Characteristics and outcomes of medication-assisted treatment care models for pregnant women with opioid use disorder: A scoping review.

<h3>Statement of Purpose</h3> Neonatal opioid withdrawal syndrome (NOWS) is an expected and treatable condition following prenatal exposure to opioids, including medication for opioid use disorder (MOUD), the recommended treatment for opioid use disorder (OUD) in pregnancy. <h3>Methods/Approach</h3> To inform intervention and reduce stigma associated with NOWS, we used 2016–2018 North Carolina birth certificate and Medicaid claims data to estimate use of MOUD and other prescription opioids in pregnancy among mothers of infants with NOWS (N=3,395) and to compare maternal and infant characteristics by patterns of use. <h3>Results</h3> Among mothers of infants with NOWS, 39% had claims for MOUD only, 14% had claims for prescription opioids only, 8% had both claims for MOUD and prescription opioids, and 39% did not have claims for either in pregnancy. Relative to other groups, the percent of younger women was higher among those with neither MOUD or prescription opioids (37% &lt;25 years), and the percent of Black non-Hispanic women was higher among those with prescription opioids only (21%) and neither MOUD or prescription opioids (30%). The percent of infants born full term and normal birthweight was highest among women with MOUD (86% and 86%) or both MOUD and prescription opioids (82% and 80%). The percent of women with no prenatal care (10%) and the rate of infant mortality (3.5 deaths per 100,000 infant days) was highest among infants of women with neither MOUD or prescription opioids. Overall, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be related to medically directed opioid use in pregnancy. <h3>Conclusion</h3> Results underscore the urgent need to prioritize efforts to improve equity in access to MOUD and promote provision of non-stigmatizing prenatal care among pregnant women engaging in opioid use or with OUD to ensure healthy maternal and infant outcomes.

Differences in Mortality Among Infants With Neonatal Opioid Withdrawal Syndrome

To evaluate the severity of neonatal opioid withdrawal syndrome (NOWS) in infants prenatally exposed to medications for opioid use disorder (MOUD) and serotonin reuptake inhibitors (SRI). A prospective cohort included 148 maternal-infant pairs categorized into MOUD (n = 127) and MOUD + SRI (n = 27) groups. NOWS severity was operationalized as the infant's need for pharmacologic treatment with opioids, duration of hospitalization, and duration of treatment. The association between prenatal SRI exposure and the need for pharmacologic treatment (logistic regression), time-to-discharge, and time-to-treatment discontinuation (Cox proportional hazards modeling) was examined after adjusting for the type of maternal MOUD, use of hydroxyzine, other opioids, benzodiazepines/sedatives, alcohol, tobacco, marijuana, gestational age, and breastfeeding. Infants in the MOUD + SRI group were more likely to receive pharmacologic treatment for NOWS (OR = 3.58; 95% CI: 1.31; 9.76) and had a longer hospitalization (median: 11 vs. 6 days; HR = 0.54; 95% CI: 0.33; 0.89) compared to the MOUD group. With respect to time-to-treatment discontinuation, no association was observed in infants who received treatment (HR = 0.59; 95% CI: 0.26, 1.32); however, significant differences were observed in the entire sample (HR = 0.55; 95% CI: 0.34, 0.89). Use of SRIs among pregnant women on MOUD might be associated with more severe NOWS. A potential drug-drug interaction between maternal SRIs and opioid medications that inhibit the reuptake of serotonin has been hypothesized but not carefully evaluated in clinical studies. Results of this prospective cohort indicate that the use of SRIs among pregnant women on MOUD is associated with more severe neonatal opioid withdrawal syndrome. This is the first prospective study which carefully examined effect modification between the type of maternal MOUD and SRI use on neonatal outcomes. This report lays the foundation for treatment optimization in pregnant women with co-occurring mental health and substance use disorders.

Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic.

Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010–2018

BackgroundAccess to providers and programs that provide medications for opioid usedisorder (MOUD) remains a systemic barrier for patients with opioid usedisorder (OUD), particularly if they live in rural areas. The Rural Accessto Medication Assisted Treatment (MAT) in Pennsylvania Project (ProjectRAMP) addressed this problem with a multisystem partnership that recruited,trained, and supported rural primary care providers to provide MOUD andimplement an integrated care model (ICM) for patients with OUD. Given thedemonstrated efficacy of Project RAMP, this article summarizes ourrecruitment strategies, including feasibility concerns for further expansioninto other regions.MethodsThe approach for recruiting implementation sites included two phases: partneroutreach and site identification. Once recruited, the Systems TransformationFramework guided planning and implementation activities. Recruitment andimplementation activities were assessed with implementation trackers andevaluated by providers via key informant interviews (KIIs).ResultsProject RAMP recruited 26 primary care practices from 13 counties, includingnine health systems and two private practice groups—exceeding the originaltarget of 24 sites. There was a median of 49 days from first contact toproject onboarding. A total of 108 primary care practices spanning 22 healthsystems declined participation. Findings from the KIIs highlighted the valueof engaging PCPs by connecting to a shared vision (i.e., improving thequality of patient care) as well as addressing perceived participationbarriers (e.g., offering concierge technical assistance to address lack oftraining or resources).ConclusionFindings highlight how successful recruitment activities should leverage thesupport of health system leadership. Findings also emphasize that aidingrecruitment and engagement efforts successfully addressed prescribers’perceived barriers to providing MOUD as well as facilitating bettercommunication among administrators, PCPs, behavioral health professionals,care managers, and patients.Plain Language Summary: Opioid use disorder (OUD) is one of theleading causes of preventable illness and death. The standard of care forOUD is the provision of medications for opioid use disorder (MOUD) and theapplication of an integrative integrated care model (ICM) where behavioralhealth is blended with specialized medical services. Unfortunately, accessto providers and healthcare facilities that provide MOUD or apply an ICMremains a systemic barrier for patients with OUD, particularly if they livein rural areas. Although there is no one-size-fits-all approach toimplementing MOUD in primary care, findings from Project The Rural Access toMedication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP)highlight strategies that may improve future MOUD and ICM implementationefforts in similar rural contexts. Specifically, future efforts to increaseMOUD capacity by recruiting new providers should be prepared to leveragehealth system leadership, address provider barriers via training and expertconsultation, and facilitate connections to local behavioral healthproviders. This approach may be helpful to others recruiting health systemsand primary care practices to implement new care models to use MOUD intreating patients with OUD.

Objectives. To estimate use of medication for opioid use disorder (MOUD) and prescription opioids in pregnancy among mothers of infants with neonatal opioid withdrawal syndrome (NOWS). Methods. We used linked 2016-2018 North Carolina birth certificate and newborn and maternal Medicaid claims data to identify infants with an NOWS diagnosis and maternal claims for MOUD and prescription opioids in pregnancy (n = 3395). Results. Among mothers of infants with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy. Non-Hispanic Black women were less likely to have a claim for MOUD than non-Hispanic White women. The percentage of infants born full term and normal birth weight was highest among women with MOUD or both MOUD and prescription opioid claims. Conclusions. In the 2016-2018 NC Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be a result of medically appropriate opioid use in pregnancy.

A large treatment gap exists for people who could benefit from medications for opioid use disorder (MOUD). People OUD accessing services in harm reduction and community-based organizations often have difficulty engaging in MOUD at opioid treatment programs and traditional health care settings. We conducted a study to test the impacts of a community-based medications first model of care in six Washington (WA) State communities that provided drop-in MOUD access. Participants included people newly prescribed MOUD. Settings included harm reduction and homeless services programs. A prospective cohort analysis tested the impacts of the intervention on MOUD and care utilization. Intervention impacts on mortality were tested via a synthetic comparison group analysis matching on demographics, MOUD history, and geography using WA State agency administrative data. 825 people were enrolled in the study of whom 813 were matched to state records for care utilization and outcomes. Cohort analyses indicated significant increases for days' supply of buprenorphine, months with any MOUD, and months with any buprenorphine for people previously on buprenorphine (all results p<0.05). Months with an emergency department overdose did not change. Months with an inpatient hospital stay increased (p<0.05). The annual death rate in the first year for the intervention group was 0.45% (3 out of 664) versus 2.2% (222 out of 9893) in the comparison group in the 12 months; a relative risk of 0.323 (95% CI 0.11-0.94). Findings indicated a significant increase in MOUD for the intervention group and a lower mortality rate relative to the comparison group. The COVID-19 epidemic and rapid increase in non-pharmaceutical-fentanyl may have lessened the intervention impact as measured in the cohort analysis. Study findings support expanding access to a third model of low barrier MOUD care alongside opioid treatment programs and traditional health care settings.

