Difference between revisions of "Expand Access to MAT/MAR for Pregnant People"

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= Introductory Paragraph =
= 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>
Medication Assisted Treatment (MAT) and Medication Assisted Recovery (MAR) are evidenced-based solutions that combine behavioral therapy and medications to support long-term recovery. This article supplements a cluster of MAT/MAR articles within SAFE Solution's Treatment menu, providing additional information specifically relevant for the role of MAT/MAR during and after pregnancy.
 
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). The higher prevalence of SUD in pregnant women and the impact on children and families in recent years led clinicians and policy-makers to move to a family-centered approach for SUD treatment, including 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>


= Key Information =
= 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>  
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> 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>   
 
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  
*What to expect in regards to pain management  
*Infant withdrawal symptoms  
*Infant withdrawal symptoms  
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'''Barriers.'''
'''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:
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.  
*The potential to have to 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>
*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>  
*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>  
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*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>   
*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>   
*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.
*Many women of child-bearing age don't qualify for insurance until they are pregnant, making it difficult to access family planning or mental health preventive care before becoming pregnant.


= Relevant Research =
= Relevant Research =


*'''Medical students.''' This study in an obstetrics and gynecology rotation documents the benefits of placing students in a residential treatment center for pregnant women. The results of their specialized training showed improvements 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>
*'''Medical students.''' This study in an obstetrics and gynecology rotation documents the benefits of placing students in a residential treatment center for pregnant women. The results of their specialized training showed improvements in assessing and educating patients about substance use during pregnancy compared to those in a regular rotation. <ref>https://pubmed.ncbi.nlm.nih.gov/23154692/</ref>


*'''Split Dosing to Reduce Risk.''' Pregnant women metabolize Methadone more quickly, necessitating dose increases, but these increases do not necessarily increase fetal exposure to Methadone. "Split Dosing" of Methadone is the practice of providing two to four doses per day rather than a single high dose. 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. 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> One study addressed the concern that high doses of Methadone worsen NAS. A meta-analysis of 67 studies found this not to be the case, because the fetus is not exposed to the maternal dose -- it is exposed to the maternal plasma level. <ref>http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/</ref> Plasma levels vary significantly, depending on genetics. DNA testing could be used to advance a precision medicine approach to MAT for pregnant women, and more research is needed on this issue.
*'''Split Dosing to Reduce Risk.''' Pregnant women metabolize Methadone more quickly, necessitating dose increases, but these increases do not necessarily increase fetal exposure to Methadone. "Split Dosing" of Methadone is the practice of providing two to four doses per day rather than a single high dose. 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. One study for women on Methadone which 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> One study addressed the concern that high doses of Methadone worsen NAS. A meta-analysis of 67 studies found this not to be the case, because the fetus is not exposed to the maternal dose -- it is exposed to the maternal plasma level. <ref>http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/</ref> Plasma levels vary significantly, depending on genetics. DNA testing could be used to advance a precision medicine approach to MAT for pregnant women, and more research is needed on this issue.


= Impactful Federal, State, and Local Policies =
= Impactful Federal, State, and Local Policies =
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*'''SAMHSA''' provides Substance Abuse Prevention and Treatment block grants. They have been revised to strengthen the capacity of states to deliver MAT for pregnant women with substance use disorders. <ref>https://www.samhsa.gov/grants/block-grants/sabg</ref>  
*'''SAMHSA''' provides Substance Abuse Prevention and Treatment block grants. They have been revised to strengthen the capacity of states to deliver MAT for pregnant women with substance use disorders. <ref>https://www.samhsa.gov/grants/block-grants/sabg</ref>  


*'''State policies''' are highly variable. Eighteen states consider substance abuse during pregnancy to be grounds for child abuse. <ref>https://www.ncbi.nlm.nih.gov/pubmed/23154692</ref> In contrast, 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> Four 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>   
*'''State policies''' are highly variable. Eighteen states consider substance use during pregnancy to be grounds for child abuse. <ref>https://www.ncbi.nlm.nih.gov/pubmed/23154692</ref> In contrast, 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> Four 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>   


