19-818 Improve Treatment of OUD in Pregnancy with These Resources
Date: 10/21/19
Improve Treatment of OUD in Pregnancy with These Resources
Useful strategies for better health outcomes
You can help improve health outcomes and prevent birth defects by providing patients with early treatment in pregnancy and being aware of recommended evidence-based strategies.
Improve maternal and infant outcomes
According to the Centers for Disease Control and Prevention (CDC), the number of pregnant women with opioid use disorder (OUD) more than quadrupled from 1999 to 2014.1 The increasing prevalence of opioid use in pregnancy has also led to a fivefold increase in neonatal abstinence syndrome over the past decade. To improve maternal and infant outcomes, an optimal early screening, treatment and care throughout pregnancy and the postpartum period are recommended.
Know your best option may be methadone or buprenorphine
Methadone and buprenorphine can offer the best treatment option for pregnant women with OUD. Too often, attempting to “detox” pregnant women who are using heroin or pain medication yields poor results. Studies have shown that most women return to drug use within a month after self-detox.2
The following recommendations are adapted from the American Society of Addiction Medicine (ASAM) practice guideline:3
· Treat pregnant women who have OUD with methadone or buprenorphine monoproduct instead of withdrawal or abstinence.
· Initiate treatment with methadone as early as possible during pregnancy.
· Hospitalization when initiating treatment with either medication may be advisable, especially in the third trimester.
· Buprenorphine monoproduct is a recommended alternative to methadone during pregnancy, but there is not enough evidence to back the safety of combination buprenorphine/naloxone formulation.
· Encourage breastfeeding for mothers receiving methadone and buprenorphine monoproduct for OUD.
Note ACOG and CDC recommendations
The following evidence-based strategies are recommended by the American College of Obstetricians and Gynecologists (ACOG) and the CDC:4
· Consider an early screening (e.g., National Institute on Drug Abuse Quick Screen and CRAFFT for women younger than age 26) and counseling to minimize the risk for the mother and the fetus.
· If clinically indicated, consider non-opioid pharmacologic treatments or non-pharmacologic therapies (e.g., exercise, physical therapy and behavioral approaches) for pain management.
· If use of opioids are indicated, discuss the treatment goals, risks and benefits of opioid use, and how opioid therapy will be discontinued if benefits do not outweigh risks. Review the Controlled Substance Utilization Review and Evaluation System (CURES) to determine whether the patient has received opioids or other high-risk medications in the past. Mandatory consultation became effective Oct. 2, 2018, before prescribing a Schedule II, Schedule III or Schedule IV controlled substance for the first time and at least once every four months thereafter.
· Consider prescribing naloxone to patients at risk of overdose if clinically indicated.
· Consider care coordination and referral to pediatric care provider for neonatal abstinence syndrome.
· Ensure access to medication assisted therapy (MAT), postpartum care, including mental health, relapse-prevention programs and family planning services.
Prevent overdose by prescribing naloxone if indicated
Offer risk mitigation strategies, including naloxone, for patients at risk for overdose. Prescribers must offer naloxone for the complete or partial reversal of opioid depression when one or more of the following conditions are present:
· Dosage for the patient is 90 or more morphine milligram equivalents (MME) of an opioid medication per day;
· Concurrently prescribing an opioid medication with a prescription for a benzodiazepine; and
· The patient presents with an increased risk for overdose, including:
- A patient with a history of overdose or a history of substance use disorder; or
- A patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.
Refer to the formularies and drug lists on the provider portal for coverage information.
Help save a life by turning in expired and unused prescriptions for safe disposal on October 26
Let your patients know if they have any prescription medications they no longer need, or which have passed their expiration date, this is the perfect time to bring them to an authorized location for proper disposal. Prescription drugs can be brought to DEA-authorized locations between 10:00 a.m. and 2:00 p.m. on October 26, 2019. Visit the Drug Enforcement Agency (DEA) website for more information at www.getsmartaboutdrugs.gov/content/national-take-back-day.
More resources for patients and providers
Tell patients about myStrength
myStrength is an evidence-based, behavioral health self-help resource. It offers interactive, individually-tailored applications that empower members to address depression, anxiety, stress, substance use, chronic pain, and sleep challenges, and has added a new nicotine recovery program and a new pregnancy and early parenting program.
