Acknowledgements
The preparation of this Maternal Opioid Use During Pregnancy toolkit would not have been possible without the valuable contribution of all the maternal health providers that encompass the Massachusetts Perinatal Quality Collaborative, the Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Boston Medical Center’s STATE OBAT-B, and Institute for Health and Recovery. We would also like to thank Massachusetts Child Psychiatry Access Project (MCPAP for Moms) and Massachusetts Perinatal-Neonatal Quality Improvement Network with whom the initial document was conceptualized.
The Massachusetts Perinatal Quality Collaborative would like this toolkit to be an active resource for all maternal health providers that can be updated periodically as new information and resources are identified. We hope this will serve as a valuable resource for all settings and clinicians working in the field.
Disclaimer
This toolkit has been provided for general maternal health information purposes only. The recommendations contained do not indicate an exclusive course of action, or serve as a standard of medical or obstetric care. Variations, taking individual circumstances into account, may be appropriate. Consideration should also be given to current clinical organizational policies and procedures that may further impact clinical practice within specific settings.
Introduction
Overall aim is to improve clinical care and coordination for pregnant women with opioid use disorders. This toolkit provides guidance in regards to the medical, psychological and social needs of pregnant women with opioid use disorders thereby improving maternal and newborn health outcomes. It has been developed to help maternal health providers advance the clinical interventions by offering screening, treatment engagement and coordinated care throughout the pregnancy and post-delivery.
Opioid Use in Pregnancy Toolkit is:
- A collaborative effort, including providers, state agencies, grant funding efforts, Mass Perinatal Quality Collaborative, MCPAP for Moms, MA-ACOG, MDPH, and BSAS.
- An overview of approaches and collaborative partnerships—bridging multi-disciplinary expertise to provide guidance to clinicians working with women of child bearing age that are currently using opioids and/or at risk for opioid use disorders.
- Providing guidance and information regarding the use of Medication Assisted Treatment (MAT), particularly Buprenorphine and Methadone, coordination of care with substance use treatment providers and opioid exposed newborn assessment and treatment.
- Acknowledging and supporting the vital role of prenatal care providers in addressing the complex medical and social needs of women with opioid use disorders especially pregnant women and their unborn child. Improved outcomes for both can be impacted with screening, early intervention and engagement in substance use treatment.
- Encourage comprehensive care coordination aimed to meet the pregnant woman’s unique needs and ability to provide concurrent substance use treatment and obstetrical care.
Quick Facts: Opioid Use Disorder and Pregnancy
SAMHSA 2014. See Opioid Abuse, 2012 and Anand & Campbell-Yeo, 2015.
- 4.6 million women (or 3.8 percent) ages 18 and older have misused prescription drugs in the past year.
- One-third of childbearing women take prescription opioids, previously occurring in 6–7% of pregnant women.
- Initial data suggest that recent neonatal abstinence syndrome (NAS) increases have resulted from increased use of prescription opioids rather than illicit drugs.
- Opioid use in pregnancy and the use of illicit opioids during pregnancy is associated with an increased risk of adverse outcomes.
- NAS is an expected and treatable condition following prenatal exposure to opioid agonist and requires collaboration with pediatric care team.
- Prenatal opioid exposures may cause birth defects, altered brain development and NAS.
What is addiction?
- Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
- Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
What are the implications of opioid use during pregnancy?
The American College of Obstetrics and Gynecology (ACOG) provides guidance and overview of the implications of opioid use during pregnancy. Specifically noting that withdrawal from opioid use during pregnancy is associated with poor neonatal outcomes, including early preterm birth or fetal demise, and with higher relapse rates among women; robust evidence has demonstrated that maintenance therapy during pregnancy can improve outcomes. Clinical guidance includes recommendations for screening, early intervention and treatment options for medical and obstetrical –gynecological clinicians. Treatment options include medication assisted treatment with methadone or buprenorphine.
Specific Treatment Needs of Women with SUD/OUD
Medication Assisted Treatment options can offer prenatal and postpartum medically supervised interventions that can improve maternal and newborn health outcomes when coordinated with prenatal care. Recognizing this is a complex health issue that is best addressed when treated with comprehensive and coordinated services including MAT with the use of addiction medications approved for use during pregnancy. Special consideration is needed for women with opioid use disorders (OUD) to engage each in appropriate clinical care for pain management, to prevent postpartum relapse and a risk of overdose, and to ensure adequate contraception to prevent unintended pregnancies.
Concurrent care of these medical conditions include ante-natal and prenatal care in addition to MAT that is combined with substance use treatment counseling and supports. Maternal health and behavioral health clinicians work as team to provide care that is able to holistically address physical, psychological and behavioral aspects of individualized care and coordination.
Best Practices:
Maternal Health Clinicians Addressing Opioid Use during Pregnancy
Responsiveness
- Integration of substance use screening and assessment with every obstetrical and gynecological appointment.
