Ve r mont’s CHARM (Childr e n and Re c ove r ing Mothe r s) T e am: A c o llab o rative appro ac h to suppo rting pre g nant and pare nting wo me n with o pio id use diso rde rs and the ir infants Anne M. Johnston , MD, Ne o na to lo g ist Unive rsity o f Ve rmo nt Childre n’ s Ho spita l de n , M.E d., E xe c utive Dire c to r Sally Bor K idSa fe Co lla b o ra tive OF A Pe e r T A We binar : Opio id Use Diso r de r , T r e atme nt, and Bar r ie r s to E mplo yme nt Amo ng T ANF Re c ipie nts Marc h 29, 2018 1
Ag e nda Opio id de pe nde nc e in pre g na nc y Opio id-e xpo se d ne wb o rns T he CHARM c o lla b o ra tive 2
Neonatal Abstinence Syndrome (NAS) Incidence Rates – 25 States, 2012-2013 Maine 30.4 Vermont 33.3 W Virginia 33.4 Vermont had the highest annual rate increase of states surveyed Ko JY, Patrick SW, Tong VT, Patel R, Lind JN, Barfield WD. Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013. MMWR Morb Mortal Wkly Rep 2016;65:799–802
INCREASE IN NAS IN VERMONT Represents: • Increased access to safe treatment, both prior to pregnancy and during pregnancy • Increased identification 4
Myth #1: Opioids during pregnancy “damaged baby” • T he re is no e vide nc e tha t o pio id e xpo sure , in a nd o f itse lf, re sults in de ve lo pme nta l de la y o r a ny o the r la sting e ffe c ts o n the e xpo se d c hild • On the o the r ha nd, a lc o ho l e xpo sure c a n re sult in pro fo und physic a l/ de ve lo pme nta l/ b e ha vio ra l e ffe c ts 5
Myth #2: Every baby born to a mother on opioids is born “addicted” • Opio id-e xpo se d: e xpo sure to o pio ids – e ithe r pre sc rib e d o r illic it • Opio id-de pe nde nt: infa nt e xhib its sig ns o f withdra wa l se ve re e no ug h to ne e d me dic a tio n • Opio id-a ddic te d: infa nts c a nno t b e a ddic ts; the dise a se o f a ddic tio n re q uire s o b se ssio n a nd c o mpulsio n, lo ss o f c o ntro l, “b re a king the rule s” • Ve rmo nt da ta sho w tha t o nly 20% o f o pio id-e xpo se d infa nts re q uire tre a tme nt “Addicted newborns” 6
Myth #3: If a baby needs treatment for opioid withdrawal, it must be because the mother “used” opioids during pregnancy • T he se ve rity o f withdra wa l is no t a sso c ia te d with the do se o f me dic a tio n during pre g na nc y • E xpo sure to to b a c c o c a n inc re a se the se ve rity o f withdra wa l • Hig he r Ne o na ta l Ab stine nc e Sc o re s do no t indic a te tha t a mo the r ha s “use d” during pre g na nc y 7
Myth #4: Opioid abuse + pregnancy = child abuse • >1500 b a b ie s b o rn to o pio id-de pe nde nt wo me n fo llo we d thro ug h o ur c linic • Ove r 80% o f the se b a b ie s we re disc ha rg e d in the c a re o f the ir mo the r +/ - fa the r (2002 – 2016) • T he ma jo rity o f pa re nts we se e a re a c tive ly e ng a g e d in tre a tme nt a nd displa y g o o d pa re nting , ma ny ne e d suppo rt in o rde r to do so • I f a pa re nt is no t a dhe ring to tre a tme nt, do e s no t wa nt to re c e ive tre a tme nt, and is a c tive ly using – the y ma y NOT b e re a dy to pa re nt a c hild 8
Why is me dic a tio n-a ssiste d tre a tme nt fo r pre g na nt wo me n with o pio id use diso rde r the sta nda rd o f c a re ? • De c re a se s pre ma turity a nd lo w b irth we ig ht • I mpro ve s the he a lth o f the pre g na nc y • L o we rs infa nt mo rta lity • Pre g na nt wo ma n fe e ls we ll (no t “hig h”) a nd ha s no c ra ving s • Suc c e ssful e ng a g e me nt in tre a tme nt inc re a se s the pro b a b ility o f g o o d pa re nting • De to xific a tio n during pre g na nc y is ra re ly suc c e ssful a nd da ng e ro us to the fe tus n: a nything tha t drive s pre g na nt o pio id-de pe nde nt Conc e r wo me n fro m se e king tre a tme nt re sults in mo re pre ma turity, hig he r infa nt mo rta lity, le ss pro b a b ility o f suc c e ssful pa re nting 9
T he untr e ate d wo ma n with o pio id-use diso rde r who de live rs a ne wb o rn • Ne o na ta l o pio id withdra wa l • Ne o na ta l c o mplic a tio ns: • Pre ma turity, lo w b irth we ig ht • Me c o nium a spira tio n, tra nsie nt ta c hypne a • F e e ding diffic ulty, se izure s, ja undic e • I f re c o g nize d tha t mo the r is o pio id-de pe nde nt: • Child pro te c tive se rvic e s invo lve me nt • Cha lle ng e o f ta king c a re o f ne wb o rn a nd sta rting tre a tme nt fo r www.the fix.c o m a ddic tio n I f unre c o g nize d a nd infa nt e xhib its no withdra wa l: • Afte r disc ha rg e infa nt ma y b e pa rtic ula rly irrita b le • F a mily’ s a b ility to c o pe a nd se e k he lp is impe de d b y fe a r o f disc o ve ry • Mo the r will pro b a b ly re ma in a c tive in he r a ddic tio n • I nfa nt ma y b e e xpo se d to unsa fe situa tio ns • Mo the r c o ntinuo usly “flying unde r the ra da r” a nd hiding he r a ddic tio n • Mo the r o fte n unwilling to c o me fo rwa rd fo r fe a r o f lo sing he r c hild/ c hildre n •
