1. Elizabeth E. Krans, MD, MSc Assistant Professor, University of Pittsburgh Magee-Womens Research Institute Department of Obstetrics, Gynecology and Reproductive Sciences Patient-Provider Communication Regarding Opioid Use Disorders during the First Obstetric Visit

2. Opioid Dependence in Pregnancy

3. 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

4. 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

5. Objective To evaluate patient-provider communication regarding opioid use disorders during the first obstetric visit.

6. 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).

7. 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.

8. Disclosing Opioid Use in Pregnancy. Disclosure and results of urine drug screen (UDS) for pregnant women using opiates (n=30) UDS ResultsN (%) Disclosed current substance use No disclosure of substance use Methadone only20 (4.7)20-- Opiates only2 (0.5)--2 Methadone + marijuana4 (0.9) 3 methadone 3 marijuana 1 methadone 1 marijuana Methadone + benzodiazepines1 (0.2) Methadone and benzodiazepines -- Methadone + cocaine1 (0.2)MethadoneCocaine Methadone + marijuana + amphetamines 1 (0.2)Methadone Marijuana, amphetamines Methadone + opiates + marijuana1 (0.2)Methadone, marijuanaOpiates

9. Medical Aspects of Opioid Use CodeDefinitionExample 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 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. 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 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.

10. Medical Aspects of Opioid Use

11. Pregnancy and OMT CodeDefinitionExample Need to stay on OMT during pregnancy Discussions regarding recommendations to stay on OMT during 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. OMT type in pregnancy Discussions over whether or not to use subutex, suboxone or methadone 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. OMT dose in pregnancy Any conversations related to the need to increase dosing in pregnancy 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.

12. Pregnancy and OMT

13. Counseling regarding opioid use CodeDefinitionExample NAS/neonatal implications Any type of counseling regarding NAS, prolonged length of stay for the baby 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. Breastfeeding Conversations about breastfeedingPr: You know we encourage women to breastfeed. Partner/IPV Any mention of partner, partner support of the pregnancy, IPV 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? Legal issues Conversation about incarceration, arrest, probation and/or legal issues Pr: Ok, what is ARD? 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…

14. Counseling regarding opioid use

15. 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.

16. 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