- Early identification of opioid use among women of child bearing age and pregnant women.
- Comprehensive care coordination among prenatal providers and medically supervised MAT throughout the pregnancy with appropriate 42 CFR Part 2 consent and documentation (42 CFR Part 2 compliant release of information forms).
- Continued coordinated care and supports postpartum to reduce risk of relapse and overdose.
- Integration of obstetric care with post-delivery pediatric care for neonatal abstinence syndrome and other effects of opioid use.
Examples
Project Respect | Obstetrics, Boston Medical Center
- Guidelines for Care of Subutex Patients Postpartum
- Oral Methadone Titration Protocol
- Patient Guidelines and Program Requirements
- Post-Op Pain Medications
- Pregnancy - Formulation Change
- Subutex Titration Protocol
UMass Memorial Medical Center
Algorithm for Treatment of Opioid Dependent Women
Pre-Natal Screening and Planning
Screening Tools and Clinical Practices
Instrument: Single-Question Screening Test - Self-Administered
drugabuse.gov | National Institute on Drug Abuse
The Institute for Health and Recovery Screeners for Pregnant Women: The IHR 5 P’s PDF File
mhqp.org | Massachusetts Health Quality Partners
Behavioral Health Risks Screening Tool for Pregnant Women PDF File
sbirtoregon.org | SBIRT Oregon, OHSU Department of Family Medicine
CRAFFT
The CRAFFT is a behavioral health screening tool for use with children ages 12–18 and is recommended by the American Academy of Pediatrics' Committee on Substance Abuse with adolescents. It consists of a series of 6 questions developed to screen adolescents for high risk alcohol and other drug use disorders simultaneously. It is a short, effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other risks and consequences of alcohol and other drug use is warranted.childrenshospital.org | Center for Adolescent Substance Abuse Research, Boston Children’s Hospital
Resources
Massachusetts Resources
ASTHO Inventory of State/Territorial Action: Prescription Drug Abuse & Overdose - Massachusetts State Profile PDF File
astho.org | Association of State and Territorial Health Officials
English: Pregnancy and Medication-Assisted Treatment
Spanish: Embarazo y el programa de Tratamiento con Ayuda de Medicamentos
mass.gov | Massachusetts Dept. of Public Health, BSAS; and Dept. of Children and Families
Health Advisory from Mass. DPH: No alcohol during pregnancy is the safest choice PDF File
mass.gov | Massachusetts Department of Public Health
Massachusetts Perinatal Quality Collaborative
mapqc.org | Massachusetts Perinatal Quality Collaborative
MCPAP for Moms Toolkit - Pediatric Provider
mcpapformoms.org | Massachusetts Child Psychiatry Access Project (MCPAP) for Moms
Massachusetts Becomes First State to Pass Statewide Cap on First-Time Opioid Prescriptions (State Health Policy - Chapter 52 of the Acts of 2016)
nashp.org | National Academy for State Health Policy
Neonatal Abstinence Syndrome (NAS) Brochure PDF File
www.healthrecovery.org | Brochure created with the assistance of the Family Recovery Project-SE
Neonatal Quality Improvement Collaborative of Massachusetts
neoqic.org | neoQIC: Neonatal Quality Improvement Collaborative of Massachusetts
Perinatal Opioid Use and Neonatal Abstinence Syndrome: Quality Improvement Efforts in Massachusetts
mapnqin.org | Massachusetts Perinatal-Neonatal Quality Improvement Network
SAMHSA Resources
A Treatment Improvement Protocol: Managing Chronic Pain in Adults with or in Recovery from Substance Use Disorders (TIP 54) PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Alcohol, Tobacco, and Other Drugs: Opioids
samhsa.gov | Substance Abuse and Mental Health Services Administration
Buprenorphine Training for Physicians
samhsa.gov | Substance Abuse and Mental Health Services Administration
Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: A Treatment Improvement Protocol (TIP 40)
ncbi.nlm.nih.gov | National Center for Biotechnology Information
Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Depression in Mothers - More Than the Blues: A Toolkit for Family Service Providers PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Medication-Assisted Treatment for Opioid Addiction: Fast Facts for Families and Friends PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Medication-Assisted Treatment of Opioid Use Disorder Pocket Guide PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Methadone Treatment for Pregnant Women PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Quick Guide for Clinicians Based on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Quick Guide for Physicians Based on TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction PDF File
samhsa.gov | Substance Abuse and Mental Health Services Administration
Treatment Improvement Protocols: Chapter 13. Medication-Assisted Treatment for Opioid Addiction During Pregnancy
