View source for Expand Access to MAT/MAR for Pregnant People

= Introductory Paragraph =

Medication Assisted Treatment and (MAR) Medication Assisted Recovery (MAR) are evidenced-based solutions that combine behavioral therapy and medications to support long-term recovery. There has been a rise in pregnant women with substance use disorder (SUD) and particularly with pregnant women with an opioid use disorder (OUD).  Data shows that the increase has been significant in the past 20 years leading to an increase in Neonatal Abstinence Syndrome (NAS). With the increase of prevalence of SUD in pregnant women and the impact on children and families in recent years clinicians and policy-makers have moved to a family-centered approach for SUD treatment to include providing comprehensive services to pregnant women and their families. <ref>https://aspe.hhs.gov/reports/expanding-access-family-centered-medication-assisted-treatment-issue-brief-0</ref> The Food and Drug Administration has approved medications for treatment of alcohol dependence (Naltrexone, Disulfiram, and Acamprosate Calcium) and opioid dependence (Methadone, Buprenorphine, and Naltrexone). <ref>https://www.ajog.org/article/S0002-9378(04)00705-7/fulltext</ref>

= Key Information =

Medically supervised tapering of opioids in pregnant women is associated with high relapse rates as compared to Methadone maintenance. For pregnant opioid dependent women, use of Methadone is the preferred standard of care. <ref>https://www.ajog.org/article/S0002-9378(04)00705-7/fulltext</ref> Individuals with co-occurring mental health and substance use disorders often require that pharmacotherapy be integrated with their other services.<ref>https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf</ref> 

Methadone clinics should provide information sessions and materials to help pregnant women prepare for the experience of delivering their babies at hospitals. These should include the following: <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>  
*What to expect in regards to pain management 
*Infant withdrawal symptoms 
*Involvement with Child Protective Services
*Treatment approaches for withdrawing infants 
*How to work with doctors and nurses to help the process go smoothly 
*Advice for comforting Methadone-exposed babies once they come home

'''Barriers.'''

Women who need MAT often struggle to get it. To get Buprenorphine, they have to find a doctor with an MAT license. To get methadone, they must go regularly to a clinic. Additional barriers include:
*The potential to have pay out of pocket. 
*There are often long waiting periods to get into treatment. <ref>https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5</ref>
*Women have misconceptions about Methadone and are unclear about the treatment process. <ref>http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403</ref> 
*Although pregnant women actually receive priority for Methadone treatment, once they are not pregnant they return to the long waiting periods and the motivation to pursue treatment may be deterred by these waits. <ref>https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5</ref>   
*Women often experience anxiety about what will happen if they can no longer pay for their Methadone treatments.  <ref>https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5/</ref>  
*There is a need for increased grant funding to help women stay in treatment once they are enrolled. <ref>https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5</ref>   
*Many women of child-bearing age don't qualify for insurance until they find themselves pregnant, making it difficult to access family planning or mental health preventive care before becoming pregnant.

= Relevant Research =
A 2012 study of medical students in an obstetrics and gynecology rotation found that when students are placed in a residential treatment center for pregnant women (i.e. specialized training) they showed greater comfort in assessing and educating patients about substance abuse during pregnancy compared to those in a regular rotation. <ref>http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/</ref></sup>PCCS MAT<ref>http://pcssmat.org/ Provider's Clinical Support System</ref> provides many free online trainings and resources to help address the opioid crisis, including Opioid Dependence in Pregnancy: Clinical Challenges.<ref>http://pcssmat.org/ Provider's Clinical Support System</ref> 

This detailed, 165-page guide has SAMHSA's latest recommendations on Clinical Guidance for Treating Pregnant Women with OUD and their Infants.<ref>https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054</ref>

