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First Do No Harm:

Initiation of Treatment and Harm Reduction for Perinatal Opioid Use Disorder

Cresta Jones * Allison Leopold * Anna Van Deelen

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Objectives

Review epidemiology of opioid use disorder
Discuss how to talk to patients about substance use
Discuss how to talk to patients about starting MOUD
Introduce protocols for inpatient initiation of MOUD including low-dose buprenorphine
Introduce the concept of harm-reduction for inpatient and perinatal substance use/disorders

No disclosures (CJ, AL, AV)

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Background information

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Do Less Harm: Language Matters

Language: Evidence-based and Person-centered

The words we use influence how others conceptualize addiction and public health

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The Power of Words to Hurt or Heal

The Rhetoric of Recovery Advocacy: An Essay On the Power of Language W.L. White; E.A Salsitz, MD., Addiction Medicine vocabulary; Substance Use Disorders: A Guide to the Use of Language Prepared by TASC, Inc. Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (DHHS), rev. 4.12.04

Stigmatizing Words	Preferred Words
Addict, Abuser, Junkie	Person in active addiction, person with a substance use disorder, person experiencing an alcohol/drug problem, patient
User	Person who misuses alcohol/drugs Person engaged in risky use of substances
Abuse	Misuse, harmful use, inappropriate use, hazardous use, problem use, risky use
Clean, Dirty	Negative, positive, substance-free
Habit or Drug Habit	Substance use disorder, alcohol and drug disorder, alcohol and drug disease, active addiction
Replacement or Substitution Therapy	Treatment, medication for opioid use disorder (MOUD), medication
Detox	Withdrawal management

Addict, Abuser, Junkie

Problem with the terms: These terms are demeaning because they label a

person by his/her illness. By making no distinction between the person and

the disease, they deny the dignity and humanity of the individual. In

addition, these labels imply a permanency to the condition, leaving no

room for a change in status.

Preferred terminology: Person in active addiction, person with a substance

misuse disorder, person experiencing an alcohol/drug problem, patient

(if referring to an individual receiving treatment services).

Abuse

Problem with the term: Although “abuse” is a clinical diagnosis in the DSMIV

and ICD10, it is stigmatizing because: (1) it negates the fact that addictive

disorders are a medical condition; (2) it blames the illness solely on the

individual with the illness, ignoring environmental and genetic factors, as

well as the ability of substances to alter brain chemistry; (3) it absolves those

selling and promoting addictive substances of any wrong doing; and (4) it

feeds into the stigma experienced not only by individuals with addictive

disorders, but also family members and the addiction treatment field.

Preferred terminology: Misuse, harmful use, inappropriate use,

hazardous use, problem use, risky use.

Clean, Dirty (when referring to drug test results)

Problem with the terms: Commonly used to describe drug test results,

these terms are stigmatizing because they associate illness symptoms

(i.e. positive drug tests) with filth.

Preferred terminology: Negative, positive, substance-free.

Habit or Drug Habit

Problem with the terms: Calling addictive disorders a habit denies

the medical nature of the condition and implies that resolution

of the problem is simply a matter of willpower in being able

to stop the habitual behavior.

Preferred terminology: Substance misuse disorder, alcohol and drug

disorder, alcohol and drug disease, active addiction.

Replacement or Substitution Therapy

Problem with the terms: This implies that treatment medications such

as buprenorphine are equal to street drugs like heroin. The term

suggests a lateral move from illegal addiction to legal addiction, and

this does not accurately characterize the true nature of the treatment.

The essence of addiction is uncontrollable compulsive behavior.

The first goal of addiction treatment is to stop this dangerous addictive

behavior. With successful buprenorphine therapy, as part of a

comprehensive treatment plan, the dangerous addictive behavior is

stopped not replaced

Preferred terminology: Treatment, medication-assisted treatment,

medication.

User

Problem with the term: The term is stigmatizing because it labels

a person by his/her behavior. It is also misleading because the term

user has come to refer to one who is engaged in risky misuse of

substances, but ‘use’ alone is not necessarily problematic.

Preferred terminology: Referring to use: person who misuses alcohol/

drugs. Referring to misuse: person engaged in risky use of substances.

