Drug Use Trends and Treatment Implications for Pregnant and Birthing People: National and State Data
February, 2024
Sarah E. Wakeman, MD
Senior Medical Director for Substance Use Disorder, MGB
Medical Director, Mass General Hospital Program for Substance Use & Addiction Services
Associate Professor of Medicine, Harvard Medical School
1
Objectives
Office of Continuing Professional Development | Confidential—do not copy or distribute
2
Epidemiology
3
Rising rates of drug-related overdose
4
US leads the globe in overdose deaths
5
Nationally, overdose deaths are rising & disparities worsening��
In just one year, overdose death rates increased 44% for Black people and 39% for American Indian and Alaska Native (AI/AN) people
6
Overdose deaths in Arizona
7
44.5% increase in overdose death rate among young people
Rossen LM, Resendez A, Behdin A, Louis MS. Trends and disparities in deaths among young persons in the US during the COVID-19 pandemic. Ann Epidemiol. 2024 Feb 2;91:37-43. doi: 10.1016/j.annepidem.2024.01.009. Epub ahead of print. PMID: 38309641.
8
Overdose contributing to increase in non-obstetric maternal deaths across the US
Huang RS, Spence AR, Abenhaim HA. Non-Obstetric Maternal Mortality Trends by Race in the United States. Matern Child Health J. 2023 Dec 26. doi: 10.1007/s10995-023-03862-7. Epub ahead of print. PMID: 38147278.
Putra M, Roy M, Nienhouse V, Patek K, Sokol R. Comparing Antepartum and Postpartum Opioid-Related Maternal Deaths in the State of Michigan From 2007 to 2015. Cureus. 2023 Nov 12;15(11):e48690. doi: 10.7759/cureus.48690. PMID: 38090407; PMCID: PMC10715364.
9
Overdose Risk Increase in Postpartum Period
Schiff et al. Obstet Gynecol. 2018 Aug;132(2):466-474
10
Ongoing Death Toll Due to Unregulated Fentanyl
11
Co-involved substance in IMF-related overdose deaths
12
Non-fatal overdoses in Arizona
13
Rising alcohol related mortality: 26% higher since COVID
14
Alcohol use in pregnancy
15
Epidemiology of Alcohol Use Disorder
AUD 12-month & lifetime prevalence 13.9% & 29.1%
Prevalence highest:
Grant et al. JAMA Psychiatry. 2015;72(8):757–766
16
Disparities in Alcohol Use Among Women: Intersectional Lens
17
High Prevalence of Unhealthy Substance Use in General Medical Settings
Wakeman SE, Herman G, Wilens TE, Regan S. Subst Abus. 2020;41(3):331-339.
18
Epidemiology of SUD
NSDUH 2022 https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-nnr.pdf
19
20
21
Proportion of delivery hospitalizations with SUD rising
Logue TC, Wen T, Friedman AM. Demographic trends associated with substance use disorder and risk for adverse obstetric outcomes with cannabis and opioid use disorders. J Matern Fetal Neonatal Med. 2022 Dec;35(26):2128658.
22
OUD clinically documented in Pregnancy
23
SUD Treatment Gaps
24
MOUD Treatment gaps
25
MOUD in pregnancy
https://www.kff.org/medicaid/issue-brief/opioid-use-disorder-and-treatment-among-pregnant-and-postpartum-medicaid-enrollees/#:~:text=Prior%20studies%20indicate%20that%20only,any%20medication%20to%20treat%20OUD.
26
What is and what isn’t SUD?
27
What is and what isn’t SUD?
The defining feature is compulsively using a substance despite negative consequences
Defined as a problematic pattern of alcohol or drug use leading to clinically significant impairment or distress within a 1-year period
Based on meeting at least 2 of 11 criteria from DSM-5
Criteria assess for loss of control of use, compulsive use, use despite consequences, and craving
28
Spectrum of Alcohol Use
Saitz R. New Engl J Med 2005;352:596
29
Spectrum of all substance use
30
Screening and Brief Intervention for Unhealthy Substance Use
31
Addiction Medicine Basics: What Does a Non-Specialist Need to Know?