== Split Dosing to Reduce Risk ==
The following quote shares some insights and potential benefits of "split dosing" of methadone. The article has more details.<ref>http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/</ref> Part of the confusion relates to the question of whether giving the mother high doses of methadone worsens NAS. A recent meta-analysis of 67 studies found this not to be the case.* The fetus is not exposed to the maternal dose; it is exposed to the maternal plasma level. We know that plasma levels vary significantly, depending on genetics. And pregnant women metabolize methadone more quickly, necessitating dose increases—but these increases do not necessarily increase fetal exposure to methadone. One mother in our pregnancy program required 270 mg/day of methadone, in four divided doses. Her plasma level, before the morning dose one week before delivery, was undetectable. After birth, the baby required no treatment for NAS. We don’t know how many physicians are willing to prescribe these high, split doses to keep the mother and fetus out of withdrawal. We don’t know whether programs use maternal plasma methadone levels to monitor changes in maternal metabolism and fetal exposure. In pregnancy, split doses of methadone protect the fetus from exposure to daily cycles of peaks and troughs, which have been shown to have negative physiologic effects on the fetus.* Even high doses, when given as single daily doses, can result in fetal withdrawal distress before the next day’s dose. That may be why high doses, at times, seem to cause more cases of NAS: The fetus may be sensitized to daily episodes of withdrawal.* Some mothers, like our patient who received 270 mg daily, are ultra-rapid metabolizers; the methadone exposure for their fetuses is far more consistent and physiologic when dosing is four times a day. <ref>https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5</ref> The approach used in one study for women on methadone (that used higher doses split into 2 or 4 doses per day yielded significantly lower rates of NAS. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793207/</ref> Another study on split dosing also showed benefits.<ref>http://atforum.com/2015/10/methadone-split-dosing-less-nas-better-maternal-recovery/ </ref> More research is needed. Since DNA tests can help to understand the way a person will metabolize different drugs, it could be tested to advance a precision medicine approach to MAT for pregnant women. More research is needed on this issue.

= Impactful Federal, State, and Local Policies =

'''SAMHSA’s Substance Abuse Prevention and Treatment''' block grants have recently been revised to strengthen capacity to deliver MAT for pregnant women with substance use disorders. <ref>https://www.samhsa.gov/grants/block-grants/sabg</ref> 

'''State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment''' <ref>https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment-0</ref> The study reviewed expansion for family-centered services and MAT.

*13 states give pregnant women priority access to general programs for drug treatment.<ref>http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403</ref> 
*4 states protect pregnant women from discrimination in publicly funded programs.<ref>http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403</ref>  
*18 states consider substance abuse during pregnancy to be grounds for child abuse. <ref>https://www.ncbi.nlm.nih.gov/pubmed/23154692</ref>

= Available Tools and Resources =

'''SAMHSA Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants''' <ref>https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf</ref> Effective Interventions and Guidelines for OUD, including medication-assisted treatment (MAT).

'''Expanding Access to Family-Centered Medication-Assisted Treatment''' <ref>https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//187071/FCMATib.pdf</ref> A brief to include information and opportunities for expansion.

'''State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment''' <ref>https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment</ref> The study examined a selection of state and local treatment programs targeted to pregnant and parenting women and their families to identify key challenges and opportunities in expanding access to comprehensive, family-centered services and MAT treatment for this population.

'''SAMHSA Family-Centered Treatment for Women With Substance Use Disorders - History, Key Elements, and Challenges''' <ref>https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf</ref>

= Promising Practices =

'''Moms MATTER''' <ref>https://www.womenandinfants.org/moms-matter</ref> Women & Infants offers office-based buprenorphine maintenance treatment for opioid use disorder during pregnancy and the postpartum period. The Moms MATTER (Medication Assisted Treatment to Enhance Recovery) clinic is a unique model of care that provides a safe place for pregnant and breastfeeding women to seek compassionate, non-judgmental care.

'''Perinatal Assistance and Treatment Home (PATHways) Program''' <ref>https://ukhealthcare.uky.edu/obstetrics-gynecology/obstetrics/prenatal-care/pathways-program</ref> - Kentucky based program that includes education, care treatment and support for substance use disorders (SUD).  The program provides services to empower women and families.
*''Buprenorphine maintenance therapy''
*Case management
*Group counseling
*Individual therapy
*Peer support
*Prenatal and postpartum care
*Specialty consultations with experts in addiction medicine, neonatology, maternal-fetal medicine, nursing, social work and substance abuse counseling

'''Maternal Opiate Medical Supports (MOMS)''' <ref>https://grc.osu.edu/Projects/MEDTAPP/MaternalOpiateMedicalSupports</ref> The model identifies promising treatment practices, including Medication Assisted Treatment (MAT), for pregnant mothers eligible for or enrolled in Medicaid who are dependent or addicted to opioids during and after pregnancy.

Tennessee's three managed care companies — Amerigroup, UnitedHealthcare's Medicaid subsidiary and BlueCross BlueShield's BlueCare program — are trying to reach these women earlier to ensure that more babies are born healthy. All have flagged drug-dependent babies as a major cost issue. BlueCross, for example, covered 775 such babies in 2013 [must be nationwide]. [at $50,000 each, which is a low estimate of incremental cost over a normal birth, that cost BlueCross about 38 million.] All three have launched efforts to help expectant mothers beat their addictions. <ref>ACOG Committee on Health Care for Underserved Women; American Society of Addiction Medicine. ACOG committee opinion no. 524: opioid abuse, dependence, and addiction in pregnancy. Obstet Gynecol 2012;119:1070–6</ref><ref>https://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/</ref>

= <br/> <br/> Sources =

----