Why we are recommending this best practice
- They believe they cannot treat OUD because they do not have a waiver to prescribe MAT (“X waiver”).
- Fact: federal law allows providers without an X waiver to administer buprenorphine on an inpatient basis for up to 72 hours. This law is known as the “three-day rule” and provides for effective treatment of acute withdrawal in the emergency department or inpatient setting.
- Possible deleterious fetal effect.
- Fact: MAT, particularly buprenorphine, is the gold standard and safe during pregnancy. Split dosing or even higher overall dosing may be required. On the other hand, withdrawal is associated with high rates of relapse and poor outcomes.
- More severe NAS, especially with the higher doses of buprenorphine needed during pregnancy.
- Fact: Buprenorphine reduces NAS severity and the dose is not correlated to NAS severity.
A clear, informed protocol that providers can leverage for safe management of OUD in pregnant women will increase provider comfort in caring for these patients and optimizing health outcomes for patients and their newborns.
It is important to recognize that not all areas of the country have access to the same resources for MAT, especially for women who are pregnant. In rural and/or underserved areas, there may be access to only one type of treatment and/or treatment setting, and each group implementing this toolkit should become familiar with the treatment options available in their community. These settings may be integrated into primary care or OB/GYN offices (e.g., office-based outpatient treatment), stand-alone outpatient treatment programs, residential treatment programs, opioid treatment programs (“methadone clinics"), emergency departments, hospital labor and delivery units, or within the general hospital setting. Each of these locations has its own unique strengths and challenges. Referral protocols should be built by individual locations to reflect assessment of the severity of OUD matched with the ASAM level of care resources that are available in their own communities with the goal of providing access to treatment for women during their pregnancy and after delivery
Strategies for implementation
- Utilize a multidisciplinary team, ideally with obstetricians, midwives, psychiatrists, nurses, anesthesiologists, addiction and pain medicine specialists, pharmacists, and social workers to create a facility-specific protocol that addresses the following:
- Evaluation of patients for OUD with a non-judgmental, trauma-informed approach (please see the Resources section of this Best Practice: Sample Evaluation of Opioid Use Disorder in Pregnancy Checklist).
- Shared decision making for OUD treatment, emphasizing the risks of OUD in pregnancy and options for MAT, as well as the risks of supervised withdrawal (Please see the Resources section of this Best Practice: Considerations for, Treatment of Opioid Use Disorder in Pregnancy).
- Development and utilization of a treatment algorithm for inpatient MAT initiation for both buprenorphine and methadone, including adjunctive therapies to optimize MAT induction (please see the Resources section of this Best Practice: Sample Inpatient Medication-Assisted Treatment Induction Algorithms and the Buprenorphine Quick Start in Pregnancy Algorithm).
- Development and utilization of a treatment algorithm for outpatient buprenorphine induction. If capacity for close follow up with provider(s) comfortable with outpatient induction of buprenorphine in pregnancy is available, develop guidelines for which patients can consider outpatient induction of MAT and develop a protocol for outpatient buprenorphine induction (please see the Resources section of this Best Practice: Sample Outpatient Buprenorphine Induction Algorithm). Consider partnering with local residential treatment facilities and withdrawal management (detoxification) centers.
- Development of a Plan of Safe Care to ensure pregnant patients with OUD are discharged with appropriate transition to outpatient care with a focus on coordination of MAT (e.g., handoffs to methadone treatment programs and buprenorphine prescribing providers) and harm reduction. The “Transitions” section of this toolkit includes multiple best practices that will support development efforts in these areas.
- Educate physicians, nurses, and other care team members on OUD in pregnancy, strategies for caring for patients with OUD, and implementation of developed protocols.
- Create awareness of OUD in Pregnancy through various mediums to educate hospital staff about OUD in pregnancy (e.g., emails, physical bulletin boards, staff meetings) and mitigate stigma, bias and discrimination toward patients with OUD.
- Create opportunities for the workforce to learn about trauma-informed care in the inpatient setting (See Best Practice #7).
- Train providers on OUD treatment protocols for pregnancy and encourage them to obtain a waiver to prescribe buprenorphine.
- Train nurses on OUD treatment protocols and the use of the Clinical Opiate Withdrawal Scale and the Ramsay Sedation Scale (refer to the Resources section of this Best Practice) in the care of patients taking buprenorphine and methadone (refer to the Resources section of this Best Practice: Considerations for Administration of Buprenorphine and Methadone).
- Create process metrics to regularly evaluate the implementation of the facility-based protocols.
- Define target metrics for OUD treatment. Develop facility-specific metrics to track implementation and effectiveness of OUD treatment protocols (e.g., development of a dashboard if enough volume vs. audit of OUD cases if a few cases) and assess for disparities in treatment (e.g., examine outcomes by race, preferred language).
- Delineate role(s) for assessment and improvement of OUD treatment. Designate either an individual or a team to take accountability for ongoing facility-level assessment and improvement of OUD treatment in pregnancy to ensure access and health equity.
Reference: Macintyre PE, Russell RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesthesia and intensive care. 2013;41(2):222-230.
- COWS: A clinical opioid withdrawal scale designed to monitor signs of opioid withdrawal.
- Ramsay Sedation Scale: Designed for use in critically ill adults that has broad applicability in evaluation of the range between agitation and over sedation in response to sedatives and analgesics.
- Considerations for Administration of Buprenorphine and Methadone.
- Considerations for Treatment of Opioid Use Disorder in Pregnancy.
- Sample Evaluation of Opioid Use Disorder (OUD) in Pregnancy Checklist.
- Sample Inpatient Medication-Assisted Treatment Induction Algorithms.
- Sample Outpatient Buprenorphine Induction Algorithm.
- NNEPQIN Opioid Use Disorder Clinical Pathway.
- ED Bridge. Buprenorphine Quick Start in Pregnancy Algorithm.
- ACOG Committee Opinion No 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130: e81-94.
- Guidelines for identification and management of substance use and substance use disorders in pregnancy. World Health Organization. https://www.who.int/substance_abuse/publications/pregnancy_guidelines/en/. Published March 21, 2014. Accessed December 19, 2019.
- The ASAM National Practice Guideline . American Society of Addiction Medicine . https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf. Accessed December 19, 2019.
- Jones HE, Martin PR, Heil SH, et al. Treatment of opioid-dependent pregnant women: Clinical and research issues. Journal of Substance Abuse Treatment. 2008;35(3):245-259. doi:10.1016/j.jsat.2007.10.007.
- Buprenorphine QuickStart in Pregnancy Algorithm. ED Bridge. Accessed 12/15/2019/; https://static1.squarespace.com/static/5c412ab755b02cec3b4ed998/t/5d6d85ef68abb200012e2ed3/1567458803475/Buprenorphine+Quick+Start+in+Pregnancy+-+9-1-2019.pdf. Accessed December 19, 2019.
- Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of internal medicine. 2006;144(2):127-134.
- Macintyre PE, Russell RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anesthesia and intensive care. 2013;41(2):222-230.