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Challenging pregnancy assumptions

All pregnant people are women
All pregnant people are or will be mothers
All pregnancies are wanted
Substance use interventions are of primary benefit for the fetus

Lowik and Knight 2019

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Why are we here?

1286

Number of drug overdose deaths in Minnesota in 2021.

Highest annual number ever recorded

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DeLaquil 2022

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DeLaquil 2022

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Over this period, opioid overdose death rates have increased in all racial and ethnic groups, but disparities exist between some groups. The opioid crisis initially affected White Americans more because they are much more likely to be prescribed opioid painkillers. However, the demographics have been shifting for years and the opioid death rate among Black or African Americans and American Indians or Alaskan (AI/AN) surpassed other racial groups in recent years.

The main driver of opioid overdose deaths in Black communities is fentanyl. There are also disparities in access to effective evidence-based treatments and naloxone. The increase in opioid overdose deaths among AI/AN is due to opioids alone and in combination with alcohol, benzodiazepines, cocaine and methamphetamine. Many underlying social factors driving this pattern include socioeconomic inequity, historical trauma, and inequities in healthcare access and treatment programs.

Race and ethnicity were used as defined in the WONDER and NCHS databases. Racial and ethnic groups were defined first by ethnicity (Hispanic or Latino) and subsequently by race (non-Hispanic American Indian or Alaska Native, non-Hispanic Black or African American, non-Hispanic White, and non-Hispanic Asian or Pacific Islander).

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In 2021 the drug overdose mortality rates increased dramatically for American Indian and African American Minnesotans, �widening the disparity in drug overdose mortality rates by race

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SOURCE: Minnesota death certificates, Injury and Violence Prevention Section, Minnesota Department of Health, 2018-2021�*NOTE: 2021 data are preliminary and likely to change when finalized.

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CDC, 2022

US Maternal Mortality, 2017-2019

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Screening for Perinatal Substance Use

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Introducing Screening

Universal Screening/Assessment

“Is it okay if I ask you some questions about alcohol, smoking, and other drugs?”
Screening can be declined (right of refusal)
Establishing trust requires time
More acceptance of questions about substance use if asked in caring and nonjudgmental manner
Selective screening based on “risk factors” perpetuates discrimination and misses some patients with addiction

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Use Is Not Use Disorder

Addiction – Treatment

Misuse – Brief Intervention

Use – Education on Risk

Slide courtesy of M Terplan 2022

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DSM-5 Substance Use Disorders¹

1. Tolerance²

2. Withdrawal²

Loss of Control

3. Larger amounts and/or longer periods

4. Inability to cut down on or control use

5. Increased time spent obtaining, using or recovering

6. Craving/Compulsion

Use Despite Negative Consequences

7. Role failure, work, home, school

8. Social, interpersonal problems

9. Reducing social, work, recreational activity

10. Physical hazards

11. Physical or psychological harm

¹Mild (2-3), moderate (4-5), severe (≥6)

²Not valid if opioid taken as prescribed

APA. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)

Slide courtesy of M Terplan 2022

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Opioid Use Disorder in Pregnancy

Standard of care - medication for opioid use disorder (MOUD, previously termed MAT)
Methadone, buprenorphine or buprenorphine/naloxone
Benefits of treatment

Prevent withdrawal symptoms and cravings
Decrease relapse risk and associated health conditions
Improve adherence with prenatal care and addiction treatment
Reduce the risk of obstetric complications

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How to talk about OUD treatment

Trust-Building through clinical discussion

What is the most important thing to you about treatment or recovery?

What do you know about methadone and buprenorphine?

Do you have any fears or concerns from previous treatment experiences?

What do you need to feel safe?

What are you looking for in a provider?

How do you feel your care is going so far?

