started to change 40 or 50 years ago and unfortunately is still
finding its way towards change and hopefully being eliminated as a common
practice. We also know that women who are in treatment for substance use disorders
have an astonishingly high rate of abuse or neglect in their own childhoods and
that maternal substance use is associated with child maltreatment. So
it’s sort of this cyclical pattern of abused in childhood/more likely to
engage in substance abuse because of that, if untreated more likely to neglect
or harm your own child, and that continues generation to generation as
those children grow up exposed to the traumas of substance abuse in their own
childhoods. These women also very understandably have this high incidence
of hostile attributions maybe to their own children based on their own
experience as children and I would also say potentially to caregivers because
sometimes we’ve not been the best allies for women when they come
seeking treatment and many women today who have opioid use disorder developed
it in a doctor’s office or a dentist’s chair or in some other medical
environment, and so the impact of that on trust is something we shouldn’t
overlook. And this essentially can formulate not only the parent-child
relationship and imbalance there, but also the doctor-patient relationship. And
so I think it’s really important to be attentive to the the risk for
maladaptive attachment that these women can have and the importance of
disrupting that cycle in protecting the next generation. So if we think about this from a neurodevelopmental perspective and how
the experience of trauma, especially early childhood trauma, impacts
development — kids who are exposed to a trauma or neglect in early childhood
instead of having that organizational structure where the cortex and our
cognitive ability and concrete and abstract thought are the most developed
area, in fact what happens is you have maladaption of the limbic system
and over-development of the midbrain which is sort of your fight or flight center where you’re you’re constantly being chased by a lion and
having to run or jump or hide or do something to escape your own death and
so if if you think about babies growing up in an environment where they don’t
have that positive reinforcement and sense of comfort and trust and safety,
their brain grows in such a way that it becomes harder for them to do those
things, and their reasoning and judgment capacities can actually be
impacted in the long term. And so I’ll give it to Hendree for this one last study
she talked about. [Dr. Jones] Yes so just thinking just in terms of not only about the
babies that we’re talking about but also for our moms, ourselves, themselves
because so many of the moms at least who I get to work with, about 90 percent of
them have sexual, physical, and emotional abuse that started as children and that
have been continuing through adulthood and so I think it’s just really
important that we need to honor and understand the trauma that moms have had
so that we can better understand how to prevent and work with any type of trauma
exposure that the child has had, and then the more that we can have that healthy
attachment the better it will be. That said, there is no one-size-fits-all
treatment approach, and so I think it’s really important when we’re thinking
about substance use that there is you know there’s a continuum
right, so we can have people that are using substances that don’t have
problems. It’s when you get into the mild, moderate, and severe substance use
disorders those are the individuals that we really need to be focused on, unless
we’re concerned about sort of preventing that use from becoming a use disorder. And
so the wonderful thing about treatment is that the ASAM has given us these
placement criteria so that we can better fit the type of substance use disorder
to the type of treatment response that’s needed. And so I just, because sometimes
people get really focused on only residential treatment for women who are
pregnant and using substances, when in fact there are many different
types of forms of treatment that women can benefit from. And I put this slide in
here, it’s old and it’s from 1993, but it is still incredibly relevant because we
know what to do. We’ve known how to really start to respond to women since
the 70s and in 1993, this was the second TIP that was a published by SAMHSA and
you can see this model program has outreach services, laboratory, it’s
integrated care, social work, it’s follow up, it’s diagnosis, it’s case management, so
all of these things are still incredibly relevant today in terms of having
integrated and comprehensive care, these are things that work. And thinking about
the NIDA principles of treatment, we can see here this is for non-pregnant
individuals and yet this can be incredibly relevant for pregnant and
parenting women too. So it’s a whole conglomeration of different services
that are the biopsychosocial, that are really important for me for being able
to change behavior and maintain those changes in behavior. And so Horizons: I
just wanted to highlight this as a model because we do work with, about 50% of our
women are pregnant, the other 50% are parenting when they come to us, and I
think one of the things that makes us unique is, or makes what we do work well,
is a uniformed philosophy of care that is informed by both a social learning
approach as well as a relationship and empowerment model. So thinking about how
women are getting to your services, do they have child care — child care is such
a huge issue for our women and sometimes they
have to choose between coming to treatment or taking care of their
children. So those barriers again we talked about in 1993 and we’re still
talking about them now and we really need resources put to that because that
is such a key part of the sort of connective tissue and glue that helps
treatment work, being able to help get women back on their feet in terms of
getting them educational opportunities that they might have missed out on,
