Session #E3c Friday, October 17, 2014 Reducing Substance Use During Pregnancy and Neonatal Abstinence Syndrome: An Integrated Approach to OB-GYN Care Eboni Winford, Ph.D. Suzanne Bailey Psy.D. Kara Johansen, Psy.D. Cherokee Health Systems Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Collaborative Family Healthcare Association 12th Annual Conference

Faculty Disclosure We currently have or have had the following relevant financial relationships (in any amount) during the past 12 months: State of Tennessee Department of Health University of Tennessee Collaborative Family Healthcare Association 12th Annual Conference

Learning Objectives At the conclusion of this session, the participant will be able to: Define neonatal abstinence syndrome (NAS) and identify its symptoms Describe the impact of NAS on infant and maternal QOL as well as health care costs associated with treating infants with NAS Describe a behaviorally enhanced obstetrical model at Cherokee Health Systems for treating pregnant women with substance use disorders Collaborative Family Healthcare Association 12th Annual Conference

Bibliography / 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 Conference

Learning Assessment A 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

Together…Enhancing Life 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. Together…Enhancing Life

Cherokee Health Systems Number of Employees: 681 Provider Staff: Psychologists - 46 Master’s 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 Systems FY 2013 Services 57 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 Problem Neonatal abstinence syndrome (NAS) due to maternal substance use has grown exponentially in the state of TN, particularly East TN As of August 30, 2014, 626 cases of NAS in TN in 2014 Compared 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, 2014

Scope of the Problem TN Department of Health, 2014

Signs & Symptoms of NAS Central Nervous System Crying/agitated Sleep disturbances Hyperactive reflexes Tremors Excoriation Increased muscle tone Jerks/convulsions Metabolic/Motor/Respiratory Sweating Fever Moaning Nasal stuffiness Sneezing Increased respiratory rate Gastrointestinal System Excessive sucking Poor feeding Regurgitation Projective vomiting Loose/watery stools Signs & Symptoms of NAS Typical onset 1-3 days after birth, but may experience onset up to one week after birth. Burgos & Burke, 2009

Costs Associated with NAS Neonatal Maternal Financial NICU stays Risk for loss of custody Extended hospital stays Withdrawal symptoms Impaired ability to bond/form attachment Risk for developmental delays Legal complications (e.g., laws re: maternal prosecution) Cost of morphine withdrawal protocol for neonates

Responding to the Epidemic Literature reviews Patients are our guide Focus groups Identified critical needs and priorities More support & “Sense of Community” More education about nutrition, breastfeeding, post-delivery care, and parenting Coordinated services to reduce fragmented care & logistical barriers to care

“When I was pregnant with my daughter, I was using crack cocaine, alcohol, and any kind of drug that could help me feel better. I didn’t 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 didn’t 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 didn’t 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 wouldn’t been for IOP and if it wouldn’t been for my other program, you know I would probably still be using today and I wouldn’t 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 Model Prevalence and comorbidity of mental health and substance use disorders Fragmentation of specialty care sector Diminished access to specialty care Longitudinal care for the family

Overview of the CHS Treatment Model All pregnant women receive behavioral enhanced OB care provided by a multidisciplinary team Continuum of services include: Health risk assessment Healthy lifestyle and wellness promotion Behavioral health assessment & intervention Case management Psychiatric medication management OB Care Referral to continuum of co-located specialty behavioral health resources

Model of Care: Treatment of Substance Use Disorders Treatment model emphasizes long-term abstinence-based alcohol and drug treatment “Strong enough, for long enough.” Pregnant women can be safely tapered to abstinence prior to delivery to prevent NAS in the infant Measured approach to MAT Long-term replacement therapies should not be the first-line treatment for pregnant women with substance use disorders

Rational for CHS Treatment Model TN Department of Health, 2014

Preliminary Outcome Data on the CHS Integrated Treatment Model Demographics Reported Substances Mental Health Diagnoses Outcomes Mean 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 Benzodiazepines Depression Anxiety (PTSD, Panic Disorder, GAD) Polysubstance Dependence (ETOH, opioid, anxiolytic) NAS diagnoses = 8 Fetal demise = 1 Lost to follow-up = 4 Undelivered = 11

Preliminary Outcome Data on the CHS Integrated Treatment Model CASE STUDY

Longitudinal Care for the Family All families receive behaviorally enhanced pediatric primary care provided by a multidisciplinary team Continuum of services include: Health risk assessment Healthy lifestyle and wellness promotion Behavioral health assessment & intervention Developmental screenings, assessments, and interventions Case management Psychiatric medication management Referral to continuum of co-located specialty behavioral health resources

Model of Care: Integrated Pediatric Primary Care Treatment model emphasizes long-term family-centered care that includes: Prevention Detection Intervention Coordination with Adult Primary Care and OB/GYN Introduction to integrated pediatric services Initial Newborn Well Child Check NAS Information Shared Parenting Support Offered

Lessons Learned Screening for and treatment of mental health and substance use disorders are vital components of routine OB care Timely access to coordinated specialty care is important There is no “one size fits all” treatment approach Assessment of engagement and motivation is essential Care is longitudinal and family-focused

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you! Collaborative Family Healthcare Association 12th Annual Conference