ncbi.nlm.nih.gov | National Center for Biotechnology Information
Women, Children & Families: Training and Technical Assistance
samhsa.gov | Substance Abuse and Mental Health Services Administration
FDA Resources
Fact Sheet: FDA Opioid Action Plan
fda.gov | US Food and Drug Administration
Information by Drug Class: Opioid Medications
fda.gov | US Food and Drug Administration
Special Report: A Proactive Response to Prescription Opioid Abuse PDF File
nejm.org | The New England Journal of Medicine
CDC Resources
CDC Guideline for Prescribing Opioids for Chronic Pain
cdc.gov | Centers for Disease Control and Prevention
Common Elements in Guidelines for Prescribing Opioids for Chronic Pain PDF File
cdc.gov | Centers for Disease Control and Prevention
HHS Resources
Medication Assisted Treatment for Opioid Use Disorders
federalregister.gov | Federal Register: The Daily Journal of the United States Government
Medication Treatment for Opioid Use Disorders: Increasing the Buprenorphine Patient Limit
hhs.gov | US Department of Health & Human Services
Opioids: The Prescription Drug & Heroin Overdose Epidemic
hhs.gov | US Department of Health & Human Services
The Surgeon General’s Call to End the Opioids Crisis: Treatment Options for Physicians and Patients
turnthetiderx.org | Turn the Tide Rx: An Initiative of the Surgeon General of the United States
Facing Addiction in America
surgeongeneral.gov | Surgeon General’s Report on Alcohol, Drugs, and Health
Final Report: Opioid Use, Misuse, and Overdose in Women PDF File
womenshealth.gov | Office on Women’s Health
NIH Resources
Prescription Drug Abuse: Opioids
drugabuse.gov | National Institute on Drug Abuse
Drugs of Abuse: Opioids
drugabuse.gov | National Institute on Drug Abuse
NIDAMED: Medical & Health Professionals
drugabuse.gov | National Institute on Drug Abuse
Review Article Outlines Strategies to Reduce Opioid Abuse Risk
drugabuse.gov | National Institute on Drug Abuse
Drug Facts: Substance Use in Women PDF File
drugabuse.gov | National Institute on Drug Abuse
ONDCP Resources
2014 National Drug Control Strategy PDF File
whitehouse.gov | White House Office of National Drug Control Policy
Women, Girls, Families, and Substance Abuse
whitehouse.gov | White House Office of National Drug Control Policy
Substance Abuse and Maternal and Child Health
whitehouse.gov | White House Office of National Drug Control Policy
Women and Treatment
whitehouse.gov | White House Office of National Drug Control Policy
Women Research and Resources
whitehouse.gov | White House Office of National Drug Control Policy
Office of the National Drug Control Policy at the White House
whitehouse.gov | White House Office of National Drug Control Policy
ASAM Resources
Opioid Addiction 2016 Facts & Figures PDF File
asam.org | American Society of Addiction Medicine
National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
asam.org | American Society of Addiction Medicine
Committee Opinion: Opioid Abuse, Dependence, and Addiction in Pregnancy PDF File
asam.org | American Society of Addiction Medicine
Other Resources
ASTHO Prescription Drug Misuse and Abuse: Neonatal Abstinence Syndrome
astho.org | Association of State and Territorial Health Officials
ASTHO State Action to Prevent and Treat Prescription Drug Abuse
astho.org | Association of State and Territorial Health Officials
Childbirth, Breastfeeding and Infant Care: Methadone and Buprenorphine Brochure PDF File
pcss-o.org | Providers’ Clinical Support System for Opioid Therapies
Health Coverage Options for Pregnant Women
nashp.org | National Academy for State Health Policy
Improving Opioid Addiction Treatment for Pregnant Women
podbean.com | Journal of Addiction Medicine: Beyond the Abstract
NASHP Site Highlighting State Laws to Combat Opioid Crisis
nashp.org | National Academy for State Health Policy
National Commission on Correctional Health Care: Women’s Health Care in Correctional Settings PDF File
ncchc.org | National Commission on Correctional Health Care
Opioid Use, Dependency, and Addiction in Pregnancy
acog.org | American Congress of Obstetricians and Gynecologists
Opioid Use Disorder In Pregnancy PDF File
acog.org | American Congress of Obstetricians and Gynecologists
Opioid Use Disorder in Pregnancy and Neonatal Abstinence Syndrome Webinar
nichq.org | National Institute for Children’s Health Quality
Pregnancy: Methadone and Buprenorphine Brochure PDF File
pcss-o.org | Providers’ Clinical Support System for Opioid Therapies
Pregnancy & Opioids: What Families Need to Know about Opioid Misuse and Treatment during Pregnancy PDF File
drugfree.org | Partnership for Drug-Free Kids
Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) Educational Training
pcssmat.org | Providers’ Clinical Support System for Medication Assisted Treatment
UN Women Policy Brief: A Gender Perspective on the Impact of Drug Use, the Drug Trade, and Drug Control Regimes PDF File
unodc.org | United Nations Office on Drugs and Crime