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Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders
Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders
Karol Kaltenbach, PhD
Emeritus Professor of Pediatrics
Sidney Kimmel Medical College
at
Thomas Jefferson University
FADAA May 30, 20171
Increasing Treatment Completion Ratesfor Pregnant Women with Substance Use Disorders
Increasing Treatment Completion Ratesfor Pregnant Women with Substance Use Disorders
Outline
• Addressing barriers to treatment
• Understanding factors that influence treatment retention for women
• Identifying components of treatment that facilitate engaging and retaining women in treatment
FADAA May 30, 2017 2
Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders
Increasing Treatment Completion Rates for Pregnant Women with Substance Use Disorders
• Much easier to say “pregnant women with substance use disorders”
• However, substance use disorder is not specific to pregnancy
• Ignores the experiences that contributed to their substance use disorder and leads to marginalization and stigma
• Will discuss gender issues related to treatment and retention in addition to specific issues related to pregnancy
FADAA May 30, 2017 3
Why Focus on Engagement and Retention?Why Focus on Engagement and Retention?
• Treatment retention is one of the most consistent predictors of positive treatment outcomes.
• It is critical that pregnant women be engaged in obtaining treatment and once in treatment be successfully retained in treatment.
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The well being of an infant is improved with the well being of the mother
The well being of an infant is improved with the well being of the mother
FADAA May 30, 2017 5
Barriers to TreatmentBarriers to Treatment
• Pregnancy and lack of substance use treatment services for pregnant women
• Fear of losing custody of child(ren)
• Reliance on public insurance to pay for treatment
• Resistance from partner and/or family members
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Barriers to TreatmentBarriers to Treatment
• Lack of child care
• History of trauma and victimization
• Homelessness
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Barriers to Treatment: Specific to Women with Opioid Use Disorders
Barriers to Treatment: Specific to Women with Opioid Use Disorders
• Federal statute requires pregnant women be given priority in Opioid Treatment Programs but some have long waiting lists
• Programs often limited to urban areas
• 1450 opioid treatment programs in the US; estimated that no more than 12 provide specialized services for pregnant women
• Buprenorphine expected to increase access to care but 43% of US counties have no buprenorphine provider*
• Less than 10% of buprenorphine providers treat at least 75 patients*
* Stein, et al. JAMA, 2016
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DCF Approved Methadone ProvidersDCF Approved Methadone Providers
FADAA May 30, 2017 9
Barriers to Treatment: Specific to Women with Opioid Use Disorders
Barriers to Treatment: Specific to Women with Opioid Use Disorders
• Fear of losing custody due to Neonatal Abstinence Syndrome
• Child Abuse Prevention and Treatment Act (CAPTA) 2010 reauthorization and the Comprehensive Addiction and Recovery Act of 2016 (CARA) requirement to report neonatal abstinence syndrome.
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Understanding Factors that Influence Treatment Retention for Women
Understanding Factors that Influence Treatment Retention for Women
First you need to understand the complex bio-psychosocial characteristics associated with women with substance use disorders.
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Keep a mother in mind in order for her to keep her child in mind….Bio-psychosocial
concerns??
Keep a mother in mind in order for her to keep her child in mind….Bio-psychosocial
concerns??
FADAA May 30, 2017 12
Personal and Family CharacteristicsPersonal and Family Characteristics
• Education <11 years• Unemployed 85% • Receiving Public Assistance 80%• Married <20%• Long term relationship <30%• Homeless in past 3 years 68% residential
21% outpatient• Majority live with family/friends or father of the baby
*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999
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Personal and Family CharacteristicsPersonal and Family Characteristics
• History of Substance Use in Family• History of Victimization• 90% experienced one or more of
Domestic violence Rape Childhood abuse and/or neglect
• History of legal problems Family legal problems Arrests Incarceration
*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999FADAA May 30, 2017 14
Personal and Family CharacteristicsPersonal and Family Characteristics
Psychiatric History
• High incidence of depression and anxiety disorders > 60%
• Prescribed medications 20%
• Inpatient psychiatric treatment 22%
• Outpatient psychiatric treatment 32%
*Comfort & Kaltenbach, Journal of Psychoactive Drugs, 1999
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Demographics of MOTHER Study Participants*
Demographics of MOTHER Study Participants*
Demographics Mean (SD)Age (years) 27.3 (5.9)Estimated Gestational Age (weeks) 17.1 (6.3)Education completed (years) 11.4 (2.0)
Race/Ethnicity: n (%)White 145 (83.3)Black 24 (13.8)Other 5 (2.9)
Marital status: Never married 125 (71.8)Married 22 (12.6)Widowed 3 (1.7)Divorced 12 (6.9)Separated 12 (6.9)
Unemployed 152 (87%)Psychiatric co-morbidity 110 (63%) Legal status:
No Legal Issues 140 (80.5)Parole 4 (2.3)Probation 24 (13.8)Impending trial 3 (1.7)Unknown/Other 3 (1.7)
Jones et al., New England Journal of Medicine, 2010.FADAA May 30, 2017 16
Impact of Co-occurring DisordersImpact of Co-occurring Disorders
Individuals with co-occurring disorders have a more challenging pathway to recovery
• Higher rates of relapse and re-hospitalization
• More ER visits, homelessness, violence, and suicide
• Increased morbidity and mortality
• Poorer treatment adherence
FADAA May 30, 2017 17
History of Violence and TraumaHistory of Violence and Trauma
• Pervasive history of violence and trauma among women with substance use disorders (SUD)Rates of physical and/or sexual abuse range from 55%-99%*.
