Session #E3c
Friday, October 17, 2014
Reducing Substance Use During Pregnancy
and Neonatal Abstinence Syndrome: An
Integrated Approach to OB-GYN Care
Eboni Winford, Ph.D.
Suzanne Bailey Psy.D.
Kara Johansen, Psy.D.
Cherokee Health Systems
Collaborative Family Healthcare Association 16th Annual Conference
October 16-18, 2014
Washington, DC U.S.A.
Faculty Disclosure
• We currently have or have had the following
relevant financial relationships (in any amount) during
the past 12 months:
– State of Tennessee Department of Health
– University of Tennessee
Learning Objectives
At the conclusion of this session, the participant will be able to:
• Define neonatal abstinence syndrome (NAS) and identify
its symptoms
• Describe the impact of NAS on infant and maternal QOL
as well as health care costs associated with treating
infants with NAS
• Describe a behaviorally enhanced obstetrical model at
Cherokee Health Systems for treating pregnant women
with substance use disorders
Bibliography / Reference
1. Burgos, A. E., & Burke, B. L. (2009). Neonatal abstinence syndrome. NeoReviews,
10, e222-e229.
2. Center for Substance Abuse Treatment (2013). Enhancing motivation for change
in substance abuse treatment. Treatment Improvement Protocol (TIP) Series, No.
35. Substance Abuse & Mental Health Services Administration: Rockville, MD.
3. Committee on Healthcare for Underserved Women & the American Society of
Addiction Medicine (2012). Committee opinion: Opioid abuse, dependence, &
addiction in pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076.
4. Jansson, L. M., & Velez, M. (2012). Neonatal abstinence syndrome. Current
Opinion in Pediatrics, 24(2), 252-258.
5. TN Department of Health (2014). NAS Summary Archive. Retrieved from
http://health.tn.gov/mch/nas/NAS_Summary_Archive.shtml
Learning Assessment
• A learning assessment is required for CE
credit.
• A question and answer period will be
conducted at the end of this presentation.
Our Mission…
To improve the quality of life
for our patients through the integration of
primary care, behavioral health and substance
abuse treatment and prevention programs.
Together…Enhancing Life
Cherokee Health Systems
Number of Employees: 681
Provider Staff:
Psychologists - 46
Primary Care Physicians - 24
NP/PA (Primary Care) - 37
Master’s level Clinicians - 80
Psychiatrists - 12
NP (Psych) - 9
Case Managers - 36
Pharmacists - 8
Cardiology - 1
Cherokee Health Systems
FY 2013 Services
• 57 Clinical Locations in 14 East Tennessee
Counties
• Number of Patients: 63,291 unduplicated
individuals
• New Patients: 15,325
• Patient Services: 484,494
Scope of the Problem
• Neonatal abstinence syndrome (NAS) due to
maternal substance use has grown
exponentially in the state of TN, particularly
East TN
• As of August 30, 2014, 626 cases of NAS in TN
in 2014
– Compared to 564 of cases reported at the same
time point in 2013, 506 in all of 2011, and 264
in 2008
TN Department of Health, 2014
Scope of the Problem
TN Department of Health, 2014
Signs &
Symptoms of
NAS
Central Nervous System
Crying/agitated
Sleep disturbances
Hyperactive reflexes
Tremors
Excoriation
Increased muscle tone
Jerks/convulsions
Metabolic/Motor/Respiratory
Sweating
Fever
Moaning
Nasal stuffiness
Sneezing
Increased respiratory rate
Typical onset 1-3 days after birth,
but may experience onset up to
one week after birth.
