Difference between revisions of "Expand Access to MAT for Pregnant Women"
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| − | <div | + | __NOTOC__<div class="mw-parser-output"><div class="wiki" id="content_view" style="display: block"> |
| − | + | Return to [[Opioid_Top-Level_Strategy_Map|Opioid Top-Level Strategy Map]] or [[ZOOM_MAP_-_Expand_Steps_to_Minimize_Opioid_Use_During_Pregnancy_or_Pregnancy_during_Opioid_Use|ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use]] | |
| − | + | <div id="toc"> | |
| − | + | = Table of Contents = | |
| − | =Table of Contents= | + | <div style="margin-left: 1em">[[#Background|Background]]</div> <div style="margin-left: 1em">[[#Current_Status|Current Status]]</div> <div style="margin-left: 1em">[[#Educate_Medical_Providers|Educate Medical Providers]]</div> <div style="margin-left: 1em">[[#New_2018_Clinical_Guide_by_SAMHSA|New 2018 Clinical Guide by SAMHSA]]</div> <div style="margin-left: 1em">[[#Split_Dosing_to_Reduce_Risk|Split Dosing to Reduce Risk]]</div> <div style="margin-left: 1em">[[#Methadone_Clinics|Methadone Clinics]]</div> <div style="margin-left: 1em">[[#Funding|Funding]]</div> <div style="margin-left: 1em">[[#Tools_.26_Resources|Tools & Resources]]</div> <div style="margin-left: 1em">[[#Scorecard_Building|Scorecard Building]]</div> <div style="margin-left: 1em">[[#Resources_to_Investigate|Resources to Investigate]]</div> <div style="margin-left: 1em">[[#Sources|Sources]]</div> </div> |
| − | <div style="margin-left: 1em">[[#Background|Background]]</div><div style="margin-left: 1em">[[# | + | = Background = |
| − | =Background | ||
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| − | * There are often long waiting periods to get women into treatment.<sup class="reference">[4]</sup> | + | '''Maintenance Therapy Drugs'''<br/> Medically supervised tapering of opioids in pregnant women is associated with high relapse rates as compared to methadone maintenance.<sup class="reference">[1]</sup><br/> <br/> Women who need maintenance therapy drugs often struggle to get them. To get buprenorphine, they must go to one of the state's few doctors with a special license. To get methadone, they must go regularly to a clinic — in Middle Tennessee there's one in Nashville and one in Columbia. Women must often pay out of pocket. And many women of child-bearing age don't qualify for TennCare until they find themselves pregnant. That makes it difficult for an addict to access family planning or mental health preventive care before becoming pregnant.<sup class="reference">[2]</sup><br/> <br/> Tennessee's three managed care companies — Amerigroup, UnitedHealthcare's Medicaid subsidiary and BlueCross BlueShield's BlueCare program — are trying to reach these women earlier to ensure that more babies are born healthy. All have flagged drug-dependent babies as a major cost issue. BlueCross, for example, covered 775 such babies in 2013 [must be nationwide]. [at $50,000 each, which is a low estimate of incremental cost over a normal birth, that cost BlueCross about 38 million.] All three have launched efforts to help expectant mothers beat their addictions.<sup class="reference">[3]</sup><br/> |
| − | ** Although pregnant women actually receive priority for methadone treatment, once they are not pregnant they return tot the long waiting periods and the motivation to pursue treatment may be deterred by these waits<sup class="reference">[5]</sup> | + | |
| − | * Women often experience anxiety about what will happen if they can no longer pay for their methadone treatments<sup class="reference">[6]</sup> | + | = Current Status = |
| − | ** There is a need for increased grant funding to help women stay in treatment once they are enrolled<sup class="reference">[7]</sup> | + | |
| − | * Women have misconceptions about methadone and are unclear about the treatment process<sup class="reference">[8]</sup> | + | *There are often long waiting periods to get women into treatment.<sup class="reference">[4]</sup> |
| − | * 13 states give pregnant women priority access to general programs for drug treatment.<sup class="reference">[9]</sup> | + | **Although pregnant women actually receive priority for methadone treatment, once they are not pregnant they return tot the long waiting periods and the motivation to pursue treatment may be deterred by these waits<sup class="reference">[5]</sup> |
| − | * 4 states protect pregnant women from discrimination in publicly funded programs.<sup class="reference">[10]</sup> | + | *Women often experience anxiety about what will happen if they can no longer pay for their methadone treatments<sup class="reference">[6]</sup> |
| − | * 18 states consider substance abuse during pregnancy to be grounds for child abuse.<sup class="reference">[11]</sup> | + | **There is a need for increased grant funding to help women stay in treatment once they are enrolled<sup class="reference">[7]</sup> |
| − | + | *Women have misconceptions about methadone and are unclear about the treatment process<sup class="reference">[8]</sup> | |
| − | =Educate Medical Providers= | + | *13 states give pregnant women priority access to general programs for drug treatment.<sup class="reference">[9]</sup> |
