Policy Consideration and Collaborative Partnerships: Working with Opioid Dependent Pregnant and Parenting Women

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1 Policy Consideration and Collaborative Partnerships: Working with Opioid Dependent Pregnant and Parenting Women 2015 San Diego International Conference on Child and Family Maltreatment January 26-30, 2015 San Diego, CA

2 Agenda Welcome Trends in Opioid Use Medication Assisted Treatment for Opioid Use Disorders Opioid Dependence and Treatment in Pregnancy Child Welfare and Collaborative Practice Considerations The CHARM Collaborative

3 A program of the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment and the Administration on Children, Youth and Families Children s Bureau Office on Child Abuse and Neglect

4 Trends in Opioid Use Initiates The overall rate of heroin initiation increased for women from.06% in compared to.10% in Estimated 43,000 in to 77,000 women in Dependence More than 100% increase of persons 12 or older who are dependent on heroin 180,000 in 2007 compared to 370,000 in 2011 Deaths Over 400% increase among women in opioid pain reliever overdose deaths since 1999 Approximately 18 women overdose and die every day from opioid pain relievers Among women, opioid overdoses surpasses motor vehicle accidents as a leading cause of death Substance Abuse and Mental Health Services Administration, (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) Rockville, MD. Center for Disease Control (CDC). Prescription Painkiller Overdoses, TEXT A PAGE Growing Epidemic, Especially Among Women. Atlanta, GA: CDC,

5 Non-Medical Use of Prescription Opioid Pain Relievers and Heroin Use A strong association exists between prior nonmedical use of opioid pain relievers and subsequent past year initiation of heroin Heroin incidence rates were 19 times higher among those who reported prior nonmedical use of opioid pain relievers Substance Abuse and Mental Health Services Administration, (2013). Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) Rockville, MD. TEXT PAGE.

6 Medication Assisted Treatment for Opioid Dependence

7 % of Basal DA Output DA Concentration (% Baseline) Natural Rewards Elevate Dopamine Levels 200 FOOD NAc shell 200 SEX Empty Box Feeding Time (min) Source: Di Chiara et al. 100 Scr Scr Bas Female 1 Present Scr Scr Sample Number Mounts Intromissions Ejaculations Female 2 Present Source: Fiorino and Phillips Copulation Frequency

8 % of Basal Release % of Basal Release % of Basal Release % of Basal Release Effects of Drugs on Dopamine Levels NICOTINE Accumbens Caudate Accumbens MORPHINE Dose (mg/kg) hr Time After Nicotine hr Time After Morphine Accumbens COCAINE DA DOPAC HVA hr Time After Cocaine Accumbens AMPHETAMINE DA DOPAC HVA hr Time After Amphetamine Source: Di Chiara and Imperato

9 Opioids, such as heroin or opioid pain medications (e.g. VICODIN, Percocet and OxyContin ) attach to a particular type of brain receptor. This results in the release of greater amounts of dopamine, which creates a pleasure response.

10 A Chronic, Relapsing Brain Disease Brain imaging studies show physical changes in areas of the brain that are critical to Judgment Decision making Learning and memory Behavior control These changes alter the way the brain works, and help explain the compulsion and continued use despite negative consequences Fowler JS, Volkow ND, Kassed CA, Chang L. Imaging the addicted human brain. Sci Pract Perspect 3(2):4-16, TEXT PAGE

11 Source: From the laboratories of Drs. N. Volkow and H. Schelbert Substance Use Disorders are similar to other diseases, such as heart disease Both diseases disrupt the normal, healthy functioning of the underlying organ, have serious harmful consequences, are preventable, treatable, and if left untreated, can result in premature death

12 Principles of Effective Drug Addiction Treatment Addiction is a complex but treatable disease that affects brain function and behavior No single treatment is appropriate for everyone Treatment needs to be readily available Effective attends to multiple needs of the individual Remaining in treatment for an adequate period of time is critical Behavioral therapies are the most commonly used forms of drug abuse treatment Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies { } An individual s treatment and services plan must be continually assessed and modified Many drug-addicted individuals also have other mental disorders Medically assisted detoxification is only the first stage of addiction treatment Treatment does not need to be voluntary to be effective Drug use during treatment must be monitored continuously as lapses do occur Treatment programs should test patients for infectious diseases National Institute on Drug Abuse (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Retrieved from on TEXT September PAGE 18, 2014

13 Medication Assisted Treatment (MAT) for Opioid Dependency As part of a comprehensive treatment program, MAT has been shown to: Increase retention in treatment Decrease illicit opiate use Decrease criminal activities Decrease drug-related HIV risk behaviors Decrease obstetrical complications Fullerton, C.A., et al. November 18, Medication-Assisted Treatment with Methadone: Assessing the Evidence. Psychiatric Services in Advance; doi: /appi.ps The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), TEXT PAGE