*'''This report''' titled "State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment," examines a selection of state and local treatment programs targeted to pregnant and parenting women and their families. It identifies key challenges and opportunities in expanding policies to improve access to comprehensive services and MAT for this population. <ref>https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment-0</ref>
*'''This report''' titled "State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment," examines a selection of state and local treatment programs targeted to pregnant and parenting women and their families. It identifies key challenges and opportunities in expanding policies to improve access to comprehensive services and MAT for this population. <ref>https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment-0</ref>
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'''Ohio.''' The Maternal Opiate Medical Supports (MOMS) is a model that identifies promising treatment practices, including MAT for pregnant mothers eligible for or enrolled in Medicaid who are dependent or addicted to opioids during and after pregnancy. <ref>https://grc.osu.edu/Projects/MEDTAPP/MaternalOpiateMedicalSupports</ref>
'''Ohio.''' The Maternal Opiate Medical Supports (MOMS) is a model that identifies promising treatment practices, including MAT for pregnant mothers eligible for or enrolled in Medicaid who are dependent or addicted to opioids during and after pregnancy. <ref>https://grc.osu.edu/Projects/MEDTAPP/MaternalOpiateMedicalSupports</ref>


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


'''Tennessee.''' Three managed care companies (Amerigroup, United Healthcare's Medicaid subsidiary, and BlueCross BlueShield's BlueCare program) have flagged drug-dependent babies as a major cost issue. They are working to reach women earlier to ensure that more babies are born healthy. <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>
'''Tennessee.''' Three managed care companies (Amerigroup, United Healthcare's Medicaid subsidiary, and BlueCross BlueShield's BlueCare program) have flagged drug-dependent babies as a major cost issue. They are working to reach women earlier to ensure that more babies are born healthy. <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>

Latest revision as of 11:00, 8 July 2024

Introductory Paragraph

Medication Assisted Treatment (MAT) and Medication Assisted Recovery (MAR) are evidenced-based solutions that combine behavioral therapy and medications to support long-term recovery. This article supplements a cluster of MAT/MAR articles within SAFE Solution's Treatment menu, providing additional information specifically relevant for the role of MAT/MAR during and after pregnancy.

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). The higher prevalence of SUD in pregnant women and the impact on children and families in recent years led clinicians and policy-makers to move to a family-centered approach for SUD treatment, including comprehensive services to pregnant women and their families. [1]

Key Information

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). [2] 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. [3] Individuals with co-occurring mental health and substance use disorders often require that pharmacotherapy be integrated with their other services. [4] 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: [5]

  • 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 to pay out of pocket.
  • There are often long waiting periods to get into treatment. [6]
  • Women have misconceptions about Methadone and are unclear about the treatment process. [7]
  • 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. [8]
  • Women often experience anxiety about what will happen if they can no longer pay for their Methadone treatments. [9]
  • There is a need for increased grant funding to help women stay in treatment once they are enrolled. [10]
  • Many women of child-bearing age don't qualify for insurance until they are pregnant, making it difficult to access family planning or mental health preventive care before becoming pregnant.

Relevant Research

  • Medical students. This study in an obstetrics and gynecology rotation documents the benefits of placing students in a residential treatment center for pregnant women. The results of their specialized training showed improvements in assessing and educating patients about substance use during pregnancy compared to those in a regular rotation. [11]
  • Split Dosing to Reduce Risk. Pregnant women metabolize Methadone more quickly, necessitating dose increases, but these increases do not necessarily increase fetal exposure to Methadone. "Split Dosing" of Methadone is the practice of providing two to four doses per day rather than a single high dose. 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. One study for women on Methadone which used higher doses split into 2 or 4 doses per day yielded significantly lower rates of NAS. [12] Another study on split dosing also showed benefits. [13] One study addressed the concern that high doses of Methadone worsen NAS. A meta-analysis of 67 studies found this not to be the case, because the fetus is not exposed to the maternal dose -- it is exposed to the maternal plasma level. [14] Plasma levels vary significantly, depending on genetics. DNA testing could be used to advance a precision medicine approach to MAT for pregnant women, and more research is needed on this issue.

Impactful Federal, State, and Local Policies

  • SAMHSA provides Substance Abuse Prevention and Treatment block grants. They have been revised to strengthen the capacity of states to deliver MAT for pregnant women with substance use disorders. [15]
  • State policies are highly variable. Eighteen states consider substance use during pregnancy to be grounds for child abuse. [16] In contrast, 13 states give pregnant women priority access to general programs for drug treatment. [17] Four states protect pregnant women from discrimination in publicly funded programs. [18]
  • This report titled "State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment," examines a selection of state and local treatment programs targeted to pregnant and parenting women and their families. It identifies key challenges and opportunities in expanding policies to improve access to comprehensive services and MAT for this population. [19]

Available Tools and Resources

SAMHSA has published "Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants." This detailed, 165-page guide has recommendations on effective interventions, including MAT. [20] SAMHSA has also published a more general report titled "Family-Centered Treatment for Women with Substance Use Disorders - History, Key Elements, and Challenges." [21]

This HHS Issue Brief includes information and opportunities for expansion of access to family-centered MAT. [22].

Provider's Clinical Support System (PCCS) provides free online trainings and resources to help address the opioid crisis, including Opioid Dependence in Pregnancy: Clinical Challenges. [23]

Promising Practices

Kentucky. The Perinatal Assistance and Treatment Home Program (PATHways) includes education, care treatment and support for SUD. The program provides the following services to empower women and families: [24]

  • 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

Ohio. The Maternal Opiate Medical Supports (MOMS) is a model that identifies promising treatment practices, including MAT for pregnant mothers eligible for or enrolled in Medicaid who are dependent or addicted to opioids during and after pregnancy. [25]

Rhode Island. Moms MATTER (Medication Assisted Treatment To Enhance Recovery) provides office-based Buprenorphine maintenance treatment for opioid use disorder during pregnancy and the postpartum period. The Moms MATTER clinic is a unique model of care that provides a safe place for pregnant and breastfeeding women to seek compassionate, non-judgmental care. [26]

Tennessee. Three managed care companies (Amerigroup, United Healthcare's Medicaid subsidiary, and BlueCross BlueShield's BlueCare program) have flagged drug-dependent babies as a major cost issue. They are working to reach women earlier to ensure that more babies are born healthy. [27] [28]



Sources

  1. ↑ https://aspe.hhs.gov/reports/expanding-access-family-centered-medication-assisted-treatment-issue-brief-0
  2. ↑ https://www.ajog.org/article/S0002-9378(04)00705-7/fulltext
  3. ↑ https://www.ajog.org/article/S0002-9378(04)00705-7/fulltext
  4. ↑ https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
  5. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  6. ↑ https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5
  7. ↑ http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403
  8. ↑ https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5
  9. ↑ https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5/
  10. ↑ https://healthandjusticejournal.springeropen.com/articles/10.1186/s40352-015-0015-5
  11. ↑ https://pubmed.ncbi.nlm.nih.gov/23154692/
  12. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3793207/
  13. ↑ http://atforum.com/2015/10/methadone-split-dosing-less-nas-better-maternal-recovery/
  14. ↑ http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/
  15. ↑ https://www.samhsa.gov/grants/block-grants/sabg
  16. ↑ https://www.ncbi.nlm.nih.gov/pubmed/23154692
  17. ↑ http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403
  18. ↑ http://www.washingtonexaminer.com/west-virginia-tackles-opioid-abuse-during-pregnancy/article/2610403
  19. ↑ https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment-0
  20. ↑ https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054
  21. ↑ https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
  22. ↑ https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//187071/FCMATib.pdf
  23. ↑ http://pcssmat.org/
  24. ↑ https://ukhealthcare.uky.edu/obstetrics-gynecology/obstetrics/prenatal-care/pathways-program
  25. ↑ https://grc.osu.edu/Projects/MEDTAPP/MaternalOpiateMedicalSupports
  26. ↑ https://www.womenandinfants.org/moms-matter
  27. ↑ 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
  28. ↑ https://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/
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