Implement an outpatient protocol for evidence-based evaluation, treatment, and continuity of care for pregnant patients with opioid use disorder (OUD). Arranging for the provision of medication assisted treatment (MAT) on site is an optimal way to deliver the standard of care for pregnant women with OUD.
Why we are recommending this best practice
The pregnant woman with OUD who presents for prenatal care has a unique opportunity to initiate treatment for OUD. While the care team may initially find such a patient challenging, they have a chance to introduce life-changing therapy. Along with the screening and brief intervention portions of SBIRT, obstetric providers can offer MAT treatment. Few obstetric providers have received training in OUD management and understandably feel reluctant to begin this practice. Obstetric providers often feel more comfortable referring patients with OUD to a stand-alone outpatient opioid treatment clinic or other office-based outpatient treatment (OBOT) program for induction and management of OUD with MAT. However, the desired future state in opioid treatment is for patients with OUD to be able to begin treatment wherever they receive medical or prenatal care. Providers who can initiate treatment for OUD will have a significant impact on the unmet treatment gap in their county.
Strategies for implementation
- Engage the whole team. Successful integration of a new service will require front office, back office, and providers all educated about the successful outcomes in pregnant women with OUD who are on MAT.
- Providers must receive a Drug Addiction Treatment Act of 2000 (DATA 2000) X waiver to be able to prescribe MAT. Federal legislation (SUPPORT Act, 2018) and previous legislation includes CNMs, NPs, and CRNAs in addition to physicians as eligible to complete this training. Online training programs are readily available. Physicians require 8 hours of training, and non-physician providers require 24 hours of training.
- Build policies/procedures for MAT to allow for a uniform care delivery system.
- Use a toolkit. Numerous toolkits exist that provide clinics with the education and resources needed to offer MAT. One such is example is the Providers Clinical Support System (PCSS). https://pcssnow.org/resources/clinical-tools/
- Identify who to call for help. Know how to refer patients who fail buprenorphine to methadone treatment programs when necessary. Consider using a consultation service such as the FREE Clinician Consultation Center at UCSF which has a Substance Use Warmline at 855-300-9595 and is available Monday through Friday during daytime business hours, and a specific Consultation line for licensed practitioners in California that is available 24/7. This line is staffed by physicians, pharmacists, and nurses with special expertise in pharmacotherapy options.
- Explore emerging therapies. Aside from traditional in-office induction, consider other modalities that best suit your patients. These include home and hospital induction, micro-dosing transition, and Buprenorphine Quick Start.
- SAMHSA Waiver Application and Training.
- Providers Clinical Support System (PCSS). Clinical Tools.
- Guidelines for Physicians Working in California Opioid Treatment Programs. Chapter 4.
- ED Bridge. Buprenorphine Quick Start in Pregnancy Algorithm.
- California Health Care Foundation Webinar: “Expanding Access to Buprenorphine in Primary Care Settings”.
- California Health Care Foundation. Everything You Need to Know About Buprenorphine.
- Urban Institute: California County Fact Sheets: Treatment Gaps in Opioid-Agonist Medication Assisted Therapy (OA-MAT) and Estimates of How Many Additional Prescribers Are Needed.
- UCSF Substance Use Warmline
- Laws and Regulations. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/about-us/who-we-are/laws-regulations. Updated April 27, 2020.
- Apply for a Practitioner Waiver. Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medication-assisted-treatment/training-materials-resources/apply-for-practitioner-waiver. Updated April 16, 2020.