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Best practice №10

Initiate medication assisted treatment in the prenatal setting

treatment

by Holly Smith, Tipu V. Khan

Last updated May 29th, 2024

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Overview

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. Many obstetric providers have not received training in OUD management and 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 best practice OUD 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. 

  • Effective January 2023 the special waiver to prescribe buprenorphine is no longer required. Any provider licensed to prescribe Schedule III controlled substances may initiate and continue treatment with buprenorphine. Moreover, that same legislation removed limitations on the number of patients with OUD, who may be treated with buprenorphine by a single provider. 

  • 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/

Multiple studies have shown beneficial effects for treatment of OUD with either methadone or buprenorphine. Recent studies have shown infants exposed to buprenorphine compared to methadone have higher birthweights, longer lengths, and less risk of prematurity, as well as lower rates of NAS and a decreased risk of admission to a neonatal intensive care unit (NICU). Other considerations aside, these factors may favor the use of buprenorphine in pregnant individuals with OUD.

Multiple forms of injectable, extended-release buprenorphine are now available and are being used more widely. These products have not been systematically studied in pregnant individuals, however, multiple case studies of extended-release buprenorphine use in this population have been published. If the safety of these medications can be demonstrated, they may play an important role in OUD treatment in pregnancy.

  • 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. 

Resources

References

  • Waiver Elimination (MAT Act). Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act Updated June 7, 2023.
  • Goshgarian, G., Jawad, R., O'Brien, L., Muterspaugh, R., Zikos, D., Ezhuthachan, S., . . . Ragina, N. (2022). Prenatal Buprenorphine/Naloxone or Methadone Use on Neonatal Outcomes in Michigan. Cureus, 14(8), e27790. doi:10.7759/cureus.27790
  • Kinsella, M., Halliday, L. O. E., Shaw, M., Capel, Y., Nelson, S. M., & Kearns, R. J. (2022). Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. Subst Use Misuse, 1-17. doi:10.1080/10826084.2022.2083174
  • Minozzi, S., Amato, L., Jahanfar, S., Bellisario, C., Ferri, M., & Davoli, M. (2020). Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev, 11(11), CD006318. doi:10.1002/14651858.CD006318.pub4
  • Suarez, E. A., Huybrechts, K. F., Straub, L., Hernandez-Diaz, S., Jones, H. E., Connery, H. S., . . . Bateman, B. T. (2022). Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med, 387(22), 2033-2044. doi:10.1056/NEJMoa2203318
  • Towers, C. V., & Deisher, H. (2020). Subcutaneous Extended-Release Buprenorphine Use in Pregnancy. Case Rep Obstet Gynecol, 2020, 3127676. doi:10.1155/2020/3127676

Holly Smith

MPH, MSN, CNM

Holly Smith is a certified nurse-midwife with 20 years' experience in diverse practice settings. She is the project manager for the CMQCC/CPQCC Mother and Baby Substance Exposure Initiative. Previous to this role, she was a the lead editor for the CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, and a clinical lead for the CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans, a large-scale quality improvement project with over 90 California hospitals. Her primary role as clinical lead focused on assisting southern California hospitals with the implementation of evidence-based practices to reduce cesarean. She is a hospital coach and steering committee member for the American College of Nurse-Midwives' Reducing Primary Cesareans Project, and expert consultant on various national and state quality improvement and health policy initiatives. Additionally, she chairs the Health Policy Committee of the California affiliate of the American College of Nurse-Midwives and is a health policy consultant to the California Nurse-Midwives Foundation. 

Tipu V. Khan

MD, FAAFP, FASAM

Dr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liaison service and outpatient specialty clinic at Ventura County Medical Center. He is the medical director of Prototypes Southern California which has hundreds of residential treatment beds as well as medical-withdrawal (detox) beds throughout Southern California. Dr. Khan is the Medical Director of the Ventura County Backpack medicine group, and Primary Care Hepatitis C Eradication Project. His niche is managing SUD in pregnancy and is a national speaker on this topic.