PQCNC: Treating Women Substance Abuse Disorders

8/9/2019 PQCNC: Treating Women Substance Abuse Disorders

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1

Hendrée E. Jones, PhD

Executive Director, Horizons ProgramProfessor, Department of Obstetrics and Gynecology

School of edicine, !niversity of "orth #arolina at #hapel Hill

Perinatal Quality Collaborative of North Carolina$earning Session % &aleigh, "# % ay '(, )*'+

Treating Wo en for !ubstan"e #se Disorders$Considerations during Pregnan"y and the Post%artu Period



) c-no.ledgements

Study patients and infants

"ational /nstitute on Drug buse – &*' D s0 *'+12(, *'+134, *'1+'3,

*'+114, *'4('*, *'4('1, *'+1(','+43)

aternal Opioid 5reatment0 HumanExperimental &esearch 6 O5HE&7

Site P/s and investigative teams

Slide ' #redits0 8Husband nd Pregnant 9ife: by David #astillo Dominici; 8Side <ie. Of Pregnant 9oman: by imageryma=estic; 8 other /s&eading >oo- ?or Her >aby: by @omphong



3 Disclosures

Discussing methadone and buprenorphine, labeled by the !S ?ood andDrug dministration 6?D 7 as #ategory # for use in pregnancy for thetreatment of maternal opioid dependence0 8 nimal reproduction studieshave sho.n an adverse effect on the fetus and there are no adeAuate and.ellBcontrolled studies in humans, but potential benefits may .arrant useof the drug in pregnant .omen despite potential ris-sC:

Pregnant .omen .ith opioid use disorders can be effectively treated .ithmethadone or buprenorphineC >oth these medications should not beconsidered 8offBlabel: use in the treatment of pregnant patients .ith opioiduse disorder @ones et alC, & J 'bstet (yne"ol C )*'(

&ec-ittB>enc-iser Pharmaceuticals for donated active placebo tablets andreimbursement for time and travel in )*''C



( Ob=ectives

'C Participants .ill revie. the historical and currentcontexts of opioid use for .omen

)C Participants .ill compare and contrast the ris-sand benefits of methadone and buprenorphine givenduring pregnancy for the fetus, child, and mother

3C Participants .ill identify treatment componentsfor comprehensive treatment programs that providemedicationBassisted treatment



+ Historical #ontext of Opioid !se during Pregnancy

Substance use during pregnancy in the!S has been a longBstandingimportant health issueC /n the '4**s0

• 22F1+ of individuals .ith opium usedisorders .ere .omen

• 9omen s most common opium source .as

medical prescriptions to treat pain• Physicians recognized neonatal opioid

.ithdra.al and the need to treat in uteroopium exposure .ith morphine in order toprevent morbidity and mortality

♦ ?ollo.ing the'I'( Harrison "arcotic ct, thetreatment of substance use disorders .assegregated from mainstream medicalpractice

6Jandall, !ubstan"e and shado) , 'II2C Earle, *edi"al !tandards , '444C7#redit0 Still from The Dividend , 'I'2C public domain .



2

• /n )*'), an estimated )3CI million mericans aged ') or older 6IC) 7 ofthe populationKhad used an illicit drug or abused a psychotherapeutic

medication 6such as a pain reliever, stimulant, or tranAuilizer7 in the pastmonthC

• 5his number is up from 4C3 percent in )**)C

#urrent #ontext of Drug !se in the !S

National Survey on Drug Use and Health (NSDUH) 2012



1

• ost common medications that aremisused

• Pain-illers containing0o Hydrocodone, such as

<icodin,o Oxycodone, such as Percoceto Oxycontin

• >enzodiazepines0o $orazepam 6 tivan7o lprazolam 6Lanax7

mericans consume 4* percent of the.orldMs supply of pain-illers BB morethan ''* tons of pure, addictiveopiates every yearC 5hat is 2(Percocet or <icodin per every !S#itizenC


http://www.dailymail.co.uk/news/article-2142481/Americans-consume-8 -percent-worlds-pain-pills-prescription-dru!-a"use-epidemic-e#plodes.html$i#%%&a'"!()oA *+* 1/22/1, pioid painkillers widely prescri"ed amon! reproducti e a!e women



