Pregnancy And Opioids: How Hospitals Handle Substance Abuse And Prenatal Care
This week officials at Memorial Hospital in North Conway announced they would establish a prenatal care program for opioid-dependent patients – mothers and babies affected by the opioid crisis. This program is set to open in early 2016, and it’s similar to a program that’s underway at Dartmouth-Hitchcock Medical Center.
For our ongoing series on the opioid crisis in New Hampshire, called Dangerous Ends, Weekend Edition talked with Dr. Sarah Akerman, director of addiction services at Dartmouth-Hitchcock and an Assistant Professor of Psychiatry at Dartmouth’s Geisel School of Medicine.
What prompted Dartmouth-Hitchcock to first establish this program?
We were noticing a trend beginning about two years ago. We, with our OB-GYN colleagues, began to think of ways to address the growing problem of opioid use, particularly heroin use, in pregnant women. We were finding that pregnant women did not really fit well into the traditional treatment model. They needed additional services, and we formed this multidisciplinary collaboration, and that's really the foundation of our program, this close partnership with our OB-GYN and addiction psychiatry [team], to develop a comprehensive model of treatment to really address the unique needs of this population.
Opioid use or abuse is not something a person is necessarily going to want to share with her OB-GYN. How do doctors find ways to confront that issue and make sure it's treated?
That's a great question. Women are, as you can imagine, often very reluctant to disclose their substance use, because they have fear there are going to be repercussions, or their babies may be taken away. What we've done is implement[ed] this evidence-based screening and intervention process, which, through a systematic way, is able to identify women that have problems through the use of various specific questions in a nonthreatening and nonjudgmental way, so that women feel comfortable and realize that treatment is there. Help is there.
That's key, first identifying who needs the treatment. Then, having the treatment program in place - one of the things that's unique about our program is that we try to bring as many programs on-site as possible, so women who come to our program come to a one-stop shop, where they get their addiction treatment, their counseling, medication treatment if that's appropriate, they get their OB-GYN services on-site, and this is also a site where they can have group perinatal education, education about neonatal abstinence syndrome and various other things.
Not every substance has the same effect on infants and fetuses. What do we know about the effects of exposure to opioids in newborns?
There's the effect of the substance itself during the pregnancy; then there's also the effect of the drug-using lifestyle. Women who are using any substances are often not taking good care of themselves - not going to prenatal visits as much as they should, not eating well, not sleeping well. That can certainly have an effect on the pregnancy.
Then there's the effect of the substances themselves. With certain substances like alcohol, we know there's a specific fetal alcohol spectrum disorder we can see in babies. In babies exposed to opioids, what we see most commonly would be neonatal abstinence syndrome, and that's true for babies exposed to illicit opioids and that's actually true for babies exposed to prescribed opioids as well, including medications like Suboxone or Subutex. Babies experience neonatal abstinence syndrome, which is a withdrawal syndrome, from the medication or the illicit opiate.
How well do these identification and treatment approaches work?
Our program has been active for about the past two years - we started small and are growing. We have some preliminary outcome data available, and what we're seeing is that we have very good treatment retention rates. More than 90 percent of pregnant women are staying in treatment for the course of their pregnancy, which is great, and they're attending more prenatal care visits. They tend to be healthier overall - one piece of evidence being that they're gaining weight well with the pregnancy. [There's] decreased substance use across the board as women proceed through the program.
Some of the outcomes we're seeing in babies are very encouraging as well. [For] babies born to moms in the program, [there's] a lower percent of them requiring treatment for neonatal abstinence syndrome. We're seeing decreased length of stay for babies born to moms in our program, which translates into lower hospital costs.
As the opioid crisis has come into the public consciousness more and more, we've seen a difference in how people talk about it and the policies they propose to deal with it - for example, chiefs of police now say we can't arrest our way out of the problem, we have to deal with treatment as well. Has there been a similar change in how health care providers talk about women who have opioid abuse issues during pregnancy?
Yeah. I think, as we are all hearing, this is really an epidemic. We're seeing more and more young women - there was some CDC data recently that demonstrated that one of the sharpest increases in heroin use was in young women ages 18 to 25. When we consider the fact that close to 90 percent of pregnancies in young women abusing opioids such as heroin are unplanned, the result is we have an epidemic of heroin use in pregnant women. I think a lot of providers are realizing that and understanding that, and we hope that as the stories get out there's more education and more willingness to identify and treat these women as they come into light.
As you look ahead over the next few years, what is it going to take to deal with this piece of the opioid crisis in New Hampshire?
The fact that more providers and more facilities in the region are open to the possibility of devoting resources to the pregnant population is wonderful. I think the more people that can be involved in treatment, bringing these resources to women, both identifying them and referring them to treatment, actually bringing them to treatment, that in part is going to help the epidemic.