| − | A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation.<sup class="reference">[12]</sup>[http://pcssmat.org/ Provider's Clinical Support System] (PCSS) fpr MAT provides many free online trainings and resources to help address the opioid crisis, including "[http://pcssmat.org/opioid-dependence-in-pregnancy-clinical-challenges/ Opioid Dependence in Pregnancy: Clinical Challenges]." | + | *4 states protect pregnant women from discrimination in publicly funded programs.<sup class="reference">[10]</sup> |
| − | =New 2018 Clinical Guide by SAMHSA= | + | *18 states consider substance abuse during pregnancy to be grounds for child abuse.<sup class="reference">[11]</sup> |
| − | This new. detailed, 165-page guide has SAMHSA's latest recommendations on [https://store.samhsa.gov/shin/content//SMA18-5054c/SMA18-5054.pdf Clinical Guidance for Treating Pregnant Women with OUD and their Infants]. | + | |
| − | =Split Dosing to Reduce Risk= | + | |
| − | The following quote shares some insights and potential benefits of "split dosing" of methadone. The article has more details.<sup class="reference">[13]</sup> | + | |
| − | =Methadone Clinics= | + | = Educate Medical Providers = |
| − | Methadone clinics should provide information sessions and materials to help pregnant women prepare for the experience of delivering their babies at hospitals. These should include the following:<sup class="reference">[16]</sup><br /> | + | |
| + | A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation.<sup class="reference">[12]</sup>[http://pcssmat.org/ Provider's Clinical Support System] (PCSS) fpr MAT provides many free online trainings and resources to help address the opioid crisis, including "[http://pcssmat.org/opioid-dependence-in-pregnancy-clinical-challenges/ Opioid Dependence in Pregnancy: Clinical Challenges]." | ||
| + | |||
| + | |||
| + | |||
| + | = New 2018 Clinical Guide by SAMHSA = | ||
| + | |||
| + | This new. detailed, 165-page guide has SAMHSA's latest recommendations on [https://store.samhsa.gov/shin/content//SMA18-5054c/SMA18-5054.pdf Clinical Guidance for Treating Pregnant Women with OUD and their Infants]. | ||
| + | |||
| + | |||
| + | |||
| + | |||
| + | = Split Dosing to Reduce Risk = | ||
| + | |||
| + | The following quote shares some insights and potential benefits of "split dosing" of methadone. The article has more details.<sup class="reference">[13]</sup> | ||
| + | |||
| + | "Part of the confusion relates to the question of whether giving the mother high doses of methadone worsens NAS. A recent meta-analysis of 67 studies found this not to be the case.* The fetus is not exposed to the maternal dose; it is exposed to the maternal plasma level. We know that plasma levels vary significantly, depending on genetics. And pregnant women metabolize methadone more quickly, necessitating dose increases—but these increases do not necessarily increase fetal exposure to methadone. | ||
| + | |||
| + | One mother in our pregnancy program required 270 mg/day of methadone, in four divided doses. Her plasma level, before the morning dose one week before delivery, was undetectable. After birth, the baby required no treatment for NAS. We don’t know how many physicians are willing to prescribe these high, split doses to keep the mother and fetus out of withdrawal. We don’t know whether programs use maternal plasma methadone levels to monitor changes in maternal metabolism and fetal exposure. | ||
| + | In pregnancy, split doses of methadone protect the fetus from exposure to daily cycles of peaks and troughs, which have been shown to have negative physiologic effects on the fetus.* Even high doses, when given as single daily doses, can result in fetal withdrawal distress before the next day’s dose. That may be why high doses, at times, seem to cause more cases of NAS: The fetus may be sensitized to daily episodes of withdrawal.* Some mothers, like our patient who received 270 mg daily, are ultra-rapid metabolizers; the methadone exposure for their fetuses is far more consistent and physiologic when dosing is four times a day."<sup class="reference">[14]</sup> | ||
| + | |||
| + | The approach used in one study for women on methadone (that used higher doses split into 2 or 4 doses per day yielded significantly lower rates of NAS.<sup class="reference">[15]</sup> | ||
| + | |||
| + | Another s[http://atforum.com/2015/10/methadone-split-dosing-less-nas-better-maternal-recovery/ tudy on split dosing] also showed benefits. More research is needed. | ||
| + | |||
| + | Since DNA tests can help to understand the way a person will metabolize different drugs, it could be tested to advance a precision medicine approach to MAT for pregnant women. . More research is needed on this issue. | ||
| + | |||
| + | |||
| + | = Methadone Clinics = | ||
| + | |||
| + | Methadone clinics should provide information sessions and materials to help pregnant women prepare for the experience of delivering their babies at hospitals. These should include the following:<sup class="reference">[16]</sup> | ||
| + | |||
| + | |||
| + | *What to expect in regards to pain management | ||
| + | *Infant withdrawal symptoms | ||
| + | *CPS involvement | ||
