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A review of nonpharmacological adjunctive treatment for postpartum women with opioid use disorder
Addictive Behaviors 105 (2020) 106323
Contents lists available at ScienceDirect
Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
A review of nonpharmacological adjunctive treatment for postpartum women with opioid use disorder Alaina Martineza, Alicia Allenb, a b
T
⁎
College of Medicine, University of Arizona, 1501 North Campbell Ave, Tucson, AZ 85719, United States Department of Family & Community Medicine, College of Medicine, University of Arizona, 3950 South Country Club Drive, Suite 330, Tucson, AZ 85714, United States
H I GH L IG H T S
adjunctive treatments (NAT) are recommended during postpartum. • Nonpharmacological review identified 4 published papers on NAT during postpartum. • Our • Effective NAT for postpartum opioid use disorder treatment is severely lacking.
A R T I C LE I N FO
A B S T R A C T
Keywords: Opioid use disorder Women Postpartum Multidisciplinary treatment Nonpharmacological treatment
Introduction: Over the past decade, opioid use disorder (OUD) among pregnant women has increased by over 400%. Although medication assisted treatment (MAT) provides necessary care for women with OUD, effective adjunctive nonpharmacological treatments have not been systematically identified. This is especially concerning for the postpartum period, which includes several unique risk factors (e.g., sleep deprivation, mood disturbances) for MAT non-adherence and relapse. This review summarizes the existing knowledge regarding nonpharmacological treatