Obstetric Care Package for Women With Opioid Use Disorder

By Will Boggs MD

July 18, 2019

NEW YORK (Reuters Health) - In an effort to reduce adverse maternal and neonatal health consequences of substance use, the National Partnership for Maternal Safety has created a consensus bundle on obstetric care for women with opioid use disorder.

"Specifically, the Bundle defines the core components of care that should be incorporated into every maternity care setting and has created a repository of clinical pathways, patient and provider educational materials, and resources to help facilitate the implementation process," Dr. Elizabeth E. Krans from Magee-Womens Research Institute, University of Pittsburgh, Pennsylvania told Reuters Health in an email interview. "The Bundle also provides a series of suggested structure, process, and outcome metrics so that hospitals can monitor maternal and neonatal health outcomes over time and compare metrics across health systems and states."

Key components include educating patients and their families on opioid use disorder and neonatal opioid withdrawal syndrome and screening all pregnant women for substance use.

Brief intervention and referral of clinical pathways for women who screen positive should be in place, and a lead coordinator should ensure that all women with opioid use disorder/substance use disorder receive an individualized plan of care that adheres to evidence-based prenatal, intrapartum, and postpartum clinical pathways.

Every health system should develop mechanisms to collect data and monitor process and outcome metrics; create multidisciplinary case review teams for patient, provider, and system-level issues; and identify ways to share outcome data with nonmedical community stakeholders.

"Each year, millions of dollars are invested to support the development of evidence-based interventions to improve health outcomes, but few of these are implemented into clinical practice," Dr. Krans said. "The Bundle was specifically designed to enhance the potential for rapid translation of evidence-based recommendations into clinical practice which is critical to combat a crisis of epidemic proportions among pregnant women and their children."

"Pregnant women with opioid use disorder often have challenging and complex healthcare needs and many maternity care settings have a limited number of resources," she said. "For this reason, each Bundle recommendation was designed to allow for local customization based the resource availability of each clinical setting."

Dr. Peter R. Martin from Vanderbilt Psychiatric Hospital, Nashville, Tennessee, who has researched various aspects of opioid use disorder and its treatment during pregnancy, told Reuters Health by email, "All pregnant women should be screened. Once women are identified, there are evidence-based approaches at every stage of the pregnancy."

"Women who have opioid use disorder are not bad; they have an illness that compromises their pregnancy," he said. "We do not label pregnant diabetics as bad, although they may well have contributed to their glucose dysregulation."

Dr. Hendree E. Jones from UNC Horizons, University of North Carolina, Carrboro, who recently reviewed the treatment for opioid use disorder of women who are pregnant and parenting and the concurrent care of their infants and children, told Reuters Health by email, "There are multiple barriers to implementation, including overcoming health care provider's own stigma, discrimination, and prejudice against women who have the illness of opioid use disorder, (and) overcoming the 'turf' or silo issues - for example, peds providers do not talk to OBs, OBs do not talk to psychiatrists, medical providers do not talk to behavioral health providers, etc. - treatment of the women is siloed and there is not good coordination of care from one type of medical provider to another and little to no communication with substance use disorder counselors."

"Another huge barrier is adequate reimbursement for services - figuring out how to bill and get reimbursed for the types of collaborative care can be a fundamental barrier to implementation," he said. "A final key barrier is that there is an assumption you can train everyone once - when we know that there needs to be ongoing training and booster training, and there need to be very clear paths for how the new information is adopted into the culture of the hospital or health care setting."

Dr. Jones said, "I also often see systems start with finding a screening tool and then implementing it, and then there is no place to send patients when they screen positive. Then the system and patients get frustrated, and it fails. What needs to happen is that foundational work must be done first to prepare the system - mapping the resources in the community, putting these findings in a place that is available on the web to find, and educating providers about these resources and what they do - not every treatment facility is right for every patient. Implementing screening should be one of the final steps in the process, not one of the first."

The entire consensus bundle appears in the August Obstetrics and Gynecology, and a variety of resources can be found online at http://bit.ly/2SlsuoM and http://bit.ly/2SiOOPO.

SOURCE: http://bit.ly/2Sv4P5v

Obstet Gynecol 2019.