Download Krans Oral 2015

Patient-Provider Communication
Regarding Opioid Use Disorders
during the First Obstetric Visit
Elizabeth E. Krans, MD, MSc
Assistant Professor, University of Pittsburgh
Magee-Womens Research Institute
Department of Obstetrics, Gynecology and Reproductive Sciences
Opioid Dependence in Pregnancy
Maternal Morbidity
• 65% have co-occurring psychiatric disorders
• 77-95% smoke tobacco
• 35% co-occuring substance abuse
o marijuana, cocaine and benzodiazepines
• 40-75% are HCV positive, 1-4% HIV positive
• Lack of effective social support, family dysfunction,
incarceration, violence and victimization
Neonatal Morbidity
• 30% rate of preterm birth (< 37
weeks gestation)
• Significantly more likely to be
low birth weight (<2500 grams)
• 60-80% develop neonatal
abstinence syndrome (NAS)
• Often require admission to the
NICU and prolonged treatment
Objective
To evaluate patient-provider communication regarding
opioid use disorders during the first obstetric visit.
Talking about Substance Use
in Pregnancy
• Secondary analysis of a larger patient-provider obstetric
communication study.
• First obstetric visits between 453 pregnant patients and their
obstetric providers were audio recorded to identify patients
who disclosed a history of substance use.
• Patient and providers were blinded to the study purpose.
• Urine drug screens were sent for 422/453 (93.1%) patients (not
recorded in medical record).
Talking about Opioid Use in
Pregnancy
• Among 453 total study patients, 38 (8.4%) admitted a history
of opioid use during their audio-recorded visit.
• Of these patients, 100% were Caucasian, 45% were single,
24% had less than a high school education and 69% made less
than $10,000/year.
• 28 (73.7%) used methadone, 3 (7.9%) used buprenorphine +
naloxone, 4 (10.5%) used buprenorphine and 3 (7.9%) used
illicit opioids.
• Urine drug screens were sent for 30 (78.9%) OD patients.
Disclosing Opioid Use in
Pregnancy
• . and results of urine drug screen (UDS) for pregnant women using opiates (n=30)
Disclosure
UDS Results
N (%)
Disclosed current
substance use
No disclosure of
substance use
Methadone only
20 (4.7)
20
--
Opiates only
2 (0.5)
--
2
Methadone + marijuana
4 (0.9)
3 methadone
3 marijuana
1 methadone
1 marijuana
Methadone + benzodiazepines
1 (0.2)
Methadone and
benzodiazepines
--
Methadone + cocaine
1 (0.2)
Methadone
Cocaine
Methadone + marijuana +
amphetamines
1 (0.2)
Methadone
Marijuana,
amphetamines
Methadone + opiates + marijuana
1 (0.2)
Methadone, marijuana
Opiates
Medical Aspects of Opioid Use
Code
Definition
Example
OMT Logistics
The dose of OMT, the clinic where they
receive their OMT, the MD who prescribes
their OMT
Pr: What is the dose?
Pt: 95
Pr: Ok, and that is through Pyramid?
OMT Side Effects
Constipation, nausea, GERD
Pr: So methadone itself is obviously constipating
as is pregnancy so you have a double whammy. So
I’d be surprised if you are pooping at all without
anything.
OMT History
Length of time they have been on OMT,
different types of OMT they have used,
OMT in prior pregnancies
Pr: How long have you been on Methadone?
Opioid Use
Past illicit opioid use, how they became
addicted/dependent on opioids,
recommendations from providers to not
continue to use illicit opioids during
pregnancy
Illicit Drug Use
Past or current illicit drug use other than
opiate use (i.e. cocaine, benzos, MJ etc.),
provider recommendations to not use illicit
drugs while pregnant
Pt: Thru a doctor, like I’ve never done heroine or
anything like that. Ever. They just had me on so…
like they just kept increasing it and increasing it
and going up and changing it and then I’m like
why am I taking it to begin with. I actually went
on vacation with my family and I couldn’t refill it
early, you know, because they are narcotics.
Pr: Any other drugs that you use? Marijuana,
heroin cocaine?
Tobacco Use
Discussions related to tobacco use
(quantity, frequency), tobacco cessation
Pr: How much are you smoking these days?
Pt: Well like a pack will last me 2 days or 3.
