Treating and Managing Opioid Use Disorder in Pregnancy

1. Treating and Managing Opioid Use Disorder in Pregnancy Mishka Terplan, MD, MPH Diana Coffa, MD

2. Agenda • Overview of the CCC Substance Use Warmline • Overview of the “Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infants” • Case study of OUD treatment in pregnancy

3. Substance Use Warmline:Free clinical consultation on managing substance use in primary care6 am – 5 pm PST, Monday – Friday1.855.300.3595 or submit cases online at nccc.ucsf.edu The Clinician Consultation Center is pleased to offer confidential telephone consultation focusing on substance use evaluation and management for primary care clinicians nationally. With special expertise in pharmacotherapy options for opioid use, our addiction medicine-certified physicians, clinical pharmacists, and nurses provide advice based on Federal treatment guidelines, up-to-date evidence, and clinical best practices. Learn more at http://nccc.ucsf.edu/clinician-consultation/substance-use-management/ This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1OHA30039-01-00 (AIDS Education and Training Centers National Clinician Consultation Center) in partnership with the HRSA Bureau of Primary Health Care (BPHC) awarded to the University of California, San Francisco.

4. Substance Use Warmline Peer-to-Peer Consultation and Decision Support (855) 300-3595 or submit cases online at nccc.ucsf.edu • Our consultants can help: • Support primary care providers in managing complex patients with addiction, chronic pain, and behavioral health issues • Improve the safety of medication regimens to help decrease risk of harm, including overdose • Enhance the treatment, care and support for people living with or at risk for HIV and viral hepatitis • Discuss useful care and communication strategies for clinicians regarding substance use, addiction and chronic pain • Develop comprehensive treatment plans for special circumstances including pregnancy

6. The Opioid Crisis in Pregnant and Postpartum Women • Opioid use in pregnant women more than doubled between 1998 and 2011 • In 2016, the number of women of childbearing age (15‒44 years) who reported past-month use of opioids (including heroin or pain reliever misuse) • 1,090,000 in 2016 • 1.49% increase from 2015 • Primary prevention: Use non-pharmacologic therapies and non-opioid medications

7. Women of reproductive age who use opioids More than 35% of women of reproductive age with Medicaid and more than 25% of women of reproductive age with private insurance filled a prescription for an opioid MMWR. Opioid Prescription Claims among Women of Reproductive Age - United States, 2008-2012. Jan 23, 2015. 64(02); 37-41

8. Unintended pregnancy • Up to 45% of pregnancies are unintended in the United States • Almost 86% of pregnancies are unintended among women who use opioids • Increased access to contraception is important to reduce neonatal abstinence syndrome (NAS) HeilSH, Jones HE, Arria A, et al. Unintended Pregnancy in Opioid-abusing Women. Journal of Substance Abuse Treatment. 2011;40(2):199-202. Terplan, M, Hand D. J., Hutchinson, M et al. Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review. Preventive Medicine. 80. 23-31

9. Barriers to OUD treatment in women • Legal consequences in seeking treatment • High rates of depression, PTSD, anxiety, bipolar and other mental health disorders • High rates of family instability • High rates of domestic violence • Childcare responsibilities

10. Neonatal Abstinence Syndrome (NAS) • Signs of withdrawal that may occur in a newborn exposed to opioids in utero • Up to 50-80% of opioid-exposed infants develop NAS • Between 2009-2012, infants diagnosed with NAS increased from 3.4 to 5.8 per 1000 hospital births • More than 20,000 infants with NAS in 2012

11. SAMHSA Guidelines • Available as a PDF https://store.samhsa.gov/product/SMA18-5054 • One of many resources used by the CCC to provide consultation • Will form the foundation for our discussion today

12. Fact Sheets

13. How to use the fact sheets

14. Factsheet #1

15. Factsheet #1 Prenatal screenings and assessment Screenings - Healthcare professionals should ask all pregnant women about their use of alcohol and other substances (i.e., past, present, prescribed, licit, and illicit use) as early as possible in the pregnancy and at every follow-up visit* - Interviews and Instruments- different tools are available (page 19) - Toxicology screens- conduct a baseline test *WHO, Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy, 2014

