1. 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, Washington, DC U.S.A.
Collaborative Family Healthcare Association 12th Annual Conference

2. 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

3. 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

4. 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 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),
Jansson, L. M., & Velez, M. (2012). Neonatal abstinence syndrome. Current Opinion in Pediatrics, 24(2),
TN Department of Health (2014). NAS Summary Archive. Retrieved from
Collaborative Family Healthcare Association 12th Annual Conference

5. 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

6. 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

7. Cherokee Health Systems
Number of Employees: 681
Provider Staff:
Psychologists Master’s level Clinicians Case Managers - 36
Primary Care Physicians Psychiatrists Pharmacists - 8
NP/PA (Primary Care) NP (Psych) Cardiology - 1

8. 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

10. 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

11. Scope of the Problem
TN Department of Health, 2014

12. 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

13. 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

14. 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

15. “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.”

16. 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

17. 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

18. 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

19. Rational for CHS Treatment Model
TN Department of Health, 2014

20. Preliminary Outcome Data on the CHS Integrated Treatment Model
Demographics
Reported Substances
Mental Health Diagnoses
Outcomes
Mean age = 27.1 years
(range = years)
Average gestational age at entry into CHS care = weeks
(range = 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

21. Preliminary Outcome Data on the CHS Integrated Treatment Model
CASE STUDY

22. 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

23. 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

24. 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

26. 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