By Mark Gold, MD
Coordinating Care for Pregnant and Postpartum OUD Patients
As opioid use disorder (OUD) continues to rise in women of childbearing age, it is more important than ever to focus upon the complex needs and challenges of pregnant women with OUD. A recent study highlighted important experiences, potential practices and associated challenges from the Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program, a collaborative care team aimed at providing care coordination for patients with a substance use disorder (SUD).
Care for Pregnant Women with OUD
All pregnant women have special healthcare needs, but those with opioid use disorder often require providers to have specialized knowledge on how to best address their needs. With this in mind, the program team at COACHH adapted a segment of their program to serve pregnant women. The American College of Obstetrics and Gynecology has focused on identifying the barriers that women face in accessing both care for pregnancy and opioid use disorder. Even separately, this care can be hard to find, and not adequate in addressing all the needs of this vulnerable patient population. For these women, the American College of Obstetrics and Gynecology recommends incorporating both prenatal care and pharmacotherapy for pregnant women with opioid use disorder.
Inadequate specialized treatment facilities can limit provider education and training, as they lack financial resources and social support. This perpetuates stigma, and creates substantial hurdles in the accessibility of integrated and effective care for the pregnant women who need it. The integrated system of care that the COACHH model focuses on is beneficial for both the mother and the child, and addresses some of these critical gaps in care.
Care providers for this population also frequently run into complex and interconnected medical and social problems that have given rise to the need to go beyond the conventional realm of prenatal care and care for people with OUD. To provide quality treatment, providers need to simultaneously address pregnancy and substance use together. There is also a need to account for the many socio-economic challenges facing pregnant women with OUD, including housing uncertainty, poverty, and domestic violence.
Present Study: Potential Strategies and Challenges
A series of semi-structured interviews were conducted with COACHH team members who worked directly with pregnant and postpartum women with OUD. Program logistics and takeaways were discussed and interviews were coded to assess recurring themes.
Results revealed five recurring themes: patient-provider relationship building, delivery of service, devising a care team, assessing outcomes and the associated structural challenges.
The following needs of this population were highlighted by the study:
Establishing a relationship is fundamental to engage the patient. Building trust and support for pregnant OUD patients, given the stigma of being a pregnant woman with the disease of addiction, was considered imperative to foster a productive relationship between provider and patient. A more holistic approach was suggested that encourages regular communication between patient and provider, and focuses on individual needs, existing gaps in care, associated social and community needs. Another key part of successful treatment was connecting patients with resources and harm-reduction.
Unique challenges of pregnant OUD patients warranted a team-based approach. The wide array of variables involved with this population required a team of diversely skilled professional, all of who shared a deep understanding of addiction and pregnancy, and a familiarity with community resources. Addiction treatment is can be high-stress and time-sensitive, requiring case members working with patients to regularly meet to process emotions, and avoid bias and burnout.
Qualitative and holistic terms measure success. Given the complexities of patients’ lives and the external influences on outcomes, quantitative measures were not considered to be effective in managing outcomes and quality of care. Relationships, engagement and openness were prioritized as signals of change.
Low referral rates presented challenges in reaching those in need. Typically referred to COACHH by obstetricians, the program expected to serve more than 40 women in 2 years, but fewer than 20 patients were enrolled. This was found to be due to highly time-sensitive nature of treating pregnant women with OUD, low provider awareness of resources for these patients, and gaps in care.
Looking to the Future
An estimated 2.3% of pregnant women used opioids in Massachusetts alone, between January of 2012 and September of 2014, a rate much higher than national estimates. The prevalence of neonatal abstinence syndrome also increased dramatically, from 3 per 1000 births to 16 per 1000 births between 2014 to 2013. Despite the increased need for care, there is still a highly limited number of providers who understand how to evaluate and treat these mothers and children. Too few providers even have the necessary buprenorphine waivers, required to prescribe the medication which has inhibited patient access to SUD treatment.
The authors emphasize integration of medical services, SUD treatment, and social support as the best way to move forward in providing care for pregnant women with OUD. Improved integration of specialized care with obstetrics and gynecology offices, community health centers, and other prenatal care facilities can increase the number of referrals, the authors concluded. Additional outreach is crucial to engage women in early prenatal care and improve outcomes.
Future studies should involve lowering the barriers to care and improving the quality and quantity of maternal-fetal providers with OUD interests and training. Additionally, patient interviews and a broader range of metrics calculating impact on health and wellbeing are needed. Assessment tools must also aggregate individualized milestones to track success rate. The results from this study can help inform the development of future tailored strategies to coordinate care for this population.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.