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Solution: Listening and Hearing

Give credibility to people who use drugs, people with addiction

Treating people as experts

Respecting their experience and preferences for treatment

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Lack of agency and autonomy surrounding medication decisions

Feeling forced to stay on medications that they wanted to try and taper
Little in the way of discussion or shared-decision making
Lack of medical support for discontinuing/tapering medication

Hesitancy to use medications because they wanted to minimize perceived harms to their newborn from withdrawal at birth

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Helping a patient with treatment options

MOUD - buprenorphine, methadone
Education and options for withdrawal management
Patient-centered discussion – boost autonomy, allow to choose what they think will work for them
Positive regard and nonjudgmental care
Meet the patient where they are

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MOUD initiation

Methadone - we can only do initial treatment, will need outpatient program outside M Health Fairview

Buprenorphine - standard and low dose induction

F/U for discharge - Recovery Clinic, Lodging Plus, CUHCC, NACC

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Methadone vs. Buprenorphine

METHADONE	BUPRENORPHINE
DAILY DOSING IN LICENSED CLINIC	OFFICE SETTING WITH LICENSED PROVIDER
INCREASED OVERDOSE RISK	DECREASED OVERDOSE RISK
LONGER NOWS DURATION	SHORTER NOWS DURATION
COMPATIBLE WITH BREASTFEEDING	COMPATIBLE WITH BREASTFEEDING
WRAP AROUND SERVICES IN PROGRAM	EXTERNAL SUPPORT NEEDED
LIMITED DIVERSION RISK	RISK OF DIVERSION
NO PRECIPITATED WITHDRAWAL	PRECIPITATED WITHDRAWAL

The ultimate decision belongs to the patient.

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Counseling for Treatment Initiation

What the process of induction will look like

Need for communication with team on symptoms and responses

Expectations during admission - leaving the unit, IV access

Side effects of medications

Options for symptomatic withdrawal treatment

Risk of overdose

Recommendation for consultation with social work team, addiction medicine

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Contraindications to MOUD

METHADONE -

Risk for prolonged QT or serious arrhythmia (consider EKG)

Baseline respiratory depression or bronchial disease

BUPRENORPHINE -

Severe liver impairment

Intolerance to either medication - try to elicit what happened

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Baseline laboratory evaluation

Toxicology testing - include fentanyl
Baseline pregnancy labs including hepatitis C
EKG if methadone an option

QTc > 500 repeat in 24hour, check CMP/Magnesium may not be able to start methadone

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Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253–9.

CLINICAL OPIATE WITHDRAWAL SCORE (COWS)

MILD = 5-12

MODERATE = 13-24

MODERATELY SEVERE = 25-36

SEVERE =

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Methadone protocol

Need to have a opioid treatment program to prescribe daily on discharge
Clinics are all closed on Sundays, and mostly closed in the afternoon
There is no priority for pregnant people
There is a new potential option for a 3-day bridge prescription (pending)

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Methadone pearls

Very slow start due to long half-life

Unlikely to reach a stable dose by discharge

3 day dose ~ 40 mg daily

Many patients stabilize on > 100 mg and split dosing

Limited data on dosing needed with chronic fentanyl

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Alcantar-Mejia L, Jones CW, 2019; Baystate Medical Ctr 2022

Prior maximum day 1 = 30 mg
Increase day 1 = 40 mg

METHADONE INITIATION

Starting dose:

COWS > 5 - 30 mg PO

COWS < 5 - 10 mg PO

Subsequent dosing:

10 mg every 4-6 hours (no less than 4 hours apart) MAX DOSE 40 mg daily

To calculate daily dose:

How much received over initial 24 hour period until 12AM - this is new morning dose

PRN comfort measures:

Ondansetron 4-8 mg PO, 4 mg IV - nausea

Clonidine 0.1-0.2 mg PO 4-6 hours - anxiety, restlessness (check BP)

Diphenhydromine 25-50 mg PO QHS - insomnia (also consider trazodone)

Dicyclomine 20 mg PO QID - abdominal pain

Loperamide 4 mg, then 2 mg after each loose stool (max 16 mg/day) - diarrhea

Accessible:

Naloxone 0.4-0.8 mg

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Methadone Resources

Valhalla Place Brooklyn Park

2807 Brookdale Drive N, Brooklyn Park, MN

Intake: Dani 651.348.5628; Brad: 651.200.6076

Valhalla Place Minneapolis

3329 University Ave SE, Minneapolis

Main clinic number is 612.454.2260.

The Intake person there is Sarah 612.454.2241

Valhalla Place Woodbury

6043 Hudson Road, Woodbury, MN

Main Clinic number is 651.925.8201

Intake: Jan: 651.200.6091

Specialized Treatment Services, Inc.