Why myStrength?
myStrength is a personal and dynamic website. Its clinically-proven resources are secured via web and mobile technology. Resources include:
· Techniques to improve mood. | · Interactive tools. | · Self-help workbooks. |
· Step-by-step eLearning modules. | · Weekly action plans. | · Daily inspirations. |
Members can access myStrength online at bh.mystrength.com/cahealthwellness.
Helplines and treatment resources
· National Council on Alcoholism and Drug Dependence – 1-800-622-2255
· Substance Abuse Treatment Services Facility Locator – 1-800-662-4357
· findtreatment.samhsa.gov
Take buprenorphine waiver training courses
You can take courses to get a waiver to prescribe buprenorphine. To learn more, visit samhsa.gov/medication-assisted-treatment/training-resources/buprenorphine-physician-training. You can also find information about trainings from the Providers Clinical Support System (PCSS). Visit their calendar of events at pcssnow.org/calendar-of-events.
Find practice gaps for treating OUD with a PCSS performance-in-practice activity
PCSS and the American Academy of Addiction Psychiatry have created an accredited activity for providers to find and assess gaps in their practice. Physicians, physician assistants, nurses, and nurse practitioners can access the activity via the American Psychiatric Nurses Association website at www.apna.org > Free Continuing Education > PCSS Training and Education > More info.
Addiction Free CA (a California expansion website)5
The Mother&Baby Substance Use Exposure Initiative is active in numerous counties in California. Health Management Associates (HMA) implemented the initiative and is working with the California Maternal Quality Care Collaborative and the California Perinatal Quality Care Collaborative to increase access to MAT treatment.5 For patient educational materials and provider resources, visit addictionfreeca.org/Resource-Library/Other-External-Resources.
Check out these selected resources on pregnancy, post-partum and OUD
Take advantage of the many training resources from PCSS at https://pcssnow.org/education-training. Resources that focus on opioid use and pregnancy include:
· ASAM Patient Handout – Pregnancy: Methadone and Buprenorphine. https://30qkon2g8eif8wrj03zeh041-wpengine.netdna-ssl.com/wp-content/uploads/2013/10/WAGBrochure-Opioid-Pregnancy_Final.pdf.
· ASAM Patient Handout – Childbirth, Breast Feeding and Infant Care: Methadone and Buprenorphine. https://30qkon2g8eif8wrj03zeh041-wpengine.netdna-ssl.com/wp-content/uploads/2013/10/ASAM-WAGBrochure-Opioid-Labor_Final.pdf.
· Innovative Methods for Addressing Substance Use in Women. https://pcssnow.org/event/innovative-methods-for-addressing-substance-use-in-pregnancy/.
· ATTC for Pregnant and Postpartum Women. http://attcppwtools.org/home.aspx.
· SAMHSA: Clinical Guidance for Treating Pregnant Women and Parenting Women with Opioid Use Disorder and Their Infants. https://store.samhsa.gov/system/files/sma18-5054.pdf.
· ACOG Issues Guidelines on Opioid Use During Pregnancy. https://pcssnow.org/resource/american-congress-of-obsetetricians-and-gynecologists-acog-issues-guidelines-on-opioid-use-during-pregnancy/.
If you have questions regarding the information contained in this update, contact CHWP at 1-877-658-0305.
1 https://www.cdc.gov/media/releases/2018/p0809-women-opiod-use.html.
2 http://pcssnow.org/wp-content/uploads/2015/10/WAGBrochure-Opioid-Pregnancy_Final.pdf.
3 https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf.
4 www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy.
5 http://www.californiamat.org/2019/08/19/motherbaby-substance-exposure-initiative/.
Additional references
www.cdc.gov/pregnancy/meds/treatingfortwo/features/pain-med-usage.html.
American College of Obstetricians and Gynecologists. (2018). Retrieved from https://www.acog.org/Patients/FAQs/Opioid-Use-Disorder-and-Pregnancy?IsMobileSet=false.
Centers for Disease Control and Prevention. (2019). Retrieved from https://www.cdc.gov/drugoverdose/pdf/pregnancy_opioid_pain_factsheet-a.pdf.
March of Dimes. (2019). Retrieved from https://www.marchofdimes.org/pregnancy/prescription-opioids-during-pregnancy.aspx.
Substance Abuse and Mental Health Services Administration. (2019). Retrieved from https://www.samhsa.gov/medication-assisted-treatment.