Burgos & Burke, 2009
Gastrointestinal System
Excessive sucking
Poor feeding
Regurgitation
Projective vomiting
Loose/watery stools
Costs Associated with NAS
Neonatal
Maternal
Financial
NICU stays
Risk for loss of custody
Extended hospital
stays
Withdrawal symptoms
Impaired ability to
bond/form attachment
NICU stays
Risk for developmental
delays
Legal complications
(e.g., laws re: maternal
prosecution)
Cost of morphine
withdrawal protocol
for neonates
Responding to the Epidemic
•
•
•
•
Literature reviews
Patients are our guide
Focus groups
Identified critical needs and priorities
– More support & “Sense of Community”
– More education about nutrition, breastfeeding,
post-delivery care, and parenting
– Coordinated services to reduce fragmented
care & logistical barriers to care
“When I was pregnant with my daughter, I was using crack cocaine, alcohol,
and any kind of drug that could help me feel better. I didn’t go actually to the
doctor until I was like six months pregnant. And, what they told me was that
they would see me again, but the next time that I came into the doctor that
my drug screen would need to be negative. Well when I came back, of
course it was positive, and they referred me to another doctor. So, I went to
another doctor and they told me the same thing and they referred me to
another doctor. So this last doctor that I went to, he kept me, and you know
of course I didn’t go like I was supposed to, you know, because I was addicted
and my addicted mind was just scared to go to the doctor. My water broke
actually when I was getting high. I was using the restroom and my water
broke. So I went on to the hospital and I told the doctor and the nurses that I
was getting high and my water broke because I didn’t want anything to
happen to me nor the baby. The day I had my baby, DCS came and got
involved. They said they wanted to take my children. So from there, I went
to a rehab. After that rehab, I went to IOP. Today, I am clean and it is a joyful
feeling. My head is clear. And, I can honestly say if it wouldn’t been for IOP
and if it wouldn’t been for my other program, you know I would probably still
be using today and I wouldn’t have my children around. I can see them
every day. So, it is a process that I have to go through, but I am going
through it. It is a wonderful feeling and I am certainly blessed.”
Rationale for the CHS
Integrated Treatment Model
• Prevalence and comorbidity of mental health
and substance use disorders
• Fragmentation of specialty care sector
• Diminished access to specialty care
• Longitudinal care for the family
Overview of the CHS Treatment Model
• All pregnant women receive behavioral enhanced
OB care provided by a multidisciplinary team
• Continuum of services include:
–
–
–
–
–
–
–
Health risk assessment
Healthy lifestyle and wellness promotion
Behavioral health assessment & intervention
Case management
Psychiatric medication management
OB Care
Referral to continuum of co-located specialty
behavioral health resources
Model of Care: Treatment of
Substance Use Disorders
• Treatment model emphasizes long-term
abstinence-based alcohol and drug treatment
– “Strong enough, for long enough.”
• Pregnant women can be safely tapered to
abstinence prior to delivery to prevent NAS in the
infant
• Measured approach to MAT
– Long-term replacement therapies should not be the
first-line treatment for pregnant women with
substance use disorders
Rational for CHS Treatment Model
TN Department of Health, 2014
Preliminary Outcome Data on the CHS
Integrated Treatment Model
Demographics
Mean age = 27.1 years
(range = 20 - 39 years)
Average gestational
age at entry into CHS
care = 17.96 weeks
(range = 6 - 35 weeks)
Reported Substances
Mental Health
Diagnoses
Outcomes
THC
Depression
NAS diagnoses = 8
Opiates
Anxiety (PTSD, Panic
Disorder, GAD)
Fetal demise = 1
Cocaine
ETOH
Amphetamines
Benzodiazepines
Lost to follow-up = 4
Polysubstance
Dependence (ETOH,
opioid, anxiolytic)
Undelivered = 11
Preliminary Outcome Data on the CHS
Integrated Treatment Model
• CASE STUDY
Longitudinal Care for the Family
• All families receive behaviorally enhanced pediatric
primary care provided by a multidisciplinary team
• Continuum of services include:
–
–
–
–
–
–
–
Health risk assessment
Healthy lifestyle and wellness promotion
Behavioral health assessment & intervention
Developmental screenings, assessments, and interventions
Case management
Psychiatric medication management
Referral to continuum of co-located specialty
behavioral health resources
Model of Care:
Integrated Pediatric Primary Care
• Treatment model emphasizes long-term familycentered care that includes:
– Prevention
– Detection
– Intervention
• Coordination with Adult Primary Care and OB/GYN
• Introduction to integrated pediatric services
– Initial Newborn Well Child Check
– NAS Information Shared
– Parenting Support Offered
Lessons Learned
• Screening for and treatment of mental health
and substance use disorders are vital
components of routine OB care
• Timely access to coordinated specialty care is
important
• There is no “one size fits all” treatment
approach
– Assessment of engagement and motivation is
essential
• Care is longitudinal and family-focused
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!