4

Opioid Pain-iller Prescribing0 9here Nou $ive a-es aDifference@uly )*'(

Each day, (2 people die from an overdose of prescriptionpain-illers in the !SC

Health care providers .rote )+I million prescriptions forpain-illers in )*'), enough for every merican adult tohave a bottle of pillsC

'* of highest prescribing states for pain-illers are in theSouth .




I

"early (4,*** .omen died of prescription pain-iller overdosesbet.een 'III and )*'*C

Deaths from prescription pain-iller overdoses among .omen haveincreased more than (** since 'III, compared to )2+ among menC

?or every .oman .ho dies of a prescription pain-iller overdose, 3* goto the emergency department for pain-iller misuse or abuseC

Prescription Pain-iller Overdoses gro.ing epidemic, especially among .omen

@uly )*'3

#urrent #ontext of Drug !se in the !S for 9omen



'*

• /nitiation of drug use

• Ho. she obtains her drugs

• 9here she uses her drugs• Ho. she recovers from drug

use

9hat Does ddiction $oo- $i-e /n 9omen

#ntreated addi"tion %la"es a )o an and her fetusat ris+ for ulti%le adverse "onse uen"es



''

5he amount of time bet.een initial use and the

development of physiological problems is shorter for.omen than men

5he amount of time bet.een initial use and theseverity of the problems that develop from use of

alcohol and drugs is shorter for .omen than men

0 reen ield3 1 '5 6ucha et al.3 2 '5 7eters et al.3 2 &

5elescoping



')

♦ 5he t.o most common drugsused by nonBpregnant .omenhave been alcohol and tobacco

♦ 5his same statement is true forpregnant .omen

♦ mong pregnant .omen in the!nited States, approximately'4 smo-ed cigarettes, IC(dran- alcohol, and + usedillicit drugs in the past month

"ational Survey on Drug !seand Health )*''B)*')

Past Month Use

6S HS Office of pplied Statistics, )*''B)*')7

& ong %regnant )o en,a%%ro-i ately . / used heroin,and .0/ used %ain relievers non1

edi"ally in the %ast onth

#urrent #ontext of Opioid !se during Pregnancy



'3 #urrent #ontext of Opioid !se during Pregnancy "eonatal bstinence Syndrome 6" S7 often

results .hen a pregnant .oman uses opioids6eCgC, heroin, oxycodone7 during pregnancyC

Defined by alterations in the0

Central nervous syste9 highBpitched crying, irritability9 exaggerated reflexes, tremors andtight muscles9 sleep disturbances

&utono i" nervous syste9 s.eating, fever, ya.ning, andsneezing

(astrointestinal distress9 poor feeding, vomiting and loosestools

!igns of res%iratory distress9 nasal stuffiness and rapid breathing

" S is not ?etal lcoholSyndrome 6? S7

" S is treatable

5here are no -no.n longBterm conseAuences fromhaving " S or beingtreated for " S

6?innegan et alC, &ddi"t Dis C 'I1+; Desmond Q 9ilson, &ddi"t Dis C 'I1+7



'(

retrospective, serial, crossBsectional analysisof a nationally representative sample ofne.borns .ith " SC#linical conditions .ere identified using /#DBIB# diagnosis codesC" S and maternal opiate use .ere described asan annual freAuency per '*** hospital birthsC

)*** )**3 )**2 )**I

)*** )**3 )**2 )**I $o. &espiratory edicaid>irth.eight Diagnoses #overage

in the United States – one infant every hour – suffers from neonatal a stinen!e syndrome (N"S)