• Women with PTSD have been found to be 5 times more likely to have a SUD than women without PTSD rates have been reported to range between 14% and 60%^.
• *Greenfield et al., Psychiatric Clinics in North America 2010
^Najavits et al., American Journal of Addiction1997
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History of Sexual AbuseHistory of Sexual Abuse
• Women may report fear of inability to protect themselves and/or their children or conversely are over protective of their children
• Residual problems develop from her sense of powerlessness.
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Impact of Physical and Sexual AbuseImpact of Physical and Sexual Abuse
• Women often have mood disorders, anxiety disorders, and low self esteem.
• Children who witness abuse may present with a spectrum of symptoms.
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Impact of Co-Occurring DisordersImpact of Co-Occurring Disorders
The history of co-occurring psychiatric disorders and trauma have a significant impact on treatment, both in terms of barriers to seeking treatment and treatment retention.
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Additional Issues for WomenAdditional Issues for Women
• Telescoping is accelerated progression from initiation of substance use to substance use disorder found for women
• Typically present with more severe clinical profile, i.e. more medical, behavioral, psychological, and social problems than men
FADAA May 30, 2017 22
Additional Issues for WomenAdditional Issues for Women
• Difficulty with transportation to treatment sites
• Inadequate health insurance
• Relationship with a partner with substance use disorder
• Less likely to have someone actively supporting them in treatment
• Often have sole responsibility for children
• Treatment entry often results from a social work referral
FADAA May 30, 2017 23
Additional Issues for WomenAdditional Issues for Women
• Last but not least – STIGMA
• Significant stigmatization of substance use disorder in general, but more so for women, especially women who are pregnant
FADAA May 30, 2017 24
Women with Substance Use Disorder who are Pregnant
Women with Substance Use Disorder who are Pregnant
• The well being of the infant is improved with the well being of the mother
• Engaging and Retaining women in Treatment ??
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Treatment for Pregnant and Parenting Women
Treatment for Pregnant and Parenting Women
Comprehensive, women-centered services offering a continuum of care is essential
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Treatment Models of CareTreatment Models of Care
• Scientific foundation of clinical practice: Opiate use in pregnant women (Finnegan, Hagan, Kaltenbach, 1991)
• Pregnancy and addiction: a comprehensive care model (Jansson, Svikis, et al, 1996)
• Comprehensive treatment for pregnant substance abusing women (Kaltenbach & Comfort, 1996)
• Gender specific substance treatment (Finkelstein, Kennedy, Thomas, & Kearns, 1997)
• Substance Abuse Treatment: Addressing the specific Needs of Women TIP 51 (SAMHSA, 2009)
• Treating women with substance use disorders during pregnancy: a comprehensive approach to caring for mother and child (Jones & Kaltenbach, 2013)
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Framework for TreatmentFramework for Treatment
Woman-centered
• Responsive to the specific needs of women
Trauma-informed
• Recognizes the role of trauma and violence
Strength based• Focus on strengths rather than deficits
Culturally competent• Acknowledges the role of culture, ethnicity,
race, racism, and sexual orientation
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Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Woman- centered
• Childcare assistance
• Pregnancy
• Parenting
• Domestic violence
• Sexual trauma and victimization
• Psychiatric co-morbidity
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Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Woman-centered
• Housing
• Income support
• Education
• Social Services
FADAA May 30, 2017 30
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Trauma –Informed Services
• Recognizes signs and symptoms of trauma in patients, families, and staff
• Responds by fully integrating knowledge about trauma into policies, procedures, and practices
• Provides trauma-informed training to all staff, including medical staff, administrative staff, and support staff
• Seeks to actively resist re-traumatization
FADAA May 30, 2017 31
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Understanding trauma
• Trauma results from an event, or series of events, that is experienced by the individual as physically or emotionally harmful and that has lasting effects on the individual’s functioning.