Pr: Ok
Pt: It is really bad on top of the methadone.
Medical Aspects of Opioid Use
35
30
25
20
15
10
5
0
OMT
logistics
OMT side
effects
OMT
history
Opioid use Illicit drug Tobacco use
use
Pregnancy and OMT
Code
Definition
Example
Need to stay on OMT
during pregnancy
Discussions regarding
recommendations to stay on OMT
during pregnancy
OMT type in pregnancy
Discussions over whether or not to
use subutex, suboxone or
methadone
OMT dose in pregnancy
Any conversations related to the
need to increase dosing in
pregnancy
Pr: In general we recommend continuing the
methadone when you are pregnant. Because we
don’t want you to withdraw from opioids while
pregnant…because there is a higher risk for
miscarriage and a higher risk for stillborns…so we
recommend that people stay on the methadone.
Also, people with a history of IV drugs and stuff, it
helps to reduce their high-risk behaviors.
Pt: Is there any way to do this in a way where I
was like weaning myself?
Pr: No, not during pregnancy.
Pt: the one person I know on methadone is high –
they look high all the time.
Pr: So, if he is comfortable with that we don’t really
have to do anything differently.
Pt: I hope so. It would be really hard to get to a
methadone clinic. I have a full-time job… a 5 yo.
Pt: They don’t want me to go up very much now
because they are scared, they said that the longer
the pregnancy goes on, they said that I’m going to
have to keep going up and up because the baby will
start taking more and more so they don’t want me
to go up now.
Pr: What kind of symptoms are you having ?
Pt: Like your typical withdrawal symptoms, like at
9:00 pm, I start to not feel very well, but by 11:00,
I’ve got the runny nose, the chills, then the sweats.
Pregnancy and OMT
35
30
25
20
15
10
5
0
Need to stay on OMT OMT type in pregnancy OMT dose in pregnancy
during pregnancy
Counseling regarding opioid use
Code
Definition
Example
NAS/neonatal
implications
Any type of counseling regarding
NAS, prolonged length of stay for
the baby
Breastfeeding
Conversations about breastfeeding
Pr: But you have to be aware…babies are monitored
in the hospital after delivery for signs and symptoms
of withdrawal and they are usually given medications
to treat those symptoms.
Pr: You know we encourage women to breastfeed.
Partner/IPV
Any mention of partner, partner
support of the pregnancy, IPV
Legal issues
Pt: My husband was on it whenever I had my first
daughter. My boyfriend doesn’t do drugs at all.
Pr: Bring him to the next visit. Do you feel safe with
him at home?
Conversation about incarceration,
Pr: Ok, what is ARD?
arrest, probation and/or legal issues Pt: It is accelerated rehabilitation disposition. It is like
probation.
Housing
Discussions related to housing,
residential support
Pr: So, that is where you are living at now?
HIV/HCV/IV use
Any questions regarding HCV/HIV
testing, IV drug use history
Pr: Have you had testing recently for HIV or HCV?
Psychiatric disorders
Any discussion focused on
psychiatric diagnoses or treatment
Pr: Any other medical issues that you have?
Pt: Um, no, besides anxiety and depression and um.
Pr: Ok
Pt: The methadone, nothing else
Pr: Any you were not on any medications early in this
pregnancy?
Pt: No, um just the methadone…
Counseling regarding opioid use
35
30
25
20
15
10
5
0
Conclusions
• Patient-provider discussions regarding opioid use primarily focused
on the medical aspects of opioid use including the type, dose and
duration of opioid maintenance therapy.
• Counseling from obstetric care providers predominantly focused on
the neonatal implications of opioid use during pregnancy such as
neonatal abstinence syndrome (NAS) and increased neonatal length
of stay for NAS.
• Few providers discussed HIV and Hepatitis C (HCV) testing, risk
factors for HIV/HCV transmission such as intravenous opioid use,
or discussed important social issues for these patients such as safe
housing, social support and available resources.
Thank you
• Judy Chang, MD, MPH
o Study Funded by the National Institute of Drug Abuse (NIDA) 1R01DA026410-01A1
(PI – J. Chang), and supported by the National Institutes of Health through Grant
Number UL1TR000005.
• Cyndi Holland, MPH
• Penelope Morrison, PhD