'+

/n the !S, it is estimated that0

'** million people have chronic pain

)) million are living .ith addiction, and ofthose individuals

2 illion isuse %res"ri%tion edi"ations




'2 #urrent #ontext of Opioid !se during Pregnancy



'1

9hy are more individuals, includingpregnant .omen, using opioids

5here has been an increase in the access tothese medications

Pain became the +th

vital sign in the early )'st

century

?ederal prosecutors allege in documents filedin !CSC District #ourt that #hris and @effGeorge from ?lorida dramatically increased

the numbers of pain clinics in ?lorida androuted opioid pain medications to Jentuc-y,Ohio and South #arolina


#redit0 8>ac- Pain During Pregnancy: by imageryma=estic



'4 Summary of Historical and #urrent #ontext

18

♦ lthough less freAuent than alcohol and tobacco use,opioid misuse during pregnancy is nonetheless aserious and gro.ing issue

♦ 5his increase in use of opioids by pregnant .omenappears to be driving an increase in the incidence ofneonatal opioid .ithdra.al

♦ Opioid use by pregnant .omen is often complicated bypolydrug use, and often occurs intert.ined .ithcomplex personal, interpersonal, family, social, andenvironmental factors that can contribute to adverseconseAuences

♦ 9omen have uniAue needs for addiction treatment andmultiBfaceted interventions are needed to help preventand treat opioidBdependence among .omen duringpregnancy and their infants



'I

/ssues facing drugBusing pregnant .omen and their children

• Exposure to violence andtrauma

• Generational drug use• $ac- of formal education• $ac- of =ob acAuisition and

maintenance s-ills• Gender ineAualityRmaleBfocused society

• $egal involvement

• ultiple drug exposures• $imited parenting s-ills and

resources• History of child abuse and neglect• ultiple psychiatric issues•

!nstable housing• $ac- of positive and supportiverelationships

• ?ood insecurity and lac- ofnutrition

These fa"tors )ith or )ithout drug use "aninfluen"e other and "hild out"o es


#redit0 8Stress Definition /ndicates Explanation Pressures nd 5ension: by Stuart iles



)*

6&evie. in Jaltenbach et alC, 'bstet (yne"ol Clin North & , 'II4C7

Pharmacotherapy for Opioid Dependence

• Prevention of erratic maternal opioidlevels lessens fetal exposure torepeated .ithdra.al episodes

• &educes maternal craving and fetalexposure to illicit drugs

• 9ith drug abstinence, other behaviorchanges can follo. .hich decreaseris-s to mother fetus of infection fromH/<, hepatitis and sexually transmittedinfections

• &educes the incidence of obstetricaland fetal complications and improvesoutcomes

#redit0 /mage in the public domain by SubDural')



)'

21

9HO )*'( Guidelines0 8Pregnant .omen dependent on opioidsshould be encouraged to use opioid maintenance treatment .heneveravailable rather than to attempt opioid detoxificationC Opioidmaintenance treatment in this context refers to either methadonemaintenance treatment or buprenorphine maintenance treatmentC:

Guidance regarding maintenance versus medicationBassisted.ithdra.al has traditionally been based largely on good clinical

=udgmentedication follo.ed by no medication treatment has freAuently been

found to be unsuccessful, .ith relatively high attrition and a rapidreturn to illicit opioid use

aintenance medication facilitates retention of patients and reducessubstance use compared to no medication

>iggest concern .ith opioid agonist medication during pregnancy isthe potential for occurrence of neonatal abstinence syndrome 6" S7 Fa treatable condition

aintenance v C edicationBassisted 9ithdra.al



)) 9hy !se Opioid edications 9ith opioid medications .e are not replacing one addiction for anotherCOpioid medications are longBacting medication that help .ith0

#& </"G

n individual s cravings are controlled

#O P!$S/O"

/ndividual is no longer compulsively using opioids

#O"5&O$

edicationBassisted treatment gives bac- control to the individual

#O"SE !E"#ES

edication assisted treatment helps the individual focus on rebuilding her life

&n individual re"eiving o%ioid %har a"othera%y ust be onitored by a edi"al teathat evaluates ade ua"y of edi"ation dosage and general health and )ell1being of theindividual.