Neonatal Outcomes Among Patients Taking Medication for Opioid Use Disorder [A248

The number of women with opioid-related diagnoses in the United States has significantly increased in recent decades, resulting in concomitantly higher rates of infants born with neonatal opioid withdrawal syndrome (NOWS). Addressing prenatal opioid exposure is a priority for Alaska health systems. The objectives of this study were to: (1) identify maternal and neonatal factors associated with receipt of Medication for opioid use disorder (MOUD) and (2) determine the impact of prenatal MOUD on discharge to parents among infants with NOWS in 3 Alaska hospitals. A retrospective chart review using a standard abstraction form was conducted to collect data on neonatal and maternal characteristics, neonatal treatment, and infant discharge disposition for infants with NOWS born at the 3 hospitals between July 2016 and December 2019. A multivariable logistic regression model was used to determine factors associated with discharge to parents. There were 10,719 births at the 3 hospitals during the study period, including 193 infants (1.8%) with NOWS. Among the 193 mothers, 91 (47.2%) received MOUD during pregnancy. Among infants with NOWS, 136 (70.5%) were discharged to parents, 51 (26.4%) were discharged to a relative or foster care. Infants were significantly (odds ratio 3.9) more likely to be discharged to parents if the mother had received prenatal MOUD. MOUD among pregnant women with opioid use disorder furthers the goal of keeping families together and is a critical step towards reducing the impact of the ongoing opioid epidemic on Alaska families, communities, and the child welfare system.

As the primary facilities authorized to dispense methadone, opioid treatment programs (OTPs) are a critical access point for medications for opioid use disorder (MOUD). However, research is limited on the extent to which OTPs offer a broad range of MOUD and on the characteristics of programs that provide more comprehensive medication offerings. To assess the percentage of US OTPs offering all 3 forms of MOUD (methadone, buprenorphine, and naltrexone) and compare organizational and county characteristics of OTPs with different MOUD service offerings. This longitudinal cross-sectional study used data on a panel of OTPs listed in the annual National Directory of Drug and Alcohol Use Treatment Facilities from 2017 to 2023. Measures included the percentage of OTPs offering buprenorphine, extended-release naltrexone, or all 3 MOUD from 2017 to 2023 (assuming all OTPs offered methadone). Descriptive statistics on organizational and county characteristics of OTPs by MOUD offerings were collected. Three longitudinal logistic regression models were used to estimate the odds of different MOUD offerings within OTPs, adjusting for organizational and county-level characteristics. This analysis included 10 298 facility-year observations, ranging from 1211 in 2017 to 1421 in 2023. From 2017 to 2023, the percentage of OTPs offering MOUD beyond methadone increased (buprenorphine: 811 [67.0%] in 2017 to 1209 [85.1%] in 2023; naltrexone: 463 [38.2%] in 2017 to 749 [52.7%] in 2023; all 3 MOUD: 402 [33.2%] in 2017 to 639 [45.0%] in 2023). OTPs offering all 3 MOUD (3985 [38.7%]) had significantly higher odds of accepting Medicare (adjusted odds ratio [AOR], 2.14; 95% CI, 1.67-2.74); offering peer services (AOR, 1.63; 95% CI, 1.25-2.12), mental health services (AOR, 2.07; 95% CI, 1.53-2.80), and telemedicine services (AOR, 1.53; 95% CI, 1.22-1.92); and being private nonprofit (AOR, 7.45; 95% CI, 4.67-11.87) or government operated (AOR, 41.83; 95% CI, 19.71-88.75) compared with private for profit. In this cross-sectional study of OTPs, although the availability of MOUD beyond methadone increased over time, most OTPs still did not offer all 3 forms of MOUD as of 2023. Specific organizational characteristics, such as being government operated and accepting Medicare, were associated with more comprehensive MOUD offerings. Future research should evaluate why OTPs vary in their MOUD offerings.

