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.
Overview
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
- 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
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