How to screen for and diagnose unhealthy substance use and SUD
How to address a positive screen
What effective treatment for SUD looks like
How to care for mild to moderate SUD
How to reduce negative consequences of ongoing use
32
Screening and Diagnosis
33
What now? Responses to a moderate risk screen result
Brief intervention: 5-15 minutes
Motivational interviewing (MI):
“Spirit” of Motivational Interviewing:
34
Brief Negotiated Interview
Provides structured format for using MI skills in the context of clinical care
Build Rapport
Explore pros and cons
Ask for permission to give feedback
Assess readiness to change
(BNI-ART Institute, BU School of Public Health)�
35
Negotiating an Action Plan
Identify health related goal– pregnancy highly motivating moment for many
Seek ideas from patient
Patient strengths and supports
Collaborate with patient to develop plan
Summarize and write plan with permission
36
Beware The Righting Reflex�
Desire to set things “right” or “fix” the patient
Most people dislike being told what to do
37
Steps For Successful BI
R - Resist the righting reflex
U - Understand the person, develop empathy (use open-ended questions)
L – Listen! (use reflections to convey understanding and empathy)
E – Build self-Efficacy (convey support and confidence in person’s ability to make changes)
Goal is to evoke the patient’s own reasons for change
38
Open-Ended Questions, Affirmations, Reflections
Open-Ended Questions
Elaborate
Affirm
Reflect
39
Ambivalence is Normal
I don’t want to change
I want to change
40
Recognizing Change Talk
I know I should stop using fentanyl but I don’t have time to go to treatment. When I took buprenorphine it made me sick, I must be allergic. I didn’t like AA meetings, everyone just complains. I can do this on my own.
41
Recognizing Change Talk
I know I should stop using fentanyl but I don’t have time to go to treatment. When I took buprenorphine it made me sick, I must be allergic. I didn’t like AA meetings, everyone just complains. I can do this on my own.
42
Strengthening Change Talk
I know I should stop using fentanyl but I don’t have time to go to treatment. When I took buprenorphine it made me sick, I must be allergic. I didn’t like AA meetings, everyone just complains. I can do this on my own.
You are determined to stop using fentanyl. What made you decide to try medication treatment and go to AA meetings in the past?
43
Strengthening Change Talk
Selective responding
Looking back at past successes
Looking ahead to future goals
44
Change Talk Bouquet
You’re worried that your opioid use could be harmful to your pregnancy, and your partner has mentioned that they are concerned. You have started thinking about making changes and you are confident you can do so. In the past buprenorphine has helped you stop using.
45
46
Diagnosis and Treatment
47
Making a diagnosis of SUD:�A problematic pattern of use leading to clinically significant impairment, meeting at least two of the following criteria in 12 month period (2-3 mild, 4-5 moderate, 6+ severe)
Substance taken in larger amounts or over a longer period of time than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time spent in activities to obtain, use, or recover from substance.
Craving, or a strong desire or urge to use substance.
Recurrent substance use resulting in a failure to fulfill major role obligations.
Continued substance use despite having persistent or recurrent social or interpersonal problems.
Important social, occupational, or recreational activities are given up or reduced.
Recurrent substance use in situations in which it is physically hazardous.
Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem that’s
likely to have been caused or exacerbated by the substance.
