Reducing Substance Use During Pregnancy and Neonatal Abstinence Syndrome: An Integrated Approach to OB-GYN Care

Reducing Substance Use During Pregnancy and Neonatal Abstinence Syndrome: An Integrated Approach to OB-GYN CareEboni Winford, Ph.D.Suzanne Bailey Psy.D.Kara Johansen, Psy.D.Cherokee Health Systems

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #E3cFriday, October 17, 2014Collaborative Family Healthcare Association 12th Annual ConferenceFaculty DisclosureWe currently have or have had the following relevant financial relationships (in any amount) during the past 12 months:State of Tennessee Department of HealthUniversity of Tennessee

Collaborative Family Healthcare Association 12th Annual ConferenceLearning Objectives

At the conclusion of this session, the participant will be able to:Define neonatal abstinence syndrome (NAS) and identify its symptomsDescribe the impact of NAS on infant and maternal QOL as well as health care costs associated with treating infants with NASDescribe a behaviorally enhanced obstetrical model at Cherokee Health Systems for treating pregnant women with substance use disorders

Collaborative Family Healthcare Association 12th Annual ConferenceBibliography / Reference

Burgos, A. E., & Burke, B. L. (2009). Neonatal abstinence syndrome. NeoReviews, 10, e222-e229.Center for Substance Abuse Treatment (2013). Enhancing motivation for change in substance abuse treatment. Treatment Improvement Protocol (TIP) Series, No. 35. Substance Abuse & Mental Health Services Administration: Rockville, MD.Committee on Healthcare for Underserved Women & the American Society of Addiction Medicine (2012). Committee opinion: Opioid abuse, dependence, & addiction in pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.Jansson, L. M., & Velez, M. (2012). Neonatal abstinence syndrome. Current Opinion in Pediatrics, 24(2), 252-258.TN Department of Health (2014). NAS Summary Archive. Retrieved from http://health.tn.gov/mch/nas/NAS_Summary_Archive.shtml

Collaborative Family Healthcare Association 12th Annual ConferenceLearning AssessmentA learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.Collaborative Family Healthcare Association 12th Annual Conference

Our Mission

To improve the quality of life for our patients through the integration of primary care, behavioral health and substance abuse treatment and prevention programs.

TogetherEnhancing Life6Cherokee Health SystemsNumber of Employees: 681

Provider Staff:

Psychologists - 46 Masters level Clinicians - 80 Case Managers - 36 Primary Care Physicians - 24 Psychiatrists - 12 Pharmacists - 8 NP/PA (Primary Care) - 37 NP (Psych) - 9 Cardiology - 1

Cherokee Health SystemsFY 2013 Services57 Clinical Locations in 14 East Tennessee Counties

Number of Patients: 63,291 unduplicated individuals

New Patients: 15,325

Patient Services: 484,494

Scope of the ProblemNeonatal abstinence syndrome (NAS) due to maternal substance use has grown exponentially in the state of TN, particularly East TNAs of August 30, 2014, 626 cases of NAS in TN in 2014Compared to 564 of cases reported at the same time point in 2013, 506 in all of 2011, and 264 in 2008

TN Department of Health, 2014Scope of the Problem

TN Department of Health, 2014Signs & Symptoms of NASCentral Nervous SystemCrying/agitatedSleep disturbancesHyperactive reflexesTremorsExcoriationIncreased muscle toneJerks/convulsionsMetabolic/Motor/RespiratorySweatingFeverMoaningNasal stuffinessSneezingIncreased respiratory rate Gastrointestinal SystemExcessive suckingPoor feedingRegurgitationProjective vomitingLoose/watery stoolsBurgos & Burke, 2009

Typical onset 1-3 days after birth, but may experience onset up to one week after birth.

