Collaborative Care for Pregnant Women with Substance Use Disorders
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1 Collaborative Care for Pregnant Women with Substance Use Disorders Alane O Connor DNP Maine Dartmouth Family Medicine Residency MaineGeneral Medical Center Dartmouth Medical School Vanderbilt University School of Nursing
2 The problem We have an opioid epidemic in Maine. It s more than just opioids 1/3 of those seeking treatment are women of child bearing age. Drug affected infants: 165 in 2005, 995 in 2015.
3 Caring for pregnant women with substance use disorders is challenging but they are often motivated for change! Collaborative care works best. You don t have to fix everything in one visit. Goal most often is harm reduction. Where do I begin?
4 MDFMR s integrated program Open to any opioid dependent pregnant woman appropriate for our level of care. Patient-centered: Provider-patient partnership; education and respect for autonomy. Therapeutic relationship is key! Comprehensive: Obstetric, primary, pediatric and substance abuse treatment in one setting. Family centered: Care for partners. Committed to quality and safety: Robust research program evaluating maternal-infant outcomes.
5 Screening for substance use during At first prenatal visit and again in midsecond trimester. And: Opioid intoxication or withdrawal. Erratic behavior, missed visits, track marks. Fear of being identified. Verbal screening standard of care. pregnancy
6 4 Ps Did any of your parents have a problem with alcohol or other drug use? Does your partner have a problem with alcohol or drug use? In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications? In the past month (present) have your drunk any alcohol or used other drugs? Scoring: Any "yes" should trigger further questions.
7 CRAFFT C Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using alcohol or drugs? R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A Do you ever use alcohol or drugs while you are by yourself or ALONE? F Do you ever FORGET things you did while using alcohol or drugs? F Do your FAMILY or friends ever tell you that you should cut down on your drinking or drug use? T Have you ever gotten in TROUBLE while you were using alcohol or drugs? Scoring: Two or more positive items indicate the need for further assessment.
8 Urine drug screening during pregnancy NOT the standard of care for screening (ACOG/ASAM). Requires consent. Is an important monitoring parameter when a patient is in substance abuse treatment. Has important limitations: duration of time substances remain in system; cost; tampering issues.
9 Polysubstance use during pregnancy Opioid dependence. Marijuana. Stimulants, benzodiazepines. Limit exposure, counseling. How about an SSRI? Alcohol. Complicated and probably more prevalent than we realize. Tobacco Many standard therapies okay during pregnancy.
10 Opioid dependent pregnant women medical care Medication assisted treatment (MAT): Methadone vs. buprenorphine.
11 Opioid dependent pregnant women medical care Higher risk for obstetric complications. Infectious diseases (most often hepatitis C). Cellulitis/endocarditis secondary to IV drug use. Increased risk of sexually transmitted infections. Constipation.
12 Opioid dependent pregnant women behavioral health care About 70% have co-occurring diagnosis (anxiety, depression, bipolar, PTSD). Those with co-occurring disorders have more severe addiction history. Distinguishing between cooccurring mental health diagnoses and opioidinduced mental health disorders can be very difficult.
13 Opioid dependent pregnant women behavioral health care Counseling essential! May require counseling for both substance use disorder and mental health diagnoses. Match counseling to patient s needs. May change over time. Coordinated care critical.
14 Opioid dependent pregnant women Domestic violence (>70% have been physically abused). Homelessness. Limited financial resources. Poor nutrition. Partner/family. barriers to treatment
15 Opioid dependent pregnant women barriers to treatment Transportation. Care of existing children. Previous involvement with DHHS. Limited parenting skills/experience. Shame/guilt/self-esteem. Available treatment options are limited.
16 Preparing for delivery Reassurance that pain will be managed. Discussion around confidentiality. Extended stay in the hospital for NAS observation. Drug affected baby reporting law. Breastfeeding institutional policies vary. MAT compatible with breastfeeding.
17
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