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

PROJECT ECHO OPIOID USE DISORDER IN PREGNANT WOMEN 1

OPIOID USE DISORDER IN WOMEN • Recognition & Prevention Date: August 14 th , Time: 8 am • • Presenters: Deepa Nagar MD, Andria Peterson PharmD • Maternal Treatment Options Date: August 28 th , Time: 8 am • • Presenters: Brian Iriye MD, Farzad Kamyar MD, MDA • Infant Treatment Options Date: September 11 th , Time: 8 am • • Presenters: Deepa Nagar MD, Andria Peterson PharmD • Reporting & Follow-up Date: September 25 th , Time: 8 am • • Presenters: Hayley Jarolimek, Kevin Schiller 2

RECOGNITION & PREVENTION DEEPA N AGAR, M D AN DRI A PET ERSON , PH ARM D 3

ABBREVIATIONS • OUD = Opioid use disorder • NAS = Neonatal abstinence syndrome • SUD = Substance use disorder • MAT = Medication assisted treatment • SBIRT = Screening, brief intervention & referral for treatment • CPS = Child protective services • PDMP = Prescription drug monitoring program 4

BACKGROUND • The United States continues to face an opioid epidemic • Compromises the health of individuals, families & communities • >27 million people reported concurrent use of an illicit drug or misuse of a prescription drug in past 30 days in 2015 • Women continue to be a high risk population • Prescription misuse & illicit drug use during pregnancy results in very poor consequences on the mother-infant dyad • Infants are at risk for withdrawal, also known as neonatal abstinence syndrome (NAS) Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159. 5

WHAT IS THE SCOPE OF THIS PROBLEM IN NEVADA? 6

EPIDEMIOLOGY • Nevada High Intensity Drug Trafficking Areas (HIDTA) Report: 2018 Threat Assessment • US opioid prescription rate • 66.5 per 100 residents • Nevada opioid prescription rates • 2013: 78.1 per 100 residents • 2016: 87.5 per 100 residents • Opioid prescription rates by select counties • Clark: 84.3 per 100 residents • Nye: 155.6 per 100 residents • Equates to more than one prescription per person!!! Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 7

2015-2016 CDC OPIOID PRESCRIPTION RATES BY COUNTY 8 Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42

EPIDEMIOLOGY • Nevada High Intensity Drug Trafficking Areas (HIDTA) Report: 2018 Threat Assessment • Prescription painkillers prescribed per 100,000 patients 2 nd highest state in US for hydrocodone & oxycodone • 4 th highest state in US for methadone • 7 th highest state in US for codeine • • Prescription drug overdose mortality rate 4 th highest state in US • • 3 out of 4 heroin users starts with prescription drugs Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 9

OVERDOSE DEATHS PER 100,000 RESIDENTS 10 Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42

WHAT IS THE SCOPE OF THE PROBLEM IN PREGNANT WOMEN? 11

EPIDEMIOLOGY • 1998-2011: Prevalence of OUD during pregnancy doubled • Increased to 4 per 1,000 deliveries • 2008-2012: # of reproductive age women filling an opioid prescription each year according to pay source • 33% enrolled in Medicaid • >25% enrolled with private insurance • 2011-2012: 31% increase in women of childbearing age (15-44 year old) reported past-month use of heroin • 3 out of 4 heroin users start with Opioid prescriptions Office of National Drug Control Policy. Nevada high intensity drug trafficking areas. 2018. p. 1-42 Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and 12 their infants. P. 1-159.

EPIDEMIOLOGY Epstein RA, Bobo WV, Martin PR, Morrow JA, Wang W, Chandrasekhar R, et al. Increasing pregnancy-related use of prescribed opioid 13 analgesics. Ann Epidemiol. 2013;23(8):498-503

NEVADA PRENATAL SUBSTANCE ABUSE 14

DIGNITY HEALTH DATA Methadone Clinic: Maternal Toxicology Data 2015 2016 P Value Overall (2015-2016) # of mothers in a 13/42 (31%) 30/59 (51%) P < 0.001 43/101 (43%) methadone clinic Non-Compliance 6/13 (46%) 16/30 (53%) P = 0.221 22/43 (51%) Rate 15

DIGNITY HEALTH DATA Methadone Clinic: Infant Toxicology Data 2015 2016 P Value Overall (2015-2016) # of infants with 13/42 (31%) 30/59 (51%) P < 0.001 43/101 (43%) mothers in a methadone clinic Non-Compliance 11/13 (85%) 22/30 (73%) P = 0.394 33/43 (77%) Rate 16