)3

• /n the 'I1*s , a positive relationship bet.een maternal methadonedose and " S severity .as reported

• &ecommendations to maintain pregnant .omen on methadonedoses bet.een )* to (* mg

• 3 decades of research sho.s an inconsistent relationship bet.eenmaternal methadone dose and " S severity

• 5he latest systematic revie. and metaBanalysis concluded that the8Severity of the neonatal abstinence syndrome does not appear todiffer according to .hether mothers are on highB or lo.Bdose

methadone maintenance therapyC:

6&evie. in #leary et alC, &ddi"tion, )*'*7

ethadone0 Dosing during Pregnancy



)(

Split Dosing

6aternal esults – increase drug negative urines during treatment – /ncreased adherence .ith treatment – decrease .ithdra.al symptoms in mother

– "o change in maternal heart rate, vagal tone or s-in conductance

(etal esults – inimizes the reduction in breathing

– inimizes the reduction in movement – ?etal movementBfetal heart rate coupling less suppressed

ethadone0 Dosing during Pregnancy

6DePetrillo et alC, 'II+; S.ift et alC, 'I4I; 9ittmann et alC,'II'; @ansson et alC, )**I; c#arthy7#redit0 8Human ?etus: by ddpavumba; 8Smiling Pregnant ?emale Holding Her 5ummy: by imageryma=estic



)+

2,

Methadone-asso ciated N AS++BI*

T 2*

(+ to 1) hrs

(* to ')* hrs

" S signs

&eAuiring medication

" S appears

" S pea-s

ost common medication for treatment is morphine

ost common assessment tool is a 8modified: ?inneganscale

"o current standard uniform protocol for treatment

ethadone0 " S

#redit0 8Sleeping sian >aby: by hin)++



)2

>reastfeeding in

ethadoneBStabilized othersethadone detected in breast mil- in very lo. levels

ethadone concentrations in breast mil- are unrelated tomaternal methadone dose5he amount of methadone ingested by the infant is lo.

5he amount of methadone ingested by the infant remainslo. even 2 months later Several studies sho. relationships bet.eenbreastfeeding and reduced " S severity and durationHepatitis # is not a contraindication for breastfeeding

#ontraindications0 H/<U, unstable recovery

6DM polito, )*'3; P )*'); c ueen et alC, )*''; @ansson et alC, )**1; @ansson et alC, )*'*7

ethadone0 >reastfeeding

#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong



)1

2;

&esearch focusing on the effects of prenatal exposure to

methadone has been inconsistent$ongBterm effects on physical gro.th have not been demonstrated

lthough some research has sho.n that methadoneBexposed schoolBage children to be less interactive, more aggressive, and sho.ingpoorer achievement than children not so exposed, other research hasfailed to sho. any differences in either cognitive or socialdevelopment

5he issue is confounded by the fact that children exposed tomethadone in utero may experience a nutritional, family, andparenting history Auite different than children not so exposed

)*'( metaBanalysis sho.ed 8no significant impairments for cognitive,psychomotor or observed behavioual outcomes for chronic intraButerine exposed infants and preBschool children compared to nonBexposed infants and childrenC:

