Expand Access to MAT/MAR for Pregnant People

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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. [1] 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]

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. [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 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 find themselves 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 abuse 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 that 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 abuse 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 Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants [20] Effective Interventions and Guidelines for OUD, including medication-assisted treatment (MAT).

Expanding Access to Family-Centered Medication-Assisted Treatment [21] A brief to include information and opportunities for expansion.

State Policy Levers for Expanding Family-Centered Medication-Assisted Treatment [22] 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 [23]

PCCS MAT [24] provides many free online trainings and resources to help address the opioid crisis, including Opioid Dependence in Pregnancy: Clinical Challenges. [25]

This detailed, 165-page guide has SAMHSA's latest recommendations on Clinical Guidance for Treating Pregnant Women with OUD and their Infants.[26]

Promising Practices

Moms MATTER [27] 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 [28] - 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) [29] 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. [30][31]



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. ↑ http://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/
  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/sites/default/files/d7/priv/sma18-5054.pdf
  21. ↑ https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//187071/FCMATib.pdf
  22. ↑ https://aspe.hhs.gov/reports/state-policy-levers-expanding-family-centered-medication-assisted-treatment
  23. ↑ https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
  24. ↑ http://pcssmat.org/ Provider's Clinical Support System
  25. ↑ http://pcssmat.org/ Provider's Clinical Support System
  26. ↑ https://store.samhsa.gov/product/Clinical-Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use-Disorder-and-Their-Infants/SMA18-5054
  27. ↑ https://www.womenandinfants.org/moms-matter
  28. ↑ https://ukhealthcare.uky.edu/obstetrics-gynecology/obstetrics/prenatal-care/pathways-program
  29. ↑ https://grc.osu.edu/Projects/MEDTAPP/MaternalOpiateMedicalSupports
  30. ↑ 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
  31. ↑ https://www.usatoday.com/story/news/nation/2014/06/15/drug-dependent-babies-challenge-doctors-politicians/10526103/
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