| + | *Treatment approaches for withdrawing infants | ||
| + | *How to work with doctors and nurses to help the process go smoothly | ||
| + | *Advice for comforting methadone-exposed babies once they come home | ||
| + | |||
| + | | ||
| + | |||
| + | = Funding = | ||
| + | |||
| + | SAMHSA’s Substance Abuse Prevention and Treatment block grants have recently been revised to strengthen capacity to deliver MAT for pregnant women with substance use disorders.<sup class="reference">[17]</sup> | ||
| + | |||
| + | |||
| + | = Tools & Resources = | ||
| + | |||
| + | [[TR_-_Expand_Access_to_MAT_for_Pregnant_Women|TR - Expand Access to MAT for Pregnant Women]] | ||
| + | |||
| + | = Scorecard Building = | ||
| + | |||
| + | [[PO_-_Expand_Access_to_MAT_for_Pregnant_Women|Potential Objective Details]]<br/> [[PM_-_Expand_Access_to_MAT_for_Pregnant_Women|Potential Measures and Data Sources]]<br/> [[PA_-_Expand_Access_to_MAT_for_Pregnant_Women|Potential Actions and Partners]] | ||
| + | |||
| + | = Resources to Investigate = | ||
| + | |||
| + | [[More_RTI_on_Expand_Access_to_MAT_for_Pregnant_Women|More RTI on Expand Access to MAT for Pregnant Women]]<br/> <br/> <span style="background-color: #ffffff; color: #222222; font-family: arial,sans-serif; font-size: 12.8px">'''<span style="color: #4d4d4d">PAGE MANAGER</span>:''' </span><span style="background-color: #ffffff; color: #ff0000; font-family: arial,sans-serif; font-size: 12.8px">[insert name here]</span><br/> <span style="background-color: #ffffff; color: #222222; font-family: arial,sans-serif; font-size: 12.8px">'''<span style="color: #4d4d4d">SUBJECT MATTER EXPERT</span>''': </span><span style="background-color: #ffffff; color: #ff0000; font-family: arial,sans-serif; font-size: 12.8px">[fill out table below]</span> | ||
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{| class="wiki_table" | {| class="wiki_table" | ||
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|- | |- | ||
| − | | | + | | '''Reviewer''' |
| − | | | + | | '''Date''' |
| − | | | + | | '''Comments''' |
| + | |- | ||
| + | | | ||
| + | | | ||
| + | | | ||
|} | |} | ||
| − | =Sources= | + | |
| + | = Sources = | ||
---- | ---- | ||
| − | # ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6 | + | #ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6 |
| − | # [http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/] | + | #[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [1]] |
| − | # [http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/] | + | #[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [2]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [3]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [4]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [5]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [6]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [7]] |
| − | # [http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403] | + | #[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [8]] |
| − | # [http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403] | + | #[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [9]] |
| − | # [http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403] | + | #[http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403 [10]] |
| − | # [https://www.ncbi.nlm.nih.gov/pubmed/23154692] | + | #[https://www.ncbi.nlm.nih.gov/pubmed/23154692 [11]] |
| − | # ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6 | + | #ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6 |
| − | # [http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/] | + | #[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [12]] |
| − | # [http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/] | + | #[http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/ [13]] |
| − | # [https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5] | + | #[https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5 [14]] |
| − | # [https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm] | + | #[https://www.cdc.gov/mmwr/volumes/66/wr/mm6609a2.htm [15]] |
| − | </div> | + | </div> </div> |
Revision as of 08:16, 8 January 2019
Return to Opioid Top-Level Strategy Map or ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use
Table of Contents
Background
Maintenance Therapy Drugs
Medically supervised tapering of opioids in pregnant women is associated with high relapse rates as compared to methadone maintenance.[1]
Women who need maintenance therapy drugs often struggle to get them. To get buprenorphine, they must go to one of the state's few doctors with a special license. To get methadone, they must go regularly to a clinic — in Middle Tennessee there's one in Nashville and one in Columbia. Women must often pay out of pocket. And many women of child-bearing age don't qualify for TennCare until they find themselves pregnant. That makes it difficult for an addict to access family planning or mental health preventive care before becoming pregnant.[2]