16. State-based Prescription Drug Monitoring Program (PDMP) • Collects data from pharmacies on prescriptions of controlled substances - Can determine if the patient is going to multiple providers to get prescriptions - Can detect use of unreported medications • Healthcare professionals should consult their states PDMP for prescription drug use history • State’s have different rules on who can access data

17. Social, Medical and Legal Consequences • Pregnant women with OUD receive no, or very little, prenatal care • Important to coordinate care between providers • Pregnancy is a time of great potential for positive changes – women may be more motivated • Women with OUD are at higher risk for HIV/AIDS and viral hepatitis • Resource: ASAM Public Policy Statement on Women, Alcohol and Other Drugs, and Pregnancy

18. Factsheet #2

19. Factsheet #2 Initiating pharmacotherapy for OUD • Medication Assisted Treatment (MAT) • Methadone or buprenorphine and behavioral interventions • Patient education – • Explain the risk of NAS • No known risk of increased birth defects with pharmacotherapy for OUD • Treatment plans need to be individualized • Healthcare professionals should educate women about potential legal, social and medical consequences of each treatment option

20. Resources Substance Abuse Mental Health Services Administration (SAMHSA) • Behavioral Health Treatment Services Locator https://findtreatment.samhsa.gov/ • Opioid Treatment Program Directory https://dpt2.samhsa.gov/treatment/directory.aspx American Society of Addiction Medicine • National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use https://www.asam.org/resources/guidelines-and-consensus-documents/npg

21. Counseling about NAS risk and prevention • Other substances contribute to NAS • Encourage quitting tobacco use • Encourage avoidance of benzodiazepines • Encourage breastfeeding after delivery • If not possible, encourage skin-to-skin, rooming in • Advise about standards of care in your setting • Length of monitoring for NAS? • Rooming in? Mother in nursery? • Dose of MAT does not predict NAS

22. Factsheet #4 Managing pharmacotherapy over the course of pregnancy • Need for periodic adjustments of pharmacotherapy for OUD • Pharmacotherapy dose does not affect NAS • Counseling can encourage women to continue treatment and prevent return to substance use • Role of peer support specialists • A Collaborative Approach to the Treatment of Pregnant women with Opioid Use Disorders (SAMHSA)

23. Factsheet #3 Changing Pharmacotherapy During Pregnancy • Medically assisted withdrawal is not recommended • What about changing from buprenorphine to methadone and vice versa? • Maintaining stability is key • Any change in medication represents a period of vulnerability to return to substance use

24. Factsheet #5 Addressing co-morbid behavioral health disorders • Comorbid behavioral health disorders are common and may require medications • Depression and other psychiatric conditions are common among women with OUD • Follow SAMHSA’s Screening, Brief Intervention, and Referral to Treatment (SBIRT) • Understand possible drug interactions with other medications

25. Factsheets #6 and #7 Factsheet #6 • Addressing polysubstance use during pregnancy Factsheet #7 • Planning prior to labor and delivery

26. Factsheet #8 Peripartum pain relief • Pregnant women with OUD need to be assured that they will receive adequate pain relief during labor and postpartum • Options include epidural and short acting opioids • During labor and delivery, she should be maintained on her current dose of opioid agonist therapy for OUD

27. Factsheet 11: Breastfeeding Considerations for infants at risk for NAS • Women who are stable on MAT should be advised to breastfeed • Levels of buprenorphine and methadone are very low in breast milk • Healthcare professionals should discuss benefits of breast feeding • Any breastfeeding can decrease infants need for pharmacotherapy treatment for NAS

28. Substance Use Warmline:Free clinical consultation on managing substance use in primary care6 am – 5 pm PST, Monday – Friday1.855.300.3595 or submit cases online at nccc.ucsf.edu The Clinician Consultation Center is pleased to offer confidential telephone consultation focusing on substance use evaluation and management for primary care clinicians nationally. With special expertise in pharmacotherapy options for opioid use, our addiction medicine-certified physicians, clinical pharmacists, and nurses provide advice based on Federal treatment guidelines, up-to-date evidence, and clinical best practices. Learn more at http://nccc.ucsf.edu/clinician-consultation/substance-use-management/ This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1OHA30039-01-00 (AIDS Education and Training Centers National Clinician Consultation Center) in partnership with the HRSA Bureau of Primary Health Care (BPHC) awarded to the University of California, San Francisco.