6>aldacchino et alC, 3*C Psy"hiatry )*'(; >ehn-e et alC, Pediatri"s , )*'3; ?arid et alC, Curr Neuro%har , )**47

ethadone0 #hild Development

#redit0 8$ady Doctor easuring Girls Height: by David #astillo



)4

45 years of do"u ented benefits of ethadone during

%regnan"y

• /nduction is relatively simple

• deAuate doses are needed to prevent .ithdra.al and other

opioid use• /ndicators of fetal .ellBbeing are less compromised .ith splitB

dosing

• " S is .orse .ith heavier smo-ing

• >reastfeeding is compatible .ith methadone

ethadone0 Summary



)I >uprenorphine

derivative of the opioid al-aloid thebaineSchedule /// opioidμBopioid receptor partial agonist

primarily antagonistic actions on κ- opioid andδ- opioid receptorsHalfBlife estimated to fall in the range of )(B2*hours

6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion , )*')7

h d



3*

• Since 'II+, over (* publishedreports of prenatal exposure to buprenorphinemaintenance

• pproximately 1+* babies prenatally exposed tobuprenorphine 6number of cases per report rangedfrom ' to '+I; *edian V'(7

• Dose range *C( to 3) mg• 44 reported concomitant drug use

6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')7

>uprenorphine and Pregnancy

3' h l



3'

&esearch .ith buprenorphine not as extensive as .ith

methadone9ellBtolerated and generally safe/n contrast to the research .ith methadone, little researchhas compared buprenorphine to an untreated control

group&ather, buprenorphine has been compared in bothretrospective and prospective studies to methadone

a=ority of research .ould suggest that maternaloutcomes are not in any .ay different than for methadone

>uprenorphine0 aternal Outcomes


3) hi 0 ? l O



3) >uprenorphine0 ?etal Outcomes

% V C*I+

% W C*'

6Salisbury et alC, &ddi"tion , )*')7

33 hi 0 " S



33

• /ncidence rate for " S is estimated to be +* F about the same as formethadone

• " S onset approximately (4 hours• Pea-ing .ithin approximately 1)BI2 hours• Exceptions to this onset history have been the fe. neonates .ith " S

onset of 4B'* days postnatal age- such a protracted .ithdra.al syndrome may to be due to . ithdra.al from

concomitant drug exposure 6eCgC, benzodiazepines7 rather than a directeffect of buprenorphine .ithdra.al

• #orrelation bet.een buprenorphine dose and " S severity has beeninconsistent

• 5ime of first dose of " S treatment medication has been sho.n to belater .ith buprenorphine than methadone 6 1' hrs vs 3( hrs, respectively7

6&evie.s in @ones et alC, Drugs , )*'), and &ddi"tion, )*')C; Gaalema et alC, D&D, )*'37

>uprenorphine0 " S

3( hi 0 f di



3(

>uprenorphine is found in breast mil- ) hours postBmaternal

dosing#oncentration of buprenorphine in breast mil- is lo.

mount of buprenorphine or norbuprenorphine the infant receivesvia breast mil- is only '

ost recent guidelines0 8the amounts of buprenorphine in human

mil- are small and unli-ely to have negative effects on thedeveloping /nfant:85he advantages of breast feeding prevail despite the ris-s of aninfant opiate intoxication caused by methadone orbuprenorphine C:

6 t-inson et alC, 'II*; arAuet et alC, 'II1; @ohnson, et alC, )**'; Grimm et alC, )**+; $indemalm et alC, )**I; @ansson et alC, )**I; Xller et alC, )*''7

>uprenorphine0 >reastfeeding

#redit0 8 other /s >reast ?eeding ?or Her >aby: by @omphong

3+ > hi 0 #hild D l t



3+

• &esearch on the neonatal conseAuences of prenatalexposure to buprenorphine is Auite limited

• "ot enough births have been follo.ed for a sufficientperiod of time to collect convincing data regardingfactors such as cognitive and social development

• Same issue of confounding parental and family factorsin teasing apart developmental effect


>uprenorphine0 #hild Development

32 O5HE&0 Si



32 O5HE&0 Sites

6ead !ite @ohns Hop-ins !niversity P/0 HC @ones>ro.n !niversity P/0 >C $ester 5homas @efferson !niversity P/0 JC Jaltenbach!niversity of <ermont P/0 SC Heil