STS-Central (Minneapolis), Intake # (612) 236-1700 - currently taking next day and walk-ins

STS-Jackson (Minneapolis), Intake # (612) 236-1710

STS-Brooklyn Park, Intake # (763) 777-5037

Website: http://www.stsmn.com/

Alliance Methadone Maintenance Clinic

Minneapolis, Intake # 1 (877) 367-1715

Website: http://www.meridianprograms.com/programs/alliance-methadone-maintenance-clinic-minneapolis-mn/

Methadone Treatment Centers in Minnesota

Dakota Treatment Center (Burnsville), Intake # (952) 890-4480

St. Paul Metro Treatment Center (Roseville), Intake # (651) 773-0832

Lake Superior Treatment Center (Duluth), Intake # (218) 786-0220

Rochester Metro Treatment Center (Rochester), Intake # (507) 282-0142

St. Cloud Metro Treatment Center (St. Cloud), Intake # (320) 202-1909

Website: http://www.methadonetreatment.com/ClinicLocations.aspx?stateID=7

Courtesy of Kelly R, 2022

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Buprenorphine

Can be prescribed through clinic, including OB
Prescribing waiver - 8 hour waiver training, certification of access to other services
Eligible practitioners - physicians, NPs, PAs, CRNAs, CNMs and Clinical Nurse Specialists
Start at 100 total patients at a time
After one year can apply to treat 275 patients at a time

Training has been considered a limiting step for prescribers

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Any provider with a DEA license can apply for an exemption to treat 30 patients at a time with buprenorphine:

Without needing to take an 8 hour training course

Without verifying capacity to provide counseling and ancillary services

https://www.federalregister.gov/documents

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Buprenorphine - standard induction

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WITHDRAWAL MEDICATIONS

Symptom	Management
Nausea, vomiting	Diphenhydramine 25-50 mg PO/IV Metoclopramide 10 mg PO/IV Ondansetron 4-8 mg PO/IV
Myalgias	Acetaminophen 650 mg PO Q6
Diarrhea	Loperamide 2 mg PO (max 8/day) Dicyclomine 20 mg Q6
Insomnia	Trazodone 50-100 mg PO QHS
Anxiety	Seroquel 25-50 mg PO Q4 (max 200/day) Hydroxyzine 50 mg Q6
Autonomic symptoms	Clonidine 0.1-0.2 PO QID Gabapentin 300 mg Q6
Abdominal pain	Bentyl 20 mg PO QID

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The Problems with Fentanyl

Induces chest wall rigidity - may contribute to fatality
Little information from controlled trials about effectiveness of standard treatment
Naloxone doses may need to be higher
Methadone and buprenorphine may be less effective
Avoiding use to allow for significant withdrawal may be more challenging
Lipophilicity of fentanyl may cause risk for precipitated withdrawal after chronic use, even if withdrawal symptoms are present or it has been > 12 hours since use

Comer and Cahill 2019

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What is precipitated withdrawal?

opioids.machealth.ca

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De Aquino et al 2021

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Low-dose buprenorphine induction

Plan: to induce onto buprenorphine, without having to stop current opioids
Stabilize withdrawal symptoms on full opioid agonist

West Bank - hydromorphone (dilaudid) 4 mg Q3 hours, increase as needed
East Bank - oxycodone 10 mg Q4

Belbuca - low dose buprenorphine buccal film:

Day 1: 450 mcg buccal film QID = 1.8 mg total
Day 2: SL buprenorphine 1 mg QID (½ a tab) = 4 mg total
Day 3: 4 mg SL buprenorphine (or buprenorphine/naloxone) BID = 8 mg total
Day 4: 4 mg SL buprenorphine TID = 12 mg total + STOP OTHER OPIOIDS

Dosing can be slower as needed

EPIC Smart phrase .rkmicroinduction

Can be done as an outpatient with divided buprenorphine pills/film

courtesy Kelly R, 2022

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Low-dose buprenorphine induction

Will require a change of current order set/protocol which doesn’t allow additional opioids
Significant change in mental model of starting treatment for opioid use disorder
Full opioids are to stabilize withdrawal symptoms, then start medication for treatment
Coverage limited for inpatient induction outside of pregnancy
Problem: this may take more than 3 days

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Preparing for precipitated withdrawal

