Hand-wringing stories about the opioid epidemic are flooding the popular press – and clincians are seeing the headlines reflected in their practices.
As clinics fill with more and more pregnant patients who have opioid use disorder, both ob.gyns. and family physicians who incorporate obstetrics are facing a steep learning curve in dealing with the medical and ethical challenges these patients bring to their clinic visits. Though there’s no panacea, collaboration with community and family stakeholders and a comprehensive care model incorporating best practices can optimize outcomes for these fragile patients.
On May 23, 2016, the American College of Obstetricians and Gynecologists (ACOG) issued a statement affirming medically assisted treatment (MAT) as the recommended standard of care for pregnant women with opioid use disorders. In a statement, Hal Lawrence, MD, ACOG’s executive vice president and CEO, said, “Robust evidence has demonstrated that maintenance therapy during pregnancy can improve outcomes.”
Methadone has been the mainstay MAT medication, in part because its long time on the market means that favorable data are more robust than for buprenorphine. For patients in rural areas facing transportation challenges, however, or for those whose jobs or caregiving duties make a daily visit to a methadone clinic difficult, buprenorphine may be the better option. Additionally, especially in smaller communities, an oral self-administered medication avoids the obvious stigma of methadone clinic visits.
In making efforts to reduce maternal opioid dependence a 2016 legislative priority, ACOG voiced opposition to any legislation that might be punitive for women with opioid use disorder, as well as for babies born with neonatal abstinence syndrome; however, ACOG also supports public health efforts to reduce these conditions.
Wanda Filer, MD, president of the American Academy of Family Physicians, concurred in an interview. “We do not support criminalization or incarceration of pregnant women with substance use disorders,” stressed Dr. Filer, who noted that the AAFP does not have a formal policy statement at this point.
Courtesy AAFP News
Dr. Wanda Filer
Mishka Terplan, MD, an ob.gyn. who also is an addiction medicine specialist and has helped shape ACOG policy in this area, said in an interview that the maternal-fetal-placental unit has a “complicated and unique biology.” About targeted legislation – or reinterpretation of existing legislation – that incarcerates pregnant women with substance use disorder, he said, “These laws in effect cleave that unit. … To me, it’s unnatural, and not in the interests of the mom.”
Most laws that target women who are pregnant and have substance use disorder are on the state rather than the federal level, said Dr. Terplan, medical director of Behavioral Health System Baltimore.
Currently, three states allow involuntary commitment for treatment of pregnant women with substance use disorder, he said. Other states will classify substance use in pregnancy as child abuse, or use “chemical endangerment” statutes as a vehicle for incarceration or prosecution. Additionally, Medicaid provisions or limitations on access to MAT may vary by state, so physicians must be familiar with their local legal landscape in these cases, he said.
Community resources, critical to providing holistic care for this fragile population, are also region specific. In interviews, two physicians caring for pregnant women with opioid use disorder talked about how their practices are tailored to their communities. Understanding which resources are available and what’s possible for their patients informs how they care for these challenging patients.
La Crosse, Wis., is situated along the eastern side of the Mississippi River, close to the Minnesota-Iowa border. Though the college town has about 100,000 people in its urban area, the surrounding area gets very rural, very quickly. Gundersen Health System, based in La Crosse, has over two dozen clinics and a handful of hospitals in three states and is the practice home for Charles Schauberger, MD, an ob.gyn. who specializes in caring for pregnant women with substance use disorder.
Dr. Schauberger sees a broad range of patients with a wide demographic and urban-rural mix. He estimates that about two-thirds of his patients have a history of previous treatment for substance use disorder, while the opioid use is a fairly new development in other one-third. And most of them face many other challenges. “Many of my patients have high concerns about housing insecurity. They do a lot of couchsurfing,” said Dr. Schauberger.
His patient panel’s high no-show rate reflects the chaotic lives and transportation challenges of many of his patients, and it’s not uncommon for Dr. Schauberger’s patients to come from jail to his office for prenatal care. “It’s about not putting up barriers” for these women, he said. “I might see one patient for just one prenatal visit. Another one, we might see 20 times. We take what we can get.” His staff and partners all realize that flexibility is key to maximizing the chance for a good outcome, he said.