Tennessee's three managed care companies — Amerigroup, UnitedHealthcare's Medicaid subsidiary and BlueCross BlueShield's BlueCare program — are trying to reach these women earlier to ensure that more babies are born healthy. All have flagged drug-dependent babies as a major cost issue. BlueCross, for example, covered 775 such babies in 2013 [must be nationwide]. [at $50,000 each, which is a low estimate of incremental cost over a normal birth, that cost BlueCross about 38 million.] All three have launched efforts to help expectant mothers beat their addictions.[3]
Current Status
- There are often long waiting periods to get women into treatment.[4]
- Although pregnant women actually receive priority for methadone treatment, once they are not pregnant they return tot the long waiting periods and the motivation to pursue treatment may be deterred by these waits[5]
- Women often experience anxiety about what will happen if they can no longer pay for their methadone treatments[6]
- There is a need for increased grant funding to help women stay in treatment once they are enrolled[7]
- Women have misconceptions about methadone and are unclear about the treatment process[8]
- 13 states give pregnant women priority access to general programs for drug treatment.[9]
- 4 states protect pregnant women from discrimination in publicly funded programs.[10]
- 18 states consider substance abuse during pregnancy to be grounds for child abuse.[11]
Educate Medical Providers
A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation.[12]Provider's Clinical Support System (PCSS) fpr MAT provides many free online trainings and resources to help address the opioid crisis, including "Opioid Dependence in Pregnancy: Clinical Challenges."
New 2018 Clinical Guide by SAMHSA
This new. detailed, 165-page guide has SAMHSA's latest recommendations on Clinical Guidance for Treating Pregnant Women with OUD and their Infants.
Split Dosing to Reduce Risk
The following quote shares some insights and potential benefits of "split dosing" of methadone. The article has more details.[13] "Part of the confusion relates to the question of whether giving the mother high doses of methadone worsens NAS. A recent meta-analysis of 67 studies found this not to be the case.* The fetus is not exposed to the maternal dose; it is exposed to the maternal plasma level. We know that plasma levels vary significantly, depending on genetics. And pregnant women metabolize methadone more quickly, necessitating dose increases—but these increases do not necessarily increase fetal exposure to methadone. One mother in our pregnancy program required 270 mg/day of methadone, in four divided doses. Her plasma level, before the morning dose one week before delivery, was undetectable. After birth, the baby required no treatment for NAS. We don’t know how many physicians are willing to prescribe these high, split doses to keep the mother and fetus out of withdrawal. We don’t know whether programs use maternal plasma methadone levels to monitor changes in maternal metabolism and fetal exposure. In pregnancy, split doses of methadone protect the fetus from exposure to daily cycles of peaks and troughs, which have been shown to have negative physiologic effects on the fetus.* Even high doses, when given as single daily doses, can result in fetal withdrawal distress before the next day’s dose. That may be why high doses, at times, seem to cause more cases of NAS: The fetus may be sensitized to daily episodes of withdrawal.* Some mothers, like our patient who received 270 mg daily, are ultra-rapid metabolizers; the methadone exposure for their fetuses is far more consistent and physiologic when dosing is four times a day."[14] The approach used in one study for women on methadone (that used higher doses split into 2 or 4 doses per day yielded significantly lower rates of NAS.[15] Another study on split dosing also showed benefits. More research is needed. Since DNA tests can help to understand the way a person will metabolize different drugs, it could be tested to advance a precision medicine approach to MAT for pregnant women. . More research is needed on this issue.
Methadone Clinics
Methadone clinics should provide information sessions and materials to help pregnant women prepare for the experience of delivering their babies at hospitals. These should include the following:[16]
- What to expect in regards to pain management
- Infant withdrawal symptoms
- CPS involvement
- Treatment approaches for withdrawing infants
- How to work with doctors and nurses to help the process go smoothly
- Advice for comforting methadone-exposed babies once they come home
Funding
SAMHSA’s Substance Abuse Prevention and Treatment block grants have recently been revised to strengthen capacity to deliver MAT for pregnant women with substance use disorders.[17]
Tools & Resources
TR - Expand Access to MAT for Pregnant Women
Scorecard Building
Potential Objective Details
Potential Measures and Data Sources
Potential Actions and Partners
Resources to Investigate
More RTI on Expand Access to MAT for Pregnant Women
PAGE MANAGER: [insert name here]
SUBJECT MATTER EXPERT: [fill out table below]
| Reviewer | Date | Comments |
Sources
- ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6
- [1]
- [2]
- [3]
- [4]
- [5]
- [6]
- [7]
- [8]
- [9]
- [10]
- [11]
- ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6
- [12]
- [13]
- [14]
- [15]