!niversity of <ienna P/0 GC ?ischer !niversity of 5oronto P/0 PC Selby<anderbilt !niversity P/0 PC artin9ayne State !niversity P/0 SC StineCoordinating Center !niversity of aryland P/0 C rria

31 O5HE&0 > hi C th d



31

• #ompared .ithmethadoneBexposed

neonates, buprenorphineBexposed neonates – &eAuired 4I less&eAuired 4I less

morphine to treat " Smorphine to treat " S – Spent (3 less time in theSpent (3 less time in the

hospitalhospital

– Spent +4 less time in theSpent +4 less time in thehospital being medicatedhospital being medicatedfor " Sfor " S

• >oth medications in thecontext of comprehensivecare produced similar

maternal treatment anddelivery outcomes

&;

Notes$ Significant results are encircledC Site .as a bloc-ing factor in all analysesC 5he O >rienB?leming Y spending function resulted in Y V C**I' for the inferential tests of the edication#ondition effect for the + primary outcome measures at the conclusion of the trialC

6@ones et alC, N Engl J *ed C )*'*7

% V C***')

% V C******')

< >uprenorphine< ethadone

O5HE&0 >uprenorphine v C ethadone

34 O5HE&0 > hi C th d



34

#linically

meaningfulattrition rate inbuprenorphinecondition$o. rates ofillicit drug useduringpregnancyand at delivery

aternaloutcomessimilar in the )study conditions

&8Note$ >onferroni s principle .as used to set family.ise Y V C**3')+6nominal Y V C*+R'27 for the secondary outcome measuresC

< ethadone < >uprenorphine

6@ones et alC, N Engl J *ed C )*'*7


3I O5HE&0 > prenorphine C ethadone



3I

/ncidence of " S signs

ll neonates in each medicationcondition had at least one total " Sscore greater than * at some point duringthe observation period

5hree individual signs .ere observed

significantly more often in thebuprenorphine than in the methadonecondition0 sneezing, loose stools, andnasal stuffiness

5here .ere no signs that .ere observedsignificantly more often in the methadonecondition than in the buprenorphinecondition

% = . 2

Heil et alC, &ddi"tion , )*')


(* O5HE&0 >uprenorphine vC ethadone



(

Severity of " S Signs

ethadoneBexposed neonates hadhigher mean " S total score, andhigher mean scores for hyperactive

oro reflex, disturbed tremors,undisturbed tremors, failure tothrive, and excessive irritability

ll %s Z *C*(

>uprenorphineBexposedneonates had higher meanscores on sneezing

Heil et alC, &ddi"tion , )*')


(' Summary0 >uprenorphine



(

O5HE& provided the first &#5 data to support the safety and efficacy ofmethadone

aternal outcomes are similar bet.een medications

Pain management and breastfeeding recommendations are similarbet.een medications

/n terms of " S severity, buprenorphine can be a frontBline medication

option for managing opioidBdependence for pregnant .omen .ho are ne.to treatment or maintained on buprenorphine preBpregnancy

" S, its treatment and elucidating factors that exacerbate and minimize it,remains a significant clinical issue for prenatally opioidBexposed neonates

#urrently there is great variation in terms of medications and use of toolsC

Summary0 >uprenorphine

() " S0 ?actors



()

Other factors that contribute to severity of " S in

neonates exposed to opioid agonists in utero0

Genetics

Other Substances-

#igarette smo-ing- >enzodiazepines- SS&/s

Hospital Protocols

B5he " S assessment and medication initiation and .eaning protocols- "ot breastfeeding- &ooming in or separating mother and baby

#redit0 89oman Smo-ing EBcigarette: by patrisyu; 8Embryonic Development: by dream designs