having them learn how to get a job and then keep a job is really important
because they’re two different set of skills. Carl already talked about that sort of parenting and early intervention piece
that’s so critical, being able to screen and assess children
that have had that sort of starting out in somewhat risky life situations and
being able to then quickly respond with the care that they need and then
obviously having psychiatry because about half of our women have some type
of mood disorder and then having that continuum of care with the residents and
outpatient care. And of course in the backdrop of medication assisted
treatment opportunities for women, and I think when we think about what works, the
whole — we have to also look at our language that we use, so this is on the
left hand side is the stigmatizing language and the preferred language is
on the right hand side. And the idea of “crack baby” you should that should be
just like gone from anybody’s language and vocabulary that we really need to be
talking about the substance exposed and infant and also thinking about how we
talk about urine samples so the idea that urines are dirty or clean, we would
not ever say that someone who has HIV has a dirty blood sample for HIV so why
do we do that with individuals that have substance use disorder? And when we can
change our language that we can actually show that we can have better, more
positive outcomes, at least in terms of retrospective record reviews, that’s been
shown. And so there are other models that are out there and resources that are out
there. I’ll give a shout out for the SHEILDS program — I think there was
somebody I saw in the participant list so if you’d like to write in anything
about your program, that’s a wonderful true family program Dartmouth and
New Hampshire and Vermont they have had a CHARM
collaborative and Dartmouth with the hub-and-spoke model of care. So there are
many different fantastic models of care out there that all have the same mission
of improving healthy moms and healthy babies, and having a more continuum and
integrated care standard. And then I think I also put this little map in here
just in terms of knowing what the resources are in your area is also
really important. And too, having an integrated care — somebody just wrote and
said could you speak to the utility of a plan of safe care? And I think so much is
how that plan of safe care is actually conducted. I can tell you in the state of
North Carolina, we’ve worked really hard as a state to have children that are
born known to be substance-exposed, that there is a referral that happens, rather
than an automatic, the triggered response by Child Protective Services, so that
there’s an opportunity for screening out those moms and babies for which just
because you have a substance exposure doesn’t mean that mom is unsafe to care
for that baby. And I think that the plan of safe care again how it gets rolled
out really becomes a part a larger part of recovery oriented system of care for
families with obviously mom and child in the center surrounded by a variety of
clinical treatments, but there’s more than this, just that there needs to be
clinical supports and community supports put in place so that when mom leaves
treatment, she has an opportunity to stay well and to not have to get as sick as
she was to meet criteria to come back into treatment. So what can we do in
terms of recovery checkups, what can we do in terms of more peer support
networks, what can we do in utilizing all of those public-private partnerships
to help people stay well. And so what can you do? There’s, on the individual level, there, so often we hear about negative things
that happen in terms of the sort of the bad stories that happened when
there’re just as many recovery and success stories. And so for you to be an
ambassador and tell those stories of recovery. When you’re thinking about care
to really not pit mom versus child but its mother *and* child and
what’s going to be best for both of them. There’re great toolkits from a number
of states as well as from SAMHSA that you can look at. And then in a
structural level, you know, enough can’t be said about responsible
prescribing and education for all types of providers from dentists to social
service to law enforcement — anybody that is going to interact with a woman of
childbearing age I think really needs to be trained on kind of that SBIRT model
so that there’s greater access and understanding and awareness that
substance use disorders can be treated and that success can happen. So just
in summary we know that opioid use disorders certainly is a concerning
medical illness. It has radiating effects not only to that person but also to
those around the individual. And that people with this illness deserve
appropriate medical care but medication in and of itself should really only be
one part of the complete treatment approach. It does great things, but it
needs more, it needs a behavioral health approach that goes with it, and we need
more options for patients and more access to patients, and when we provide a
strengths-based perspective, sometimes we have to be the people that hold the hope
for the patient when they can’t hold it for themselves, but if we don’t have
confidence and hope for the patient, the chances that they’re gonna get better
are going to be diminished. And so we’re gonna leave you with this quote and then
we’ll be happy to answer questions. That to treat babies for drug
withdrawal, we have to help the moms too, and rather than stigmatizing moms
with addiction, research suggests that a holistic approach to improving the lives
of both mother and child is most effective. And thank you so much for your
time and attention then. We look forward to answering questions. [Meg] Wonderful thank
you so much that was really great. I’m gonna take control back from you and we
can start with questions. I saw a couple come in that I don’t think you
answered yet. So one was a question about something you had said where you had
said — why is ten minutes the range permitted before consoling a crying baby?