DIGNITY HEALTH DATA Infant Toxicology Data of Mothers in a Methadone Clinic: Illicit vs Controlled vs Polysubstance Use 2015 2016 P Value Overall (2015-2016) Infants of mothers 11/13 (85%) 22/30 (73%) P = 0.938 33/43 (77%) in a methadone clinic positive for > 1 substance (polysubstance use) 17

DIGNITY HEALTH DATA Infant Toxicology Data: Illicit vs Controlled vs Polysubstance Use 2015 2016 P Value Overall (2015-2016) Infants positive for 20/42 (48%) 43/59 (73%) P =0.01 63/101 (62%) an illicit substance Infants positive for a 22/42 (52%) 39/59 (66%) P =0.165 61/101 (60%) controlled substance Infants positive for 23/42 (55%) 48/59 (81%) P =0.015 71/101 (70%) > 1 substance (polysubstance use) 18

DIGNITY HEALTH DATA Infant Toxicology Results: Specific Substances 2015 2016 P Value Overall (2015-2016) Opiates 20/42 (48%) 34/59 (58%) P = 0.320 54/101 (54%) Benzodiazepines 3/42 (7%) 13/59 (22%) P = 0.043 16/101 (16%) Methamphetamine 14/42 (33%) 31/59 (53%) P = 0.056 45/101 (45%) Marijuana 11/42 (26%) 18/59 (31%) P = 0.636 29/101 (29%) Cocaine 0/42 (0%) 2/59 (3%) P = 0.228 2/101 (2%) 19

DIGNITY HEALTH DATA Prenatal Care/Discharge Information 2015 2016 Overall (2015-2016) Infants admitted for NAS 11/42 (26%) 11/59 (19%) 22/101 (22%) with no prenatal care Infants discharged with 12/42 (29%) 22/59 (37%) 34/101 (34%) someone other then parents 20

UNDERSTANDING BARRIERS TO TREATMENT FOR PREGNANT WOMEN… 21

BARRIERS TO TREATMENT DURING PREGNANCY • Shame • Misinformation • Legal consequences implemented by several states • Goal: Protect the infant from opioid exposure • Consequence: Drives women away from seeking or continuing care leading to worse outcomes for infant & the mother • Healthcare professionals & systems are often reluctant to provide care • Typically due to misunderstanding & lack of experience in treating pregnant women 22 Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159.

BARRIERS TO TREATMENT DURING PREGNANCY • Multiple policies exist on screening, treatment, reporting of substance use during pregnancy/postpartum period & involvement of child protective services (CPS) which can be confusing • American Academy of Addiction Psychiatry • American Society of Addiction Medicine • Committee on Healthcare for Underserved Women • American College of Obstetricians & Gynecologists • American Academy of Pediatrics • Substance Abuse & Mental Health Services Administration Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and 23 parenting women with opioid use disorder and their infants. P. 1-159.

BARRIERS TO TREATMENT DURING PREGNANCY • Take home point: • Without treatment, pregnant women with OUD face increased risks of preterm delivery, low infant birth weight & have an increased risk for transmitting HIV to their infants • Effective interventions, including medication-assisted treatment (MAT), can lead to healthy outcomes for mother & infant • Requires recognition by health care professionals!!!! Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and 24 parenting women with opioid use disorder and their infants. P. 1-159.

WHAT WOMEN SHOULD I SCREEN FOR SUBSTANCE USE DISORDER (SUD)? 25

RECOGNITION • World Health Organization (WHO) recommendations • Who? • Healthcare professionals should ask ALL pregnant women about their use of alcohol & other substances • Universal screening • Ask about past, present, prescribed, licit & illicit use • How often? • As early as possible in pregnancy & at every follow-up visit • 2017 American College of Obstetricians & Gynecologists (ACOG) recommendations: • Screening for SUD should be part of comprehensive OB care & should be done at the 1 st prenatal visit • Screening based only on factors, such as poor adherence to prenatal care or prior adverse pregnancy outcome, can lead to missed cases & may add to stereotyping/stigma • It is ESSENTIAL that screening be UNIVERSAL 26 Substance abuse and mental health services administration. Clinical Guidance for treating pregnant and parenting women with opioid use disorder and their infants. P. 1-159.

HOW DO I SCREEN? 27