6@ansson and <elez, Curr '%in Pediatri"s , )*')7

S0 ?actors

(3 Smo-ing and "eonatal bstinence Syndrome 6" S7



&ES!$5S

Higher average daily number ofcigarettes smo-ed in the past 3* days.as

U related to in"reasing 0

• 5otal amount of morphine needed to treat" S

• "umber of days neonate .as medicatedfor " S

• "eonatal length of hospital stay

B related to de"reasing 0

• "eonatal .eight at birth

O$S and Poisson regression analyses .ere used to test average daily number of cigarettes smo-ed in the past 3* days at YV C*+, ad=usting for bothedication #ondition and SiteC >elo.Baverage cigarette smo-ing .as defined as 2 cigarettesRday 6B' !D 7, average cigarette smo-ing as '(cigarettesRday 6 ean7, and aboveBaverage cigarette smo-ing as )' cigarettesRday 6U' !D 7C 6@ones et alC, D&D, )*'37

Smo-ing and eonatal bstinence Syndrome 6 S7

SelfBreported past 3*Bday daily average number of cigarettes smo-ed,measured at study entry, .as used to predict neonatal and maternaloutcomes in '3' pregnant participants in the O5HE& studyC

(( >uprenorphine vC ethadone



44

>uprenorphine v C ethadone

(+ Program #omponents for 9omen



#onsiders the needs of .omen in all aspects of program designand delivery, including location, staffing, program development,program content, and program materials

Provides safe and comfortable environments in .hich .omendevelop supportive relationships that allo. them to address theirrecovery needs

Services need to include0Outreach and engagementScreeningDetoxification#risis intervention

ssessment5reatment planning#ase management

Program #omponents for 9omen

Progra should be a""redited by an outside body li+e C&78 or JH&C'

Substance use counseling and education 5rauma specific and informed services edical and mental health care

Pharmacotherapy Drug monitoring #ontinuing care

(2 Substance !se Disorders during Pregnancy



Substance !se Disorders during Pregnancy

?e. medications are successful in the treatment of anysubstance use disorders, except for alcohol and opioidsC

Opioid medications such as methadone and buprenorphine canbe successful components in treating opioid use disorder, bothin the general population and in pregnant .omenC

Opioid medications are best provided in the context of acomprehensive treatment plan that includes behavioral

treatment li-e individual counselingC comprehensive treatment plan is developed follo.ing anassessment that determines .hich life areas have been affectedby drug use and to .hat extent they have been affectedC

5he patient and provider then develop specific goals for

improved life functioning in each life area and a plan for ho.and .hen the goals .ill be metC

Part of the plan may eventually include .ellness indicators of.hen patients can taper off of their medicationC

ScreenScreen

ssessssess

PlanRPlanR5reat5reat

EvaluateEvaluate

(1 ?actors to $oo ?or in Good 5 Program



?actors to $oo- ?or in Good 5 Program

Do they use the merican Society of ddiction edicine 6 S 7standards for opioid treatment .ith opioid medications in alldecisions regarding the initiation and continuation of themedication for substance use treatment

Do they use evidenceBbased instruments .hich include at aminimum0

the memberMs report of physical and emotional comfortan instrument to assess for possible .ithdra.al symptomsurine toxicology screen results and any other laboratoryfindingsan instrument for assessing impairment

(4 ?actors to $oo- ?or in Good 5 Program




Do they perform regular toxicology screening0

minimum of eight 647 tests per year .ill be performed per patient&andom testing for each patient&eAuires specific drugsRclasses .ill be tested including methadoneand SH s 6sedatives, hypnotics, anxiolytics7; testing should alsoinclude those substances in the memberMs personal history and thosecommon in the region!se certified labs and accepted technologies for appropriateinterpretation of results .ill be used to validly interpret test results