[Dr. Seashore] That’s a great question and it highlights I think an important difference between
quality improvement-based scholarly projects and research and the Grossman
work was a quality improvement in and so I can’t speak to their intention
but I can assume that they arrived at ten minutes based on consensus between
the people on the baby’s treatment team. All babies cry and it’s a common thing
we encounter among parents that they’re they’re concerned obviously when their
baby is crying, but the vast majority of babies who are crying for whatever a
reason, whether it’s they have a dirty diaper, they’re hungry, or they’re tired
or or it’s too bright in the room, or whatever, we don’t know, can typically be
consoled within five to ten minutes and so I think that number was probably
picked somewhat arbitrarily but as a means to have an objective cut off that
if the baby’s not consoled within 10 minutes, then the physician the nurse and
the mother all need to be, and father to address one of the other questions in
the queue, there, whoever is involved in the care of the baby needs to be there
at the bedside assessing whether that irritability is is potentially being
caused by withdrawal and another level of treatment is needed. And so really
that was a trigger to bring the providers back to the bedside to
clinically reassess the baby just like you would do if the blood sugar was you
know not responding to your insulin dose, right, you would go reassess the patient
and then maybe adjust your insulin dose and so that that was really put in there
as a trigger to to prompt evaluation. [Meg] Interesting okay so another person asked
if you could discuss a little bit the induction strategy for buprenorphine
versus methadone. [Dr. Jones] Sure so with regard to buprenorphine, because it’s done in
provider’s office, there’s typically, well it sort of depends it depends on the
provider, but the way that you would manage someone who did not have, who is
not pregnant, is very much the way that you’re going to manage somebody who is
pregnant. So the idea is that you would have them come into your office, you
would do some kind of objective assessment of withdrawal, objective and
subjective assessment of withdrawal, because we don’t want to be giving
buprenorphine to somebody that isn’t in
withdrawal because then you don’t want to take the chance of precipitating the withdrawal. So they need to, usually for us that we use the COWS, which is the Clinical Opioid Withdrawal Scale and we wait for something between eight to
twelve and then we provide the first dose. We split the dose in half in the
first day, so we usually start out around four and then give another four to eight,
with an opportunity for more. The patient has to get her own prescription and so I
can talk more about that. I think that might be, it depends on what state you’re
in and what type of Medicaid, what’s going on with Medicaid or private
insurance, but we basically then monitor and make sure that they’re having a good
response. We’ll provide phone support if they’re outpatient and they’re going
home, and so there’s a lot of there’s handhold, psychological hand-holding that
happens and our women — we’ve been doing this for several years and have had no
problems with it. It’s worked really well. And we actually have a paper under
review right now to talk more specifically about that induction, but in
a thumbnail sketch that’s what we do. With methadone, that would be, you know,
they have to — women have to go to a provider of an opioid treatment program
and so that induction often is done on an outpatient basis and again you’re
going to start with a minimum dose of methadone somewhere around you know 20 to 30
milligrams and then gradually increase over time. You need to be careful to not
overdose or not move the dose up too quickly. But that’s it’s pretty it’s not
it’s not that difficult. It’s pretty simple. [Meg] Hmm okay. So this next question
I’m going to read to you and then I’m hoping that maybe you can explain a
little bit what the question means because it’s very clinical and I’m not
sure everyone will understand that question to begin with. Okay
so it says, I see a lot of OBs willing to move to universal verbal and rare
urine but PEDIs, I don’t know if that’s pediatrician,s tend to want more urine or
universal urine tox on high-risk newborns — how can we sway them? [Dr. Seashore] Yeah I have a
pretty clear understanding I think of what the question is getting at and
please feel free to chime in in the box, Heather, if there’s more clarification
you’d like but yes I think pediatricians have been perhaps
a bit slower, and in fact there’s been a lot of discussion about universal urine
toxicology screening in quote-unquote high-risk delivery areas, so parts of the
Ohio and Mississippi river valley, the so-called Rust Belt, certainly northern
New England, there are pediatricians wondering and publishing
on whether Universal screening is necessary and I think the clearest
response to that is that urine screening toxicology screening in a newborn should
a be objectively determined. In other words, if you’re using it as a practice,
you should have clear, consistent criteria you apply to make that decision,
and so that might be clinical factors during the pregnancy, or it might be that
you do pursue Universal screening in a high-risk area but it should be applied
consistently so that we eliminate some of the implicit biases that Hendree