Objectives/Goals: Summarize literature on parenting stress and treatment outcomes among postpartum women with opioid use disorder (OUD). Describe the causes of parenting stress identified by postpartum women who received medication for OUD (MOUD) and service providers. Discuss recommendations for parenting support services for postpartum women receiving MOUD in outpatient treatment settings. Methods/Study Population: We will conduct focus groups with postpartum women who received MOUD up to one-year after childbirth (2 groups; n = 10) and service providers (e.g., obstetrics, psychiatry, pediatrics, primary care; 2 groups; n = 10) to identify causes of and contributors to parenting stress to inform the adaptation of a parenting intervention for postpartum women receiving MOUD in an outpatient clinic setting. Participants will be recruited via flyers, email, and social media reach-outs, clinic staff and patient group meetings, and community-based outreach methods. Participants will be compensated for their participation. Focus groups will be audio-recorded and transcribed. Data will be analyzed via rapid analytic procedures using a summary template matrix. Results/Anticipated Results: We will use parenting-related stressors identified by mothers with substance use disorders in previous research to guide our interview questions. We expect to hear participants speak about their knowledge and experiences with stigma, guilt and shame, mental health symptoms, neonatal opioid withdrawal or neonatal opioid withdrawal syndrome (NOWS), fear of being reported to child protective services, and difficulties with mother–infant bonding and attachment. We will also ask participants about structural barriers that are known to increase parenting stress, such as housing instability, financial strain, and availability and cost of childcare. We will also report on new themes that emerge from the data that are shown to increase stress, challenge sobriety, and hinder continued engagement in the treatment. Discussion/Significance of Impact: Discontinuation of MOUD in the postpartum period is high and can lead to opioid recurrence and overdose. Outpatient treatment programs who offer psychiatric and behavioral health care, and parenting programs that target contributors of early postpartum parenting stress could improve health and MOUD treatment outcomes for mothers with OUD.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

Buprenorphine uptake during pregnancy following the 2017 guidelines update on prenatal opioid use disorder

The aim of this study was to identify distinct trajectories of prescription opioid exposure in pregnancy-encompassing both medication for opioid use disorder (MOUD) and opioid analgesics-and explore their associations with birth outcomes. Trajectories were identified using latent class analysis among Wisconsin Medicaid-insured live births 2011-2019. Logistic regression estimated associations between these trajectories and neonatal opioid withdrawal syndrome (NOWS), small for gestational age, preterm birth, birth weight, and gestational age. Of 138,123 births, 27,293 (19.8%) had prenatal opioid exposure. Five trajectory classes were identified: (1) stable MOUD treatment (5.8%), (2) inconsistent MOUD treatment (3.9%), (3) chronic analgesic use (4.2%), (4) intermittent analgesic use (7.8%), and (5) low-level use of MOUD and analgesics (78.3%). NOWS incidence per 1000 infants was 667 for class 1 (adjusted odds ratio [aOR]: 21.74, 95% confidence interval [CI]: 17.89, 26.41), 570 for class 2 (aOR: 15.35, 95% CI: 12.49, 18.87), 235 for class 3 (aOR: 19.42, 95% CI: 15.93, 23.68), 67 for class 4 (aOR: 6.23, 95% CI: 4.99, 7.76), and 12 for class 5 (aOR: 1.73, 95% CI: 1.47, 2.02). Classes 1-4 had elevated risk of small for gestational age, preterm birth, lower birth weight, and shorter gestational age, with no significant differences among these classes. Among individuals with opioid use disorder, stable MOUD treatment was associated with higher birth weights and longer gestational ages compared to inconsistent treatment, despite higher odds of NOWS. Early initiation and consistent MOUD treatment may improve birth weight and gestational age. For pregnant individuals with opioid use disorder using chronic analgesics, transition to MOUD may promote birth outcomes.