14 Three FDA-approved Medications for the Treatment of Opioid Dependence Methadone (Dolophine ) Agonist: Binds to opioid receptors and mimics the action of naturally occurring neurotramsmitters Similar to a key that opens a lock Buprenorphine (Suboxone, Subutex ) Partial Agonist: Similar action as a agonist at lower levels Naltrexone: Oral (ReVia, Depade ) and Extended Release Injection (Vivitrol ) Antagonist: Binds to opioid receptors and blocks opioids Similar to a key that fits in a lock but does not open it and prevents another key from being inserted to open the lock

15 Methadone Used successfully for more than 40 years Full mu-receptor agonist Can be used in detoxification and maintenance Suppresses withdrawal and craving and reduces nonmedical opioid use Prescription and dispensing is restricted to providers who are certified by SAMHSA as Opioid Treatment Programs (OTPs), registered with the DEA and are subject to state and local regulations TEXT PAGE

16 Methadone Therapeutic doses, determined by trained physicians, to ensure maximum effectiveness Daily doses are provided at OTPs until the patient stabilizes and can receive take-home doses Not a pharmacy benefit in commercial health plans except for pain management TEXT PAGE

17 Opioid Treatment Provider (OTP) Certification Guidelines Medical Director licensed to practice medicine and has experience in addiction medicine. Responsible for monitoring and supervising all medical services Provision of adequate medical, counseling, vocational, educational, and other assessment and treatment services Special services for pregnant patients, including priority access and provision of or referral for prenatal care and other gender specific services TEXT PAGE

18 Buprenorphine Available for opioid treatment since 2002 and generic formulations are now available Partial mu-receptor agonist, produces a ceiling effect (e.g. will not experience increased side effects, even with an increased dose) Also an antagonist at the kappa receptor Combination product with short-acting antagonist naloxone was developed to prevent misuse Can be used for detoxification and maintenance For maintenance, clients are given a daily dose and then can be given take-home doses Available from specially trained primary and generalist physicians who are granted a DATA waiver; including OTPs TEXT PAGE

19 Naltrexone Oral form approved in 1984, long acting (24 to 30 hours) antagonist Extended release (up to 30 days) injectable form (Vivitrol) approved 2010 Can only be used with fully detoxified patients, causes immediate withdrawal if opioids are still in system Once on maintenance dose, eliminates effects of opioids by blocking the receptor sites TEXT PAGE

20 Naltrexone Prescribed by any healthcare provider who is licensed to prescribe medications (e.g., physician, doctor of osteopathic medicine, physician assistant, and nurse practitioner). Special training is not required; the medication can be administered in OTP clinics

21 Key Points of Medications Each medication varies in its ability to: Prevent or reduce withdrawal symptoms Prevent or reduce drug craving Medical doctors determine the appropriate type of medication, dosage and duration based on each person s: Biological makeup Addiction history and severity Life circumstances and needs

22 Medication Assisted Treatment for Opioid Dependence During Pregnancy

23 Opioids During Pregnancy

24 Pregnancy and Prescription Opioid Abuse Among Substance Abuse Treatment Admissions Increase from 2% to 28% among pregnant treatment admissions for any prescription opioid abuse. Increase from 1% to 19% among pregnant treatment admissions for prescription opioids as the primary substance of abuse. Martin, C.E., et al., Recent trends in treatment admissions for prescription opioid abuse during pregnancy. Journal of Substance Abuse Treatment (2014),

25 Proportion Reporting Any Prescription Opioid Use Among Pregnant Admissions Martin, C.E., et al., Recent trends in treatment admissions for prescription opioid abuse during pregnancy. Journal of Substance Abuse Treatment (2014),

26 Prenatal Screening Universal screening, brief intervention and referral to substance use treatment is a recommended best practice in the prenatal phase. Prenatal screening tools include: 4 P s Plus: 5 questions to identify pregnant women who need an in depth assessment or follow up monitoring for risk of drug, alcohol, and tobacco use CRAFT: 6 questions for use with adolescents and young adults (under the age of 24 years) to determine a need for further assessment for substance or alcohol use during pregnancy American College of Obstetricians and Gynecologists, Committee on Ethics. (2004, May). At risk drinking and illicit drug use: Ethical issues in obstetric and gynecologic practice. ACOG Committee Opinion No American College of Obstetricians and Gynecologists. Obstetrical Gynecology, 103, TEXT PAGE