Opio id de pe nde nc e : T re a tme nt o ptio ns • De to xific a tio n – g e ne ra lly no t sa fe no r a dvisa b le in pre g na nc y • Me dic a tio n Assiste d T re a tme nt (MAT ): the sta nda rd o f c a re in pre g na nc y • Me tha do ne • Bupre no rphine • Ha rm Re duc tio n • Ne e dle e xc ha ng e 11
I ssue s fa c ing sub sta nc e -using pre g na nt wo me n a nd the ir c hildre n • Generational substance use • Untreated mental health problems • Legal involvement • Unstable housing • Unstable transportation • Lack of positive and supportive • Limited parenting skills and relationships resources • Exposure to trauma 12 Slide c o urte sy o f H Jo ne s
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F o c us o n the mo the r’ s he a lth to ha ve b e tte r o utc o me s • Build trust • Focus on respect and strengths • Decrease fear and shame • Promote breastfeeding 14
UVM CHI L DRE N’ S HOSPI T AL : E VAL UAT I ON AND MANAGE ME NT OF NAS • NAS sc o ring using mo difie d F inne g a n, tra nsitio ning to E SC; ma ximize no n-pha rma c o lo g ic c a re • I npa tie nt me tha do ne fo r ne wb o rns re q uiring me dic a tio n • Onc e infa nts a re sta b le o n me tha do ne fo r 72 ho urs, the y a re disc ha rg e d ho me • I mpo rta nc e o f a sse ssing ho me a nd sa fe ty c o nc e rns • I mpo rta nc e o f c a re g ive r e duc a tio n re g a rding me tha do ne • Ne o Me d Clinic visits within 1 we e k a nd the n e ve ry 2 we e ks fo r we a ning o f me tha do ne , mo nito ring o f g ro wth a nd de ve lo pme nt, mo nito ring o f pa re nt(s) re c o ve ry 15
UVM Childre n’ s Ho spital: I nfa nts b o rn (a t UVM) to o pio id de pe nde nt wo me n with sub sta nc e use diso rde r o n me tha done o r bupre norphine a t de live ry (N = 1,119)
UVM CHI L DRE N’ S HOSPI T AL BAYL E Y I I I : ME AN PE RCE NT I L E RANK (N=277) 7-14 MONT HS OF AGE
K e y Po ints • T he inc ide nc e o f ne o na ta l a b stine nc e syndro me is inc re a sing – do e s this re pre se nt inc re a se d ide ntific a tio n o f c a se s, inc re a se d a c c e ss to c a re fo r pre g na nt o pio id-de pe nde nt wo me n? • Be hind e ve ry c a se o f ne o na ta l a b stine nc e syndro me , the re is a mo the r suffe ring fro m the dise a se o f a ddic tio n – this is whe re e ffo rts ne e d to b e the g re a te st – ne e d to de c re a se judg e me nt, inc re a se a c c e ss to tra uma -info rme d tre a tme nt • De ve lo pme nta l/ b e ha vio ra l o utc o me s a re o ve ra ll no t a ffe c te d b y o pio id-e xpo sure in ute ro o n its o wn, unlike a lc o ho l e xpo sure • Co mmunity stra te g ie s tha t fo c us o n punishme nt will re sult in inc re a se d mo rb idity a nd mo rta lity fo r c hildre n a nd the ir fa milie s • He a lthy c o lla b o ra tio n b e twe e n pa rtne rs wo rking with fa milie s is e sse ntia l
CHARM: Children and Recovering Mothers CHARM is an inter-disciplinary and cross-agency team that coordinates care for pregnant and postpartum mothers with a history of opioid use disorder and their babies. Model collaborative approach (US Dept. of Health and Human Services, SAMHSA 2016) CHARM Goal : To improve the health and safety outcomes of babie s born to women with a history of opioid use disorder by coordinating medical care, substance abuse treatment, child welfare, and social service supports 19
Challenges for TANF Recipients Health Care: Prenatal and Postpartum Care • • Substance Abuse Treatment: MAT; Counseling: Level of Care • Services and Supports: Child Care, Housing, Transportation • “Reach Up” Requirements CHARM: Promising Prevention Model • Pregnancy: Opportunity for Change • Early Access to Prenatal Care and Substance Abuse Treatment • Early child welfare involvement, assessment and develop plans of safe care prior to birth • Coordinated Services and Supports • Systems for collaboration: information sharing to support health/safety of moms and infants 20
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