Shared Decision-Making Tool for Treatment of Perinatal Opioid Use Disorder

Guille, Constance; Jones, Hendrée E.; Abuhamad, Alfred; Brady, Kathleen T.

doi:10.1176/appi.prcp.20180004

Cited by 27 publications

(14 citation statements)

References 26 publications

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“…Poverty, maternal mental health, and substance use disorders are leading causes of maternal and infant morbidity and mortality 35 and can have a significant negative effect on child development. 17,36 Rural and impoverished communities and counties in the United States with the greatest long-term unemployment and deficit in mental health clinicians are also the counties with the highest rates of NAS. 4 This finding highlights the complex needs of the mother-infant dyad and underscores the biopsychosocial challenges that this population faces.…”

Section: Discussionmentioning

confidence: 99%

“…Women were seen and evaluated by a psychiatrist with perinatal and addiction training. Pregnant women who received a diagnosis of OUD and were considered appropriate to receive pharmacotherapy for OUD underwent shared decision making 17 to decide to continue or initiate pharmacotherapy for OUD (ie, buprenorphine). A patient-physician agreement detailing the individual's treatment plan and frequency of visits as well as understanding of how medication would and would not be prescribed was reviewed and signed by both the patient and clinician (eAppendix 2 in the Supplement).…”

Section: Methodsmentioning

confidence: 99%

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Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine

et al. 2020

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IMPORTANCE There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption.OBJECTIVE To compare maternal and newborn outcomes among pregnant women with OUD receiving care via telemedicine vs in person. DESIGN, SETTING, AND PARTICIPANTSA nonrandomized controlled trial including 98 women receiving perinatal OUD treatment in 4 outpatient obstetric practices by telemedicine or in person and followed up until 6 to 8 weeks post partum was conducted from September 4, 2017, to December 31, 2018. Logistic regression with propensity score adjustment was applied to reduce group selection bias and control for potentially confounding variables.INTERVENTIONS Participants were seen weekly for 4 weeks, every 2 weeks for 4 weeks, and monthly thereafter and provided relapse prevention therapy and buprenorphine. MAIN OUTCOMES AND MEASURESThe outcomes were retention in treatment, defined as uninterrupted addiction treatment during pregnancy through 6 to 8 weeks post partum; urine drug screen results at delivery and 6 to 8 weeks post partum; and a neonatal abstinence syndrome (NAS) diagnosis collected via electronic health records. RESULTSThe mean (SD) age of the 98 pregnant women was 30.23 (5.12) years. Of these, 41 of 44 women (93.2%) in the telemedicine group and 48 of 54 women (88.9%) in the in-person group chose to continue treatment in the program after an initial evaluation. After propensity score weighting and doubly robust estimation, no significant differences were found between groups in retention in treatment at 6 to 8 weeks post partum (telemedicine: 80.4% vs in person: 92.7%; treatment effect, −12.2%; 95% CI, −32.3% to −4.4%). Similarly, after propensity score weighting and doubly robust estimation, there were no significant group differences in rates of NAS (telemedicine: 45.4% vs in person: 63.2%; treatment effect, −17.8%; 95% CI, −41.0% to 8.9%). CONCLUSIONS AND RELEVANCEIn this nonrandomized controlled trial, virtually integrated OUD care in obstetric practices produced similar maternal and newborn outcomes compared with in-person care. These findings may have important public health implications for combatting the opioid crisis and its consequences on pregnant women and their families. Future large randomized clinical trials are needed. (continued) Key Points Question Is opioid use disorder treatment received via telemedicine in obstetric practices associated with similar maternal and newborn outcomes compared with opioid use disorder treatment received in person in obstetric practices? Findings In this nonrandomized controlled trial including 98 pregnant women with opioid use disorder, there were no statistically significant differences in rates of retention in treatment between women receiving opioid use disorder treatme...

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine

et al. 2020

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“…A collaborative process of shared decision-making with the patient was promoted during on-shift didactic sessions and one-on-one technical assistance provided by SUNs and an addiction specialist physician. 28 , 29 Clinicians were not required to participate in the high-dose pathway. APPs were able to order buprenorphine without prior approval of a physician.…”

Section: Methodsmentioning

confidence: 99%

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

et al. 2021

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IMPORTANCE Emergency departments (EDs) sporadically use a high-dose buprenorphine induction strategy for the treatment of opioid use disorder (OUD) in response to the increasing potency of the illicit opioid drug supply and commonly encountered delays in access to followup care.OBJECTIVE To examine the safety and tolerability of high-dose (>12 mg) buprenorphine induction for patients with OUD presenting to an ED. DESIGN, SETTING, AND PARTICIPANTSIn this case series of ED encounters, data were manually abstracted from electronic health records for all ED patients with OUD treated with buprenorphine at a single, urban, safety-net hospital in Oakland, California, for the calendar year 2018. Data analysis was performed from April 2020 to March 2021.INTERVENTIONS ED physicians and advanced practice practitioners were trained on a high-dose sublingual buprenorphine induction protocol, which was then clinically implemented. MAIN OUTCOMES AND MEASURESVital signs; use of supplemental oxygen; the presence of precipitated withdrawal, sedation, and respiratory depression; adverse events; length of stay; and hospitalization during and 24 hours after the ED visit were reported according to total sublingual buprenorphine dose (range, 2 to >28 mg). RESULTSAmong a total of 391 unique patients (median [interquartile range] age, 36 [29-48] years), representing 579 encounters, 267 (68.3%) were male and 170 were (43.5%) Black. Homelessness (88 patients [22.5%]) and psychiatric disorders (161 patients [41.2%]) were common. A high dose of sublingual buprenorphine (>12 mg) was administered by 54 unique clinicians during 366 (63.2%)encounters, including 138 doses (23.8%) greater than or equal to 28 mg. No cases of respiratory depression or sedation were reported. All 5 (0.8%) cases of precipitated withdrawal had no association with dose; 4 cases occurred after doses of 8 mg of buprenorphine. Three serious adverse events unrelated to buprenorphine were identified. Nausea or vomiting was rare (2%-6% of cases).The median (interquartile range) length of stay was 2.4 (1.6-3.75) hours. CONCLUSIONS AND RELEVANCEThese findings suggest that high-dose buprenorphine induction, adopted by multiple clinicians in a single-site urban ED, was safe and well tolerated in patients with untreated OUD. Further prospective investigations conducted in multiple sites would enhance these findings.

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“…A shared decision-making tool is available to assist patients and health-care providers in discussing the decision to continue or taper buprenorphine or methadone during pregnancy and ensure that women are making informed, evidence-based decisions that reflect their values and preferences. 105 Other components of pregnancy care for women with OUD Antenatal counseling and care…”

Section: Smfm Special Reportmentioning

confidence: 99%