Educate all providers and administrative staff about opioid use disorder (OUD) in pregnancy, strategies for caring for patients with OUD, and develop protocols that address all team members’ roles.
Why we are recommending this best practice
Treatment of OUD is a multidisciplinary endeavor that begins with a patient’s first encounter in the health care environment. For this reason, all staff need to have a strong foundational understanding of OUD as a chronic illness and must be provided with adequate training and tools to interact with patients in a way that does not undermine a patient’s effort to seek care. Understanding the underlying stigma and biases that nurses and ancillary staff may unintentionally bring to the treatment of patients should be a primary focus of all inpatient, outpatient, and ambulatory care staff.
While the OUD epidemic affects women from all socioeconomic, racial, and cultural backgrounds, many caregivers and staff members have mistaken ideas about the reality of addiction. These misconceptions often result in a patient being denied needed treatment or alienated from the medical system before she has established care with a provider.
In all medical settings, it is important that the first contact a woman with OUD has with the health system is one that is free of stigma and alienating language, incorporates Trauma-Informed Care, and is tailored to the individual woman’s needs. This initial meeting should be one that helps move a patient forward to an empowering relationship with her provider and toward medication assisted treatment (MAT) before her intrapartum period. If a patient is initiating care during the intrapartum period, it is equally important that the care is viewed by all staff as an opportunity to implement the best practices for mothers and newborns included in this toolkit during the postpartum period and beyond. Pregnancy provides a unique window of opportunity when a woman is highly motivated to enter treatment not only out of concern for the health of the fetus but also because during pregnancy, she can envision a different future for herself and her child.
Staff and provider training is key to disrupting the stigmatizing interactions that women with OUD encounter or perceive when they present for care. Recognizing OUD as a chronic illness is imperative to providing patient-centered care that establishes a trusting and safe environment. The first contact for these women in both inpatient and outpatient settings, often at registration or reception, needs to be free of stigmatizing behaviors and language. The subsequent encounter with a medical assistant or nurse is profoundly influenced by the presentation of the patient from the initial contact. Whether or not a patient has sought prenatal care, her parity, family structure, history, and other factors all influence how she is perceived and received. Many factors can contribute to initial perceptions of patients by staff and nurses, and targeted interventions have been shown to significantly impact how women with substance use disorder (SUD) or opioid use disorder (OUD) are distinguished from other patients presenting for care.
Strategies for implementation
- Create Awareness of OUD in Pregnancy: Determine appropriate avenues through which to educate office/clinic and hospital staff about OUD in pregnancy (e.g., emails, physical bulletin boards, staff meetings) with a focus on mitigation of discrimination and bias toward patients with OUD. Utilize content such as our “Education on OUD Tool” (Refer to the Resources section of this Best Practice).
- Train Staff and Providers on Trauma-Informed Care: Create opportunities for staff and providers to learn about Trauma-Informed Care.
- Be Aware of Local Cultures: Identify “cultural coaches” to help explain the nuances of local culture that may impact care and treatment.
- Train Providers on Use of OUD Treatment Protocols: Create opportunities for providers responsible for evaluating and treating pregnant patients to learn and ask questions about facility-specific OUD treatment protocols and to obtain a waiver to prescribe buprenorphine.
- Train Nursing on Use of OUD Treatment Protocols: Create opportunities for nurses responsible for caring for pregnant inpatients to learn and ask questions about the facility-specific protocol developed as well as how to use the Clinical Opiate Withdrawal Scale (COWS) and the Ramsay Sedation Scale (Ramsay Sedation Scale) in the care of patients with OUD and how to administer buprenorphine and methadone.
Educating providers and staff about OUD may seem overwhelming at first, especially if the culture of care at your center has historically taken a punitive or judgmental approach to caring for mothers with a substance use disorder. Demystifying the educational “roadmap” can go a long way in giving clinical champions the most important starting points for educating the multidisciplinary health care team. This may consist of the following basic concepts:
- Every pregnant woman should be verbally screened for substance use at multiple points in care
- OUD is a chronic medical condition that can be treated
- Substance use is almost always connected to significant past trauma and/or Adverse Childhood Events (ACEs). A Trauma-Informed Care approach that emphasizes empathy and reduces stigma and bias is the standard of care and improves outcomes.
- MAT (methadone or buprenorphine) is the standard of care for pregnant women with OUD. Withdrawal is dangerous for both mother and fetus. MAT is linked to better maternal and neonatal outcomes and reduces overdose deaths.
- Education about the signs, symptoms, and treatment of NAS is critical. Non-pharmacologic treatment of NAS such as rooming-in, skin-to-skin contact, swaddling, and reducing external stimuli results in better support of the mother/baby dyad, reduced need for pharmacologic treatment, and shorter hospital stays.
- Treatment requires provider, peer, family, and community support. Systems of care for women with OUD should always address transitions from one location of care to another, including comprehensive discharge planning and the development of a Plan of Safe Care that ensures maternal continuation of treatment and recovery, and appropriate medical, developmental, and safety follow-up for the newborn.
- The overarching goal is to preserve the mother/baby dyad.
- Confronting the Stigma of Opioid Use Disorder and Its Treatment.
- AMA Opioid Task Force Resources.
- Words Matter: How Language Choice Can Reduce Stigma.
- SAMHSA. Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054, Rockville, MD, 2018. Factsheet #2 Initiating Pharmacotherapy for Opioid Use Disorder. Factsheet #4 Managing Pharmacotherapy Over the Course of Pregnancy.
- Clinical Opiate Withdrawal Scale (COWS).
- Ramsay Sedation Scale.
- Education on OUD Tool.
- Facing addiction in America: the surgeon general's report on alcohol, drugs, and health. Chap 6: health care systems and substance use disorders. Accessed December 15, 2019. https://www.ncbi.nlm.nih.gov/books/NBK424848/.
- Opioid use disorder and pregnancy FAQ. American College of Obstetricians & Gynecologists https://www.acog.org/- /media/For-Patients/faq506.pdf?dmc=1&ts=20190509T0049178971.
- Committee opinion on opioid use and opioid use disorder in pregnancy. https://www.acog.org/Clinical-Guidance-and- Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid- Use-and-Opioid-Use-Disorder-in-Pregnancy?IsMobileSet=false. Accessed December 15, 2019.