27 Withdrawal from Opioids During Pregnancy Withdrawal or the abrupt discontinuation of opioids in an opioid-dependent pregnant woman is not recommended as it can result in preterm labor, fetal distress, or fetal demise Medically supervised withdrawal can be accomplished in some instances and should be undertaken by a physician experienced in perinatal addiction treatment The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), TEXT PAGE

28 Treatment of Opioid Dependence During Pregnancy The current standard of care for pregnant women with opioid dependence is opioid assisted therapy with methadone Buprenorphine is an effective option for pregnant women who are new to treatment or maintained on buprenorphine pre-pregnancy. Maternal outcomes, pain management considerations and breastfeeding recommendations are similar between the medications used in the treatment of opioid dependence The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), Hendree Jones, Presented at the NADCP Annual meeting, May 28, 2014, Anaheim, CA. TEXT PAGE

29 Intrapartum and Postpartum Special considerations are needed for women who are opioid dependent to ensure appropriate pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies Neonatal Abstinence Syndrome is an expected and treatable condition that follows prenatal exposure to opioids The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), Hendree Jones, Presented at the NADCP Annual meeting, May 28, 2014, Anaheim, CA. TEXT PAGE

30 Neonatal Abstinence Syndrome (NAS) Occurs with notable variability: 13-94% of exposed infants exhibiting symptoms Symptoms begin within 1-3 days after birth, or may take 5-10 days to appear Symptoms include blotchy skin, difficulty with sleeping and eating, trembling, and irritability Timing of onset is related to a variety of factors, including the type of substance, dose, timing, metabolism and whether the baby is premature or full-term Most opioid exposed babies are exposed to multiple substances U.S. National Library of Medicine, National Institutes of Health. Neonatal Abstinence Syndrome. Retrieved from on July 24, 2014 Hudak, M.L., Tan, R.C. The Committee on Drugs and the Committee on Fetus and Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012, 129(2): e540 Jansson, L.M., Velez, M., Harrow, C. The Opioid Exposed Newborn: Assessment and Pharmacological Management. Journal of Opioid Management. 2009; 5(1):47-55 The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), TEXT PAGE

31 Rate of NAS per 1,000 Hospital Births Incidence of Neonatal Abstinence Syndrome Over Time Year TEXT PAGE Patrick SW, et. al. Neonatal Abstinence Syndrome and Associated Healthcare Expenditures United States, JAMA May 9;307(18):

32 Estimated Number of Infants* Affected by Prenatal Exposure, by Type of Substance and Infant Disorder Past Month Substance Use by Pregnant Women Incidence of Infant Disorder Includes nine categories of illicit drugs, including heroin and the nonmedical use of prescription medications. *Approximately 4 million (3,952,841) live births in 2012 Estimates based on: National Survey on Drug Use and Health, 2012; Martin, Hamilton, Osterman, Curtin & Mathews. Births: Final Data for National Vital Statistics Report, Volume 62, Number 9; Patrick, Schumacher, Benneyworth, et al. NAS and Associated Health Care Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18): doi: /jama ; May, P.A., and Gossage, J.P.(2001).Estimating the prevalence of fetal alcohol syndrome: A summary.alcohol Research & Health 25(3): Retrieved October 21, 2012 from TEXT PAGE

33 Different Populations of Women Can Give Birth to Infants with NAS Symptoms Chronic pain or other medical conditions maintained on medication Misuse of own prescribed medication In recovery from opioid addiction & maintained on methadone or buprenorphine (e.g. medication assisted treatment) Actively abusing or dependent on heroin Misuse of nonprescribed medication Adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy 9;307(18):

34 NAS Screening and Assessment Finnegan Neonatal Abstinence Scoring System: Assesses for signs and symptoms of withdrawal at ongoing intervals to determine severity and inform treatment decisions. Infant Meconium or Urine Analysis: Determines whether the infant was exposed to substances TEXT PAGE

35 NAS Treatment Treatment to relieve NAS symptoms can involve both: Non-pharmacological: Minimize Environmental Stimuli, Swaddling, Breastfeeding, Gentle Rocking, Rooming with Mother Pharmacological: methadone, morphine, etc. Decision to treat NAS with pharmacological methods is based on a variety of factors, including a medical assessment of the severity of the symptoms, the infant s gestational age, overall health, medical history, exposure to other substances and tolerance or response to medications TEXT PAGE

