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 care 6 am – 5 pm PST, Monday – Friday 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
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 U1OHA (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) 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
Reference??

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
Data from the CDC shows that many women between the ages of years fill prescriptions for opioids.
During 2008–2012, more than one third of Medicaid-enrolled and more than one fourth of privately insured reproductive-aged women (15–44 years) filled a prescription for an opioid from an outpatient pharmacy each year.
MMWR. Opioid Prescription Claims among Women of Reproductive Age - United States, Jan 23, (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)
Heil SH, Jones HE, Arria A, et al. Unintended Pregnancy in Opioid-abusing Women. Journal of Substance Abuse Treatment. 2011;40(2):
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

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

11. SAMHSA Guidelines Available as a PDF
One of many resources used by the CCC to provide consultation
Will form the foundation for our discussion today
A short statement on how the guidance was developed?

12. Fact Sheets Mention how fact sheets were developed
Evidence based recommendations based on the literature and an expert panel

13. How to use the fact sheets
Each fact sheet consists of
The clinical scenario
Clinical action steps
Supporting evidence and clinical considerations
Web resources

14. Factsheet #1
In the guidance, there are summaries of each fact sheet for your reference too.

15. Factsheet #1 Prenatal screenings and assessment
- 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
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 (WHO, Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy, 2014)
Interviews and Instruments—different tools are available which are provided in the manual
- Toxicology screens- should be performed as a baseline
State-based Prescription Drug Monitoring Program (PDMP)
Social, medical, and legal consequences- varies per state

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
SAMHSA’s

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
Opioid Treatment Program Directory
American Society of Addiction Medicine
National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
SAMHSA has nationwide directories of health care professionals who help people with substance use disorders
Pregnant women and new mothers can get treatment at behavioral health treatment centers or opioid treatment programs. Locations can be found in these two web-based resources
The American Society of Addiction Medicine
National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use

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)
A pregnant woman will likely need periodic adjustments to the dose of her pharmacotherapy in response to the physiological changes of pregnancy.
Metabolism rates increase as the pregnancy progresses
Typically doses need adjusting upwards, especially in the third trimester
Adjustments in medication should be individualized.
Pharmacotherapy doses does not affect the risk of NAS
Counseling can encourage and motivate women to continue treatment, enhance coping skills and prevent the risk of return to substance use
The women’s care should be coordinated by a team of health care professionals, including physicians, substance use disorder specialists, nurses , case managers and peer recovery coaches
A resource available is SAMHSA’s A Collaborative Approach to the Treatment of Pregnant women with Opioid Use Disorders which provides information on treating pregnant women with OUD, summarizes guidelines, and presents a framework for organizing community efforts

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
Comorbid behavioral health disorders are common and may require medications
A women with comorbid behavioral health disorders may need to continue other psychiatric medications
Depression and other psychiatric conditions are common among women with OUD. Many women with OUD have a history of sexual assault, trauma or domestic violence
Follow SAMHSA’s Screening, Brief intervention, and referral to treatment (SBIRT) to screen for depression, anxiety, and tobacco and alcohol use
Understand possible drug interactions with other medications

25. Factsheets #6 and #7 Factsheet #6 Factsheet #7
Addressing polysubstance use during pregnancy
Factsheet #7
Planning prior to labor and delivery
There are factsheets #6 and #7 which we will not go into today with additional information

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
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
Her existing opioid agonist dose should not be expected to provide adequate pain relief during or after delivery

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
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 and the length of therapy and hospitalization.
May be due to the contact between mother and infant during breastfeeding

28. Substance Use Warmline: Free clinical consultation on managing substance use in primary care 6 am – 5 pm PST, Monday – Friday 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
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 U1OHA (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.