Tolerance*
Withdrawal*
* Tolerance and withdrawal insufficient to make diagnosis if due to prescribed medication
48
Initiating effective treatment
MEDICATION
PSYCHOSOCIAL INTERVENTIONS
RECOVERY SUPPORTS
HARM REDUCTION
49
Pharmacotherapy: FDA approved (and non-approved) medications for AUD, OUD, TUD, no FDA-approved medications for stimUD, some with limited benefit in trials�
Alcohol use disorder: naltrexone, acamprosate, disulfiram (all category C)
Opioid use disorder: methadone, buprenorphine (both considered first line in pregnancy)
Tobacco use disorder: varenicline, bupropion, NRT
50
Most treated patients with OUD achieve remission
CONTINUING MEDICAL EDUCATION DEPARTMENT OF MEDICINE
51
SBIRT to STIR: screen, treatment initiation, refer if needed
Identify patients through screening or acute presentation
Make a diagnosis
Initiate treatment without delay
Retain patients in treatment
52
What are the goals of treatment? Patient-centered, patient-driven care
53
Essential components of care are just like those for other medical conditions
Identify
Discuss diagnosis
Treat
Refer (when needed)
54
Unique issues in perinatal SUD management
55
Caring for Pregnant & Parenting People with SUD
Pregnant people are also human beings– deserve same standard of care
During pregnancy, methadone or buprenorphine standard of care
Lactation support!
56
Racial disproportionality has long existed in perinatal toxicology testing
In a national cohort study of 26,366 births from 2014 to 2020, clinicians were more likely to order drug tests for Black newborns (7.3%) compared with White newborns (1.9%) and other racial and ethnic groups
Schoneich S, Plegue M, Waidley V, et al. Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization. JAMA Netw Open. 2023;6(3):e232058.
57
In 2019, >5% of Black infants in the US were subjected to child welfare investigation from medical professional report
Edwards F, Roberts SCM, Kenny KS, Raz M, Lichtenstein M, Terplan M. Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data. Health Equity. 2023 Sep 29;7(1):653-662. doi: 10.1089/heq.2023.0136. PMID: 37786528; PMCID: PMC10541941.
58
Impact of Custody Loss
Substance use is a main reason for child welfare involvement
Economically disadvantaged Black communities experience intense social surveillance and more likely to be reported to child welfare authorities
Research on effect of parent-child separation on the child has demonstrated negative impact, less known about impact on the parent
Significant psychological toll, “emotions of guilt, bitterness, anger, feelings of failure as a parent, and helplessness”
Harp KL, Oser CB. Child Abuse Negl. 2018 Mar; 77: 1–12.
59
Impact of custody loss
Harp KL, Oser CB. Child Abuse Negl. 2018 Mar; 77: 1–12.
Longitudinal analysis of 339 Black women analyzed the effects of custody loss on subsequent drug use
Losing official custody increased drug use by a factor of 4.14
Unofficial custody loss increased drug use by a factor of 1.72
60
Call to action from the Biden-Harris Administration: All pregnant people with SUD should be prioritized to receive evidence-based treatment & support
Five key values from federal report:
1. Having SUD in pregnancy is not, by itself, child abuse or neglect.
2. Criminalizing SUD in pregnancy is ineffective and harmful as it prevents pregnant women with SUD from seeking and receiving the help they need.
3. Everyone has the right to effective treatment, and denying such care on the basis of sex or disability is a violation of civil rights.
4. Pregnant women using substances or having SUD, should be encouraged to access support and care systems, and barriers to access should be addressed, mitigated, and eliminated where possible.
5. Improving coordination of public health, criminal justice systems, treatment and early childhood systems can optimize outcomes and reduce disparities.
61
“ASAM strongly supports reforms to reverse the punitive approach taken to substance use and SUD during and after pregnancy and respond to the shared interests of the parent-newborn dyad by providing ethical, equitable, and accessible, evidence-based care.”
62
An approach to supporting equitable perinatal SUD care
Universal screening to identify pregnant people in need of support
Thoughtful and judicious use of toxicology testing, with written consent
Immediate access to person-centered treatment and low barrier initiation of pharmacotherapy
Rooming in and dyadic care during delivery hospitalization
Trauma-informed, equity-informed care models and policies
Disentangling substance exposure from protective concerns
63
Thank you!
@DrSarahWakeman
64
65