FADAA May 30, 2017 32
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Effects of trauma
• Inability to cope with normal stress of daily living
• Inability to trust
• Inability to manage cognitive processes such as memory and attention
• Inability to regulate behavior or to control the expression of emotion
• Hyper-vigilance or constant state of arousal
• Emotional numbing or avoidanceFADAA May 30, 2017 33
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Key Principles of Trauma-informed Approach
• Safety
• Trustworthiness
• Peer support
• Collaboration and mutuality
• Empowerment, voice, and choice
• Cultural, historical, and gender respect
FADAA May 30, 2017 34
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Safety
• All staff and patients feel physically and psychologically safe.
• The physical setting is safe.
• Interpersonal interactions promote a sense of safety.
FADAA May 30, 2017 35
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Trustworthiness and Transparency
• Operations and decisions are conducted
with transparency with the goal of maintaining trust.
FADAA May 30, 2017 36
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Peer Support
• Peer support and mutual self help important for establishing safety and hope, building trust, enhancing collaboration, and utilizing lived experiences to promote recovery and healing.
FADAA May 30, 2017 37
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Empowerment, Voice, and Choice
• Individual strengths and experiences are recognized and support is provided for shared decision making, choice, and goal setting.
FADAA May 30, 2017 38
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Cultural, Historical, and Gender Respect
• Incorporate policies, protocols, and processes that are responsive to the racial, ethnic, and cultural needs of served individuals served and recognize and address historical trauma.
FADAA May 30, 2017 39
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Strength Based
• Identifies and builds on the woman’s strengths.
• Uses available resources to develop and enhance resiliency and enhance recovery skills, deepen a sense of competency and improve the quality of her life.
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Culturally competent
• Understands the world views and experiences of women from different racial, ethnic, and cultural backgrounds.
• Understands the interaction among gender, culture and substance use.
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
FADAA May 30, 2017 41
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Issues Specific to Opioid Use Disorder (OUD) during Pregnancy
• Need to ensure women are receiving appropriate treatment, i.e. medications should be based on what is best for the mother/fetal dyad.
• Education may be required for woman, partner and/or family regarding risk/benefits of medication for treatment of OUD.
• Dose should be determined on an individual basis in order to achieve a therapeutic effect.
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Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Issues specific to OUD during pregnancy
• Medical withdrawal or taper from methadone or buprenorphine is not recommended
Very high rate of relapsePlaces fetus at additional risk
FADAA May 30, 2017 43
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Recommendations in support of treatment rather than withdrawal
• WHO 2014 Guidelines
• American College of Obstetricians and Gynecologists and American Society of Addiction Medicine Joint Opinion 2012
• Treatment Improvement Protocol, US Department of Health and Human Services 2005
FADAA May 30, 2017 44
Framework for Treatment: Engaging and Retaining Women in Treatment
Framework for Treatment: Engaging and Retaining Women in Treatment
Issues specific to OUD during pregnancy
• Relationships should be established with obstetrical provider to ensure continuity of care
• Liaisons should be established with child protective services to provide support for women who adhere to treatment
FADAA May 30, 2017 45
Components of Comprehensive Services for Pregnant and Parenting Women
Components of Comprehensive Services for Pregnant and Parenting Women
Multidisciplinary treatment approach needs to include• Medical, obstetrical, and psychiatric services• Prenatal education and women’s health• Individual and group psychotherapy• Family therapy• Trauma counseling• GED training• Comprehensive case management • DHS liaison• Transportation• Parent child services including developmental
child care, individual parenting counseling, parent education groups and parenting activities
• Mindfulness Based ParentingFADAA May 30, 2017 46
Components of Comprehensive Services for Pregnant and Parenting Women
Components of Comprehensive Services for Pregnant and Parenting Women
• Often difficult to provide within one program
• New models of collaboration have been developed
Vermont Charm Collaborative
The Maternal Opiate Medical Supports (MOMS) project
Project ECHO
FADAA May 30, 2017 47
Collaborative ModelsCollaborative Models
� Vermont Charm Collaborative
Substance Abuse Mental Health Administration (2016) A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No(SMA) 16-4978
Available online
FADAA May 30, 2017 48
Collaborative ModelsCollaborative Models
� Maternal Opiate Medical Support (MOMS)
www.momsohio.org
FADAA May 30, 2017 49
Collaborative ModelsCollaborative Models
� Project Echo
ATTC Center of Excellence on Behavioral Health for Pregnant and Parenting Women and their Families
www.attcppwtools.org
FADAA May 30, 2017 50
Keep a mother in mind in order for her to keep her child in mind…
Keep a mother in mind in order for her to keep her child in mind…
Meeting the needs of pregnant women with substance use disorders includes not only substance abuse treatment, including medication assisted treatment for opioid use disorder, but requires a comprehensive model of care that addresses the complex array of bio-psychosocial problems associated with maternal addiction.FADAA May 30, 2017 51
ReferencesReferences
• Ashley OS, Sverdlov L, Brady TM. (2004) Health services utilization by individuals with substance abuse and mental health disorders. Rockville, MD: Substance Abuse Mental Health Administration.