#an they sho. you a staffing plan for recruitment, training anddevelopment

9hat standards can they sho. to document that they are facilitatingrecovery

Do they have a plan for case management in place 9hat are its mainfeatures

(I ?actors to $oo- ?or in Good 5 Program




5he case management factors are lin-ed to successful outcomes0

ssigned case manager to individual patient

#larity about the role of the case managers

/nterventions recommended meet identified care needs

schedule for the patient to meet .ith the case manager

5he case manager actively collaborating .ith the other

providers

5he case manager empo.ers patients to be an active

participant in her care

+* #ontinuum of ?amilyB>ased Services



6E9E6 :$ Services for .omenC 5reatment plan includes family issues, 5reatment9ith family involvementC Goal0 improved outcomes for .omenC

6E9E6 $ #hildren accompany .omen to treatmentC 9omen s #hildren participatein child care but receive no 5reatment 9ith therapeutic servicesC Only .omen have#hildren Present treatment plansC Goal0 improved outcomes for .omenC

6E9E6 ;$ #hildren accompany .omen to treatmentC 9omen s and 9omen andattending children have treatment #hildren s plans and receive appropriateservicesC Goals0 Services improved outcomes for .omen and children, betterparentingC

6E9E6 <$ #hildren accompany .omen to treatment; ?amily Services .omen andchildren have treatment plansC Some services are provided to other familymembersC Goals0 improved outcomes for .omen and children, better parentingC

6E9E6 4$ ?amilyB#entered 5reatment Each family member has a treatment planand receives individual and family servicesC Goals0 improved outcomes for.omen, children, and other family members; better parenting and familyfunctioningC

#ontinuum of ?amilyB ased Services

+' odel of #are for 9omen and #hildren



odel of #are for 9omen and #hildren

Trauma andAddiction

Treatment

Childcare and Transportation

VocationalRehabilitation

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+2 5reatment of Substance !se Disorders during Pregnancy



Substance Treatment Approaches Comments

Tobacco

• Nicotine Replacement Therapy (NRT): nicotine gum, transdermal nicotinepatches, nicotine nasal spray, nicotine lozenge, and nicotine inhaler

• Bupropion• arenicline• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,

contingency management• $As (As%, Ad!ise, Assess, Assist, Arrange) as a Brie# &nter!ention

] ery limited data #or NRT and bupropion usein pregnancy, and no data a!ailable #or !arenicline,both o# "hich are ' A pregnancy category C

] oucher based rein#orcement has been pro!ene##icacious as a beha!ioral treatment

Alcohol

• *edication assisted "ithdra"al #rom alcohol use #or pregnant "omen#re+uently uses a benzodiazepine (e g , diazepam) as pharmacotherapy

• -sychosocial treatment should be considered as an integral component o# any "ithdra"al strategy

] -harmacotherapy (e g , acamprosate, naltre.one,disul#iram) should generally not be used inpregnancy due to ris% to the #etus

] Beha!ioral treatments ha!e been #ound to be in#erior topharmacotherapy in non pregnant "omen

Cannabis •

Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management ] No %no"n e##icacious pharmacotherapy

Cocaine • Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,

contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy

Amphetamines/*ethamphetamines

• Beha!ioral treatments ha!e been sho"n to be e##ecti!e: cogniti!e beha!ioral,contingency management, *oti!ational &nter!ie"ing ] No %no"n e##icacious pharmacotherapy

Benzodiazepines

• 0radual taper "ith a long acting benzodiazepine (e g , diazepam) "ith the goal

o# being benzodiazepine #ree at birth• -sychosocial treatment should be considered as an integral component o# anydose reduction strategy

] Beha!ioral treatments are thought to be in#erior topharmacotherapy

1pioids• 1pioid agonist pharmacotherapy: *ethadone, Buprenorphine• 1pioid antagonist pharmacotherapy: naltre.one• *edication assisted "ithdra"al (deto.i#ication)

] *edication assisted "ithdra"al has a %no"n high#ailure and may only be appropriate in certaincases

] Beha!ioral treatments ha!e been #ound to be in#erior topharmacotherapy

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Documents

PQCNC: Treating Women Substance Abuse Disorders