alluded to earlier. And then the other piece of it is that how you interpret
and use those results is really critical. So those results should be used to just
help define a treatment plan and your approach to caring for that baby, and
not necessarily a safety or punitive course, if that’s not appropriate, and
interestingly enough with marijuana legalization there’s been a swing back
in the other direction of we don’t want to see these toxicology reports because
so many of them have marijuana and we don’t know what to do about it. And so I
think it’s an area that’s in flux, but what I would encourage folks to think
about is how you use those toxicology results if you get them to guide
treatment rather than to guide something that would be more punitive in nature. And so if you do discover a substance use disorder with Universal screening of
urine in newborns, then your outcome better be to refer moms to treatment and
hook them up with appropriate care rather than to just refer it to CPS and
take away the baby and and kick them out on the street after 48 hours when
she’s been discharged. And so that requires some dialogue obviously between
everybody on the health care team and and clear policies and and practice
protocols that you follow and adhere to. [Meg] Okay so the next question and this might
not be one you can just answer off the top of your head but it says can you
share your top three journal articles supporting dual product buprenorphine/naloxone in pregnancy. [Dr. Jones] Yep so I can’t quote chapter and verse — sometimes I can! Yes I can, I can definitely tell you that there was article, I’m one
of the authors on that, and that was the first ten babies that were born with the
combination product, we’ve done a review of that. There are a couple of papers out
of Canada and I can follow up and send the whole list or at least a good
example of several examples, so I don’t because I don’t know page numbers. [Meg] Yeah
if you sent me if you sent me those I could forward that out to everyone who
is on the webinar today, if you wanted Okay great uh-huh let’s see,
scooting down, are there any resources for mother child centered care in
southern Ohio Northern Kentucky or southeastern Indiana and again you might
not know that off the top of your head but maybe you could suggest where
someone could find out? [Dr. Jones] Yeah so definitely like the Children’s Hospital
out of Cincinnati has done with MaryHaven, there’s the Clinical Trials
Network I know that Mary Haven was a site for them for a long period of time
and actually Theresa Winhusen did a CTN study that’s looking at using
buprenorphine during pregnancy, so I know that she’s out of Ohio, so she would have a lot of great resources, I would expect, but I definitely know that Mary Haven was one of those centers that have been around for a long time that has done a lot of work in terms of Ohio. Then Kentucky there is a PCORI
study that was funded, it’s like, I know the University of Kentucky with Michele
Lofwall and Sharon Walsh, they would be wonderful resources for what’s
happening in Kentucky around perinatal substance use disorder treatment. Indiana
I don’t know off the top of my head, I’m really sorry because I haven’t had
contact really in much in Indiana. [Meg] Well I’m amazed you knew the other
ones off the top of your head, that’s very impressive. Okay next question how does North Carolina avoid the CAPTA rule that
seems to require CPS report for babies that have withdrawal? [Dr. Jones] Yeah so we’re not
avoiding it and and I think I actually might have misspoken so let me clarify
what I said earlier. So when babies are born that would meet
the criteria for like FASD, the being born substance affected, the etc, then
there is a notification that goes to Child Protective Services but it doesn’t
automatically mean an open case. So so we basically have — the way our state’s set up
the reporting is that there’s almost like a dual system so that not every
single case becomes an open CPS case but there is a notification and that seems
to have worked quite well. So then there is a period of time where there’s more
in-depth screening that happens and then the CAPTA requirements are still all
reported in terms of babies that have been substance affected, and is there a
plan of safe care and our referrals made? [Dr. Seashore] And that that’s gonna vary
obviously state to state because the states were charged with
operationalizing that law and so to think about it more generally,
essentially what we’re aiming to do in North Carolina with these kids is refer
them to early intervention like you would with a child who has developmental
delay in the first three years of life rather than referring them to child
protective services. So conceptually, if you want to think about a model,
depending on how your state laws are written and enforced, you know how can we
get these kids services and their mothers support while also satisfying
the letter of the law, and how can we work collaboratively with
different state agencies so that the mothers accept that referral as a
supportive one and aren’t skeptical of it as a as a punitive one. [Meg] Okay I
thought this was a really good question. Lisa is asking how should we manage
counseling patients on breastfeeding when provider of buprenorphine counseling for
breastfeeding and other provider, often the lactation consultant, at the hospital
who are more conservative, differ in opinion? [Dr. Seashore] Oh boy that’s a that’s the art of medicine in a question. I you know I