36 Long-Term Impact Studies demonstrate cognitive development to be within the normal range up to age 5 Advances in the field call for additional studies on the long-term impact of opioid prenatal exposure Family characteristics, improved prenatal care, exposure to multiple substances, and other medical and psychosocial factors have a significant impact on longterm outcomes The American College of Obstetricians and Gyneocolgoists. (2012) Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), Emmalee, S. B. et al. (2010) Prenatal Drug Exposure: Infant and Toddler Outcomes. Journal of Addictive Diseases, 29(2), Baldacchino, A., et al. (2014). Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and preschool children: a systematic review and meta-analysis. BMC Psychiatry, 14(104). TEXT PAGE

37 Barriers to Best Practice Variation in Child Welfare and Dependency Court Response: Decisions on case opening, child removal, reunification, etc. Lack of Medication Availability Lack of Collaboration Lack of Sufficient, Comprehensive, Long-Term Treatment for Women and Their Children Knowledge and Practice Gaps in Best Practices in Screening and Assessment: Pregnancy, Post Pregnancy, Neonatal Abstinence Syndrome

38 Parrino, M. (2011, July 11). Medication Assisted Treatment for Families Affected by Substance Use Disorders presentation. As of 09/04/2013, there are 1,291 reported active Opioid Treatment Programs.

39 Overall Findings Medicaid Coverage for Treatment of Opioid Dependence: ASAM 2013 Study Coverage and use limitations differ from state to state, resulting in difficulties in accessing Medicaid coverage Coverage limitations are compounded by issues in utilization management, financing, reimbursement and regulatory issues The American Society of Addiction Medicine The Voice of Addiction Medicine. Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment TEXT PAGE

40 Medicaid Coverage for Treatment of Opioid Dependence: ASAM 2013 Study Challenges reported by surveyed states: Complex authorization and re-authorization processes Lengthy approval processes Minimal coverage or reimbursement of counseling services to accompany MAT while also requiring counseling services as a preauthorization requirement. Fail first or Step therapy criteria that require documentation that less costly therapies have proven ineffective The American Society of Addiction Medicine The Voice of Addiction Medicine. Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment TEXT PAGE

41 Medicaid Coverage for Treatment of Opioid Dependence: ASAM 2013 Study A few states have implemented strategies that promote access to MAT through Medicaid: 100% coverage of associated substance use counseling Medicaid coverage of all three approved Food and Drug Administration (FDA) approved medications No requirements for fail first or step therapy Implementation of a statewide network of providers who participate in ongoing quality and cost assessments The American Society of Addiction Medicine The Voice of Addiction Medicine. Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment TEXT PAGE

42 Practice Considerations

43 National Working Group Develop guidance that will: Articulate the questions and policy considerations that guide practice for a wide range of professionals working with pregnant opioid dependent women, their infants and families Provide possible approaches for working together on behalf of the woman and her child, that reflects the input of this working group and identified supportive practices Intended audience at the State and local level: Child Welfare agencies Family Courts Medical and nursing professionals serving women and children affected by these issues Substance Abuse Treatment providers TEXT PAGE

44 Child Abuse and Prevention Treatment Act Policies and procedures including appropriate referrals to child protection service systems and for other appropriate services to address the needs of infants born with and identified as being affected by illegal substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum Disorder, including a requirement that health care providers involved in the delivery or care of such infants notify the child protective services system of the occurrence of such condition in such infants except that such notification shall not be construed to establish a definition under Federal law of what constitutes child abuse or neglect The development of a plan of safe care for the infant born and identified as being affected by illegal substance abuse or withdrawal. TEXT PAGE

45 Child Welfare Practice Considerations Prenatal Is screening for substance use part of the standard risk-assessment protocol? Can services be provided to pregnant women? [ ] Labor and Delivery What are the protocols for responding to CAPTA referrals made by hospitals on substance exposed infants? [ ] Across Points in Time When can a child welfare case be opened? What information is communicated across systems? What is the communication protocol? [ ] Postpartum What are the considerations for keeping the infant with mother or removing the infant? Do the considerations vary by the type of exposure (e.g. heroin, appropriate vs inappropriate use of prescription medications, medication assisted treatment)? How is progress in treatment monitored? How are decisions on reunification or case closure made? [ ] TEXT PAGE

46 A Collaborative Approach Women with opioid use are identified during pregnancy and Engaged into prenatal care, medical care, substance use treatment, and other needed services and A case plan or plan of safe care for mother and baby is developed.reducing the number of crises at birth for women, babies, and the systems! TEXT PAGE

47 The Children and Recovering Mothers (CHARM) Collaborative

48 CHARM Overview A multidisciplinary group of agencies serving pregnant women with opiate addiction and their infants Provides comprehensive care coordination for pregnant women with opiate addiction and consultation for child welfare, medical, and addiction professionals across the state of Vermont The collaborative serves about 200 women and their infants annually