• Center for Substance Abuse Treatment (2005) Medication Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series, No. 43, Rockville, MD: Substance Abuse Mental Health Service Administration, USA.
• Center for Substance Treatment (2009) Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51, Rockville, MD: Substance Abuse Mental Health Service Administration, USA.
• Comfort ML, Kaltenbach K. (1999) Bio-psychosocial characteristics and treatment
outcomes of pregnant cocaine dependent women in residential and outpatient
substance abuse treatment. Journal of Psychoactive Drugs, 30(3:) 279-289.
FADAA May 30, 2017 52
ReferencesReferences
• Comfort ML, Loverro J, Kaltenbach K. (2000) A search for strategies to engage women in substance abuse treatment. Social work in Health Care, 31(14): 59-70.
• Comfort ML, Kaltenbach K. (2000) Predictors of treatment outcomes for substance
abusing women: a retrospective study. Substance Abuse, 21(1): 33-45.
Covington S. (2002) Helping women recover: creating gender-responsive
treatment. In Straussner SLA, Brown S, Eds. Handbook of Women’s Addiction
Treatment: Theory and Practice. San Francisco: Josey-Bass: 52-72.
• Covington S. (2008) Women and addiction: a trauma informed approach. Journal of Psychoactive Drugs, (Suppl 5), 377-385.
• Greenfield SF, Brooks AJ, Gordon CA, Kropp F, Lincoln M, Hien D, Miele GM. (2007) Substance abuse treatment entry, retention and outcome: a review of the literature. Drug and Alcohol Dependence, 86(1): 1-21.
• Greenfield SF, Back SE, Lawson K, Brady KT. (2010) Substance abuse in women. Psychiatric Clinics in North America, 33(2): 127-138.
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ReferencesReferences
Jones HE, Kaltenbach K, Heil S, et al.,(2010) Neonatal abstinence syndrome after methadone or buprenorphine exposure. New England Journal of Medicine, 363(24):2320-2331.
Najavits LM, Weiss RD, Shaw SR. (1997) The link between substance abuse and post-traumatic stress disorder in women: a research review. American Journal of Addiction. 6(4): 273-283.
Opioid abuse, dependence and addiction in pregnancy. (2012) Committee Opinion No. 524, American College of Obstetricians and Gynecologists, Obstetrics and Gynecology, 119:1090-1076.
Stein BD, Gordon AJ, Dick RM, et al. (2016) Physician capacity to treat opioid use disorder with buprenorphine assisted treatment. JAMA, 316(11): 1211-1212.
Substance Abuse Mental Health Service Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma Informed Approach. HHS Publication No(SMA) 14-4884, 2014
FADAA May 30, 2017 54
ReferencesReferences
•Sun AP. (2006) Program factors related to women’s substance abuse treatment retention and other outcomes: a review and critique. Journal of Substance Abuse Treatment, 30(1): 1-20.
•Tuchman E. (2010) Women and addiction: the importance of gender in substance abuse research. Journal of Addictive Diseases, 29(2): 127-138.
•World Health Organization (2014) Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnant Women.
WHO Document Production Services, Geneva Switzerland
FADAA May 30, 2017 55