Shared decision making before starting medication
Symptom management and supportive environment assured
Choices if occurs:

Continue induction
Delay/pause induction
Stop induction

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Preparing for precipitated withdrawal

Worsening of symptoms within 30 minute of first dose

COWS getting worse→ Precipitated withdrawal
Treat with clonidine 0.1-0.2 mg PO every 4-6 hours
Use other supportive withdrawal management medications

Recheck COWS one hour after first dose

If better, wait 2-4 hours after first dose and then continue induction protocol
If worse, consider pushing through with 2 mg buprenorphine
Aggressive use of comfort medications

If patient wants to stop induction

Supportive withdrawal treatment
Offer methadone stabilization
Harm reduction on discharge

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Preparing for discharge

Coordination with long term clinic/prescriber

Bridge prescription - does not obligate you to prescribe long term but allows for discharge. Must have X-waiver

Coordination for OB care

Social work for support services - you do not need to report the patient for substance use, but you should engage in support services

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Preparing for discharge – other support

No more Rule 25 (7/1/2022)

DIRECT ACCESS - addiction treated like other chronic conditions
Must be enrolled in medical insurance (some counties may have other options)
If a patient wants residential treatment → Chemical Dependency consult on either bank

If patient can’t be seen can call 1-800-468-3120 MH and Addiction Line

For assessment for SUD diagnosis, Addiction medicine consult on either bank, can see virtually and prescribe MOUD as well

Peer recovery services - not consistent yet - working on this option

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NALOXONE/NARCAN

Don’t forget to order on every admission, and every discharge, even if they leave without treatment

Narcan (naloxone) nasal spray - 4 mg/0.1 mL

Spray in nostril, repeat every 2-3 minutes until response

Can also be given IM/IV/SC if needed

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Addiction as Chronic Disease

Adapted from Terplan 2022

Slide courtesy of M Terplan

Another example of addiction as disease –

Slide 26: Effectiveness of treatment

According to several studies, drug treatment reduces drug use by 40 to 60 percent and significantly decreases criminal activity during and after treatment. For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more. Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses. Treatment can improve the prospects for employment, with gains of up to 40 percent after treatment. (Note: Although these effectiveness rates hold in general, individual treatment outcomes depend on the extent and nature of the patient’s presenting problems, the appropriateness of the treatment components and related services used to address those problems, and the degree of active engagement of the patient in the treatment process.)

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Departmental Data

Unpublished data, Jones and Homich 2022

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Departmental Data

Unpublished data, Jones and Homich 2022

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Departmental Data

Unpublished data, Jones and Homich 2022

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Departmental Data

Unpublished data, Jones and Homich 2022

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Next Steps

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Resources

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harmreduction.org

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https://cpo.uoregon.edu/substance-use-and-recovery-pregnancy-and-early-parenting

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References

https://nihcm.org/publications/visualizing-the-impact-of-the-opioid-overdose-crisis?utm_source=NIHCM+Foundation&utm_campaign=0529414757-072122-opioid-charts&utm_medium=email&utm_term=0_6f88de9846-0529414757-167831112
https://cpo.uoregon.edu/substance-use-and-recovery-pregnancy-and-early-parenting
De Aquino JP, Parida S, Sofuoglu M. The Pharmacology of Buprenorphine Micro-induction for Opioid Use Disorder. Clinical Drug Investigation. 2021 May;41(5):425-436.
Handelsman L, Cochrance KJ, Aronson MJ et al. Two new rating scales for opiate withdrawal. 1987; American Journal of Alcohol Abuse, 13: 293-308.
Schiff DM, Work EC, Muftu S, Partridge S, MacMillan KDL, Gray JR, Hoeppner BB, Kelly JF, Greenfield SF, Jones HE, Wilens TE, Terplan M, Bernstein J. "You have to take this medication, but then you get punished for taking it:" lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period. J Subst Abuse Treat. 2022 Aug;139:108765.
Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs, 35(2), 253–9.
Comer SD and Cahill CM. Fentanyl: receptor pharmacology, abuse potential, and implications for treatment. Neuroscience and Biobehavioral Reviews. 2019; 106:49-57.

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Harm reduction and clinical care

Allison Leopold MS-2

Anna Van Deelen MS-2