49 CHARM Goal Improve the health and safety outcomes of babies born to women with a history of opioid dependence 1. Engage women in prenatal care as early in the pregnancy as possible 2. Reduce cravings and withdrawal symptoms using medication assisted treatment (MAT: methadone or buprenorphine) 3. Engage women (and partners when possible) in substance abuse counseling 4. Provide social support and basic needs referrals for the family

50 CHARM Partners Department of Children and Families Department of Corrections Department of Health, Alcohol & Drug Abuse Programs Department of Health, Maternal and Child Health Department Healthcare Access (Medicaid)

51 Key Elements The team meets monthly and reviews a list of current cases including: All new pregnant patients Patients due in the next month Highest risk prenatal patients New babies/post-partum patients Highest risk post-partum patients and their babies A Shared Philosophy: Improving care and supports for mothers is the most important factor in helping to ensure healthy and safe infants.

52 Information Sharing Sharing information is critical to providing the best care and services to moms and babies Decisions are made best with current information Value of coming together monthly to share information: Time-saver Develop trust Minimize misunderstandings Improved understanding of patients more comprehensive view Improved understanding of each other s roles and perspectives TEXT PAGE

53 Information Sharing Resources and Tips Memorandum of Understanding Consent to Release Information VT Law: Empaneled Child Protection Team: The Commissioner or his or her designee may empanel a multidisciplinary team or a special investigative multitask force team or both wherever in the state there may be a probable case of child abuse or neglect which warrant the coordinated use of several professional services. These teams shall participate and cooperate with the local special investigation unit Hard copy notes; no electronic information sharing Client level information

54 Collaborative Staffing: Indicators of Strengths and Challenges Prenatal Attendance and engagement at prenatal appointments Participation in substance abuse counseling Progress in recovery Participation in Medication Assisted Treatment Partner/Household engagement in substance use treatment Birth and Delivery Mother-infant bonding and attachment Results of NAS assessment and treatment indications Toxicology results TEXT PAGE

55 Collaborative Staffing: Indicators of Strengths and Challenges Postpartum Assessment of parental administration of NAS treatment Continued engagement in substance use treatment and MAT Risk for relapse Engagement in follow-up care and services Child development needs Across Phases Safety concerns Family support Co-occurring issues Social service needs TEXT PAGE

56 Prenatal Care Comprehensive Assessment: Confirm Pregnancy, Assess for Opioid Dependency, Assess for Additional Needs Enhanced Prenatal Care: Urine Drug Test; Monitoring of Prenatal Visits; Monitoring for Relapse or Dose Adjustment Assessment for Medication Assisted Treatment Substance Abuse Counseling: Required for all Women Receiving MAT Prenatal Neonatal Consultation: Education on Newborn Care and Neonatal Abstinence Syndrome Our Care Notebook: Developed by CHARM women; Includes Resources, Personal Stories, and Encouragement

57 Birth and Postnatal Care Needs and Plan of Care Developed Prior to Labor CAPTA Plan of Safe Care Collaboratively Developed Assessment and Treatment of Neonatal Abstinence Syndrome Assessment Parent(s)/Caregiver(s) Trained to Administer Pharmacological Treatment to Infants Post-Discharge, when necessary Intense Level of Support Provided: Assistance and Support Available 24 hours, 7 days

58 Infancy, Postpartum and Ongoing Care Follow-up Services Continue for Both Mother and Infant Infant Visits NeoMed Clinic Regularly Until months Infant Visits Include Monitoring of Growth and Development; Parent Education on Child Development; Safe Sleep; Breastfeeding, etc. Continued Monitoring of and Support Provided to Parent(s)/Caregiver(s) who Administer Pharmacological Treatment to Babies with NAS

59 3-Part Webinar Series Medication Assisted Treatment for Families Affected by Substance Abuse Disorders s/medication-assisted-treatment-familiesaffected-substance-abuse-disorders Medication Assisted Treatment During Pregnancy, Postnatal and Beyond rs/medication-assisted-treatment-duringpregnancy-postnatal-and-beyond Opioid Use in Pregnancy: A Community s Approach, The Children and Recovery Mothers (CHARM) Collaborative rs/opioid-use-pregnancycommunity%e2%80%99s-approach-childrenand-recovering-mothers-cha Contact the NCSACW for a copy of the case study and additional materials and resources on opioid dependence and treatment during pregnancy.

60 nginchildwelfare.pdf training/default.aspx Exposed-Infants.pdf

61 Contact Information Nancy K. Young, PhD Director National Center on Substance Abuse and Child Welfare National Center on Substance Abuse and Child Welfare

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