Costs Associated with NASNeonatalMaternalFinancialNICU staysRisk for loss of custodyExtended hospital staysWithdrawal symptomsImpaired ability to bond/form attachmentNICU staysRisk for developmental delaysLegal complications (e.g., laws re: maternal prosecution)Cost of morphine withdrawal protocol for neonates13Responding to the EpidemicLiterature reviewsPatients are our guideFocus groups Identified critical needs and priorities More support & Sense of CommunityMore education about nutrition, breastfeeding, post-delivery care, and parentingCoordinated services to reduce fragmented care & logistical barriers to careWhen I was pregnant with my daughter, I was using crack cocaine, alcohol, and any kind of drug that could help me feel better. I didnt go actually to the doctor until I was like six months pregnant. And, what they told me was that they would see me again, but the next time that I came into the doctor that my drug screen would need to be negative. Well when I came back, of course it was positive, and they referred me to another doctor. So, I went to another doctor and they told me the same thing and they referred me to another doctor. So this last doctor that I went to, he kept me, and you know of course I didnt go like I was supposed to, you know, because I was addicted and my addicted mind was just scared to go to the doctor. My water broke actually when I was getting high. I was using the restroom and my water broke. So I went on to the hospital and I told the doctor and the nurses that I was getting high and my water broke because I didnt want anything to happen to me nor the baby. The day I had my baby, DCS came and got involved. They said they wanted to take my children. So from there, I went to a rehab. After that rehab, I went to IOP. Today, I am clean and it is a joyful feeling. My head is clear. And, I can honestly say if it wouldnt been for IOP and if it wouldnt been for my other program, you know I would probably still be using today and I wouldnt have my children around. I can see them every day. So, it is a process that I have to go through, but I am going through it. It is a wonderful feeling and I am certainly blessed.

Rationale for the CHS Integrated Treatment ModelPrevalence and comorbidity of mental health and substance use disordersFragmentation of specialty care sectorDiminished access to specialty careLongitudinal care for the family

Overview of the CHS Treatment ModelAll pregnant women receive behavioral enhanced OB care provided by a multidisciplinary teamContinuum of services include:Health risk assessmentHealthy lifestyle and wellness promotionBehavioral health assessment & intervention Case managementPsychiatric medication managementOB CareReferral to continuum of co-located specialty behavioral health resources

17Model of Care: Treatment of Substance Use DisordersTreatment model emphasizes long-term abstinence-based alcohol and drug treatmentStrong enough, for long enough.Pregnant women can be safely tapered to abstinence prior to delivery to prevent NAS in the infantMeasured approach to MAT Long-term replacement therapies should not be the first-line treatment for pregnant women with substance use disordersRational for CHS Treatment ModelTN Department of Health, 2014

Preliminary Outcome Data on the CHS Integrated Treatment ModelDemographicsReported SubstancesMental Health DiagnosesOutcomesMean age = 27.1 years (range = 20 - 39 years)

Average gestational age at entry into CHS care = 17.96 weeks (range = 6 - 35 weeks)

THC

Opiates

Cocaine

ETOH

Amphetamines

BenzodiazepinesDepression

Anxiety (PTSD, Panic Disorder, GAD)

Polysubstance Dependence (ETOH, opioid, anxiolytic)NAS diagnoses = 8

Fetal demise = 1

Lost to follow-up = 4

Undelivered = 11Preliminary Outcome Data on the CHS Integrated Treatment ModelCASE STUDY Longitudinal Care for the FamilyAll families receive behaviorally enhanced pediatric primary care provided by a multidisciplinary teamContinuum of services include:Health risk assessmentHealthy lifestyle and wellness promotionBehavioral health assessment & intervention Developmental screenings, assessments, and interventionsCase managementPsychiatric medication managementReferral to continuum of co-located specialty behavioral health resources

Model of Care: Integrated Pediatric Primary CareTreatment model emphasizes long-term family-centered care that includes: Prevention DetectionInterventionCoordination with Adult Primary Care and OB/GYNIntroduction to integrated pediatric services Initial Newborn Well Child CheckNAS Information SharedParenting Support OfferedLessons LearnedScreening for and treatment of mental health and substance use disorders are vital components of routine OB careTimely access to coordinated specialty care is importantThere is no one size fits all treatment approach Assessment of engagement and motivation is essentialCare is longitudinal and family-focused

25Session EvaluationPlease complete and return theevaluation form to the classroom monitor before leaving this session.Thank you!

Collaborative Family Healthcare Association 12th Annual Conference