think it requires team building and trust and education, it requires sharing
literature, whether that’s primary literature or summative literature like
from SAMHSA or the CDC and other agencies. One resource that I use constantly, and I
work both as a pediatrician in our unit and also on our breastfeeding
consultative service, is the LactMed database from the National Library of
Medicine, which is also closely linked to Thomas Hale’s book and now website out of Texas Tech that is Mother’s Medication and Mother’s Milk and they
have a 24-hour hotline where you can actually call, and if you look at those
references, they all have that similar benefits-outweigh-risk language around
breastfeeding with buprenorphine and/or methadone and then would
specifically be able to also answer any other questions that the providers might
have about other medication use. And the most common one that we see as an actual
contraindication, although the less so since we revisited our opioid
prescribing patterns in the postpartum period, is the total opioid use
postpartum, especially for women after a c-section, and I think it’s 30 milligrams
a day. You have to question the safety of that mother’s milk if mom is using a lot
of opiates postpartum for analgesia. Buprenorphine in particular and
methadone have been studied and the neonatal outcomes are actually better in
women who are breastfeeding while taking those medications despite very small
amounts of medication being being present in milk and so I would say go
ahead to the questioner and reach out to those colleagues and start a dialogue
and maybe share with them the LactMed website from the Library of
Medicine or the Medications and Mother’s Milk resource from Thomas Hale. [Dr. Jones] And the SAMHSA guidance document published in 2018 also has a fact sheet about breast
breastfeeding and medication assisted treatment. [Meg] Great. Ok next question do you
specifically have universal education conversations about current violence,
particularly intimate partner violence, with women who are both pregnant and
using substances? And then it says you talked a bit about violence but
concurrent reproductive coercion and substance use coercion from the partner
choosing abusive behavior is something doctors can screen for. For example using
universal education conversations with tools like the Futures without Violence
safety card that talks about reproductive coercion. [Dr. Jones] Yes fantastic. I’m
so glad that the writer wrote that, who was that — Emily. — for bringing that
up. Absolutely we definitely, like I had mentioned
before, there’s such a high prevalence of our women being involved in different
types of intimate partner violence from you know really starting from their
first relationship and continuing through to the current one. So yes
medical, you know, ob/gyn care and psychiatry visit is the perfect time to
be able to really to talk about that, to ask about that, and to provide some
resources to help women deal the best they can in those types of
situations. So thank you for bringing that up. Couldn’t agree more. [Meg] Does Horizons use a
specific trauma or strengths-based treatment model? [Dr. Jones] So we in terms of
treatment interventions that we use for trauma, we have we’ve used Seeking Safety,
we also use Stephanie Covington’s work, so we, yeah, so anyway those are
two examples of models that we use in group settings, and then as well as
individual work, and then we also think about just sort of a trauma-informed
care using, obviously, the tools that SAMHSA has beautifully developed. [Meg] Great.
Barbara sort of has a related question: she asked, you mentioned the conceptual
models upon which UNC Horizons is based, can you describe the main elements of
these? [Dr. Jones] mm-hmm So the conceptual model, just in terms of
like the social learning theory that we use. So again thinking about you know
behavior, understanding of behavior, how behavior is motivated, and thinking about
not so much from a punitive aspect but really from what are those rewards? Treatment
is — we often say that treatment is really hard and so what can we do to make
treatment more attractive and engaging. So we use some contingency management in
there, where a very concrete example of that is we have a donations room and so
when women complete a full dose of treatment, so that means they’ve attended
for example four groups for the day that gets verified, and then they can come in
the next day and they can go shopping in our donations room. And so that’s just
one small example of how we’re using contingency management, which is a
behavioral theory, in practice. So I hope — that didn’t cover it completely, but that
just gives you an example of what we do using conceptual models into practice. [Meg] Great. Are there any other questions from anybody? If not I think that might be it.
I just put a slide on the screen that just notes that next week the NWATTC’s
having another webinar if you’re interested that’s about compassion
fatigue among human services professionals and you’re all welcome to
register for that if that sounds interesting to you. Thank you so much to our
speakers this was really, really great and great audience as well always fun
when people are really engaged so thank you so much for that as well. All right I
think that’s it thank you. [Speakers] Thank you very much!

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