1. Integrating Perinatal Substance Abuse Care into a Family Medicine Residency
Mary Beth Sutter, MD Hannah Watson, MD
Sherry Weitzen, MD PhD
Larry Leeman, MD MPH
University of New Mexico
Department of Family and Community Medicine

2. Disclosures
We have nothing to disclose

3. Objectives
On the completion of this session participants should be able to:
Describe the epidemiology of perinatal substance abuse in the United States, and explain the role family physicians can play in caring for families with substance abuse
Describe a successful model of family medicine resident education in perinatal substance abuse
Assess the opportunities, potential barriers, and keys to successful implementation of a perinatal substance abuse clinic in their community

4. Opiate Dependence in Pregnant Women is Rising
5% pregnant women report illicit drug use
1 in 5 pregnant women in Medicaid filled opiate prescription
Prevalence of NAS = 6/1,000 births
$1.5 billion hospital charges for NAS

5. New Mexico is at the Center of the Perinatal Opiate Epidemic
2nd highest overdose death rate nationally
UNM referral center for high risk deliveries statewide
Intergenerational substance abuse

6. Family Medicine is Uniquely Suited to Perinatal Substance Abuse Treatment
We are experts in biopsychosocial model of chronic disease management
We recognize importance of cultural humility and trauma-informed care
We have specialized knowledge in mother-baby dyad care

7. UNM Family and Community Medicine Residency
Opposed program
14 residents/year + 4 rural program interns
2-year Maternal Child and Reproductive Health Fellowship

8. Our model Maternal Child Health Service Antenatal opiate dependence
Labor management
Deliveries
Mother-baby dyad care postpartum
R1, R2, R3
MCH Fellows
Milagro Prenatal Clinic
Outpatient
prenatal care R3
MCH Fellows
FOCUS Clinic
Well child care
Family substance abuse treatment R3

9. Milagro Prenatal Care Individual and group prenatal care
Multidisciplinary team =
5 generalist + 4 FM-Ob trained faculty family medicine physicians, 4 MCH fellows
2 full-time RN’s
1 full-time community support worker
1 counsellor
Back-up system for high risk consults .

10. Medication Assisted Therapy
80% patients on MAT
2/3 buprenorphine
1/3 methadone
All providers have waivers to prescribe buprenorphine
University-affiliated methadone clinic

11. Labor and Delivery MCH service staffed by R1, R2/R3, FM attending
Residents first-line providers from induction to delivery to mother-baby care
Continuity is critical for medically and socially high-risk patients
In % of MCH deliveries received care at Milagro
Residents well-prepared for perinatal substance abuse treatment at graduation

12. Infant Care for NAS
Term infants admitted to a rooming-in unit when possible
Level 2-3 Nursery for more complex cases
3 resident rotations include NAS care with a variety of preceptors
FM generalist faculty
FM-Ob faculty
Pediatricians
CNM

13. FOCUS Well Family Care
Primary care substance abuse clinic for children and families to age 3
Resident continuity clinic site
Collaboration with early intervention specialists with home visits

14. Perinatal Substance Abuse is a Critical Part of Resident Education
2016 Resident Experience Survey:
“Pretty inspiring and awesome”
“I like Milagro mamas”
“One of my favorite parts of residency”
“Some [births] beautiful, some painful”
“Similar to non-Milagro deliveries”

15. Challenges of Substance Abuse Work
Substance abuse work is polarizing, and requires space for emotional processing:
“What’s the point?”
Not “bread and butter” obstetrics
“Not an NSVD”

16. Continuity Care
“The psychosocial aspects of the clinic were extremely relevant. It was completely necessary to see women at the beginning of their treatment for their addiction and follow them through FOCUS over the years. If people do Milagro, I think it's absolutely imperative that they do FOCUS. It changes the perspective to see that these women truly do benefit from the integrated care.”

17. Resident Evaluation = Milagro Milestones
Residents practice perinatal substance abuse skills every day:
Coordinating team-based care
Advocating for individual and community health
Partnering with family and community to improve health through disease prevention and health promotion

18. Key Best Practices Work in multi-disciplinary teams
Have a back-up system for high risk patients
Transition care to postpartum / early childhood

19. What does your community need ?
What is the burden of perinatal substance use in your community?
Who is caring for patients with perinatal substance abuse now?
What works well about the existing model, and what could improve?

20. What are the barriers to implementation?
What support systems are needed to back-up this work?

21. References
Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. (2014).
Desai, R. J., Hernandez-Diaz, S., Bateman, B. T. & Huybrechts, K. F. Increase in Prescription Opioid Use During Pregnancy Among Medicaid-Enrolled Women: Obstet. Gynecol. 123, 997–1002 (2014).
Incidence of Neonatal Abstinence Syndrome — 28 States, 1999–2013 | MMWR. Available at: (Accessed: 7th May 2017)
Patrick, S. W. et al. Neonatal Abstinence Syndrome and Associated Health Care Expenditures: United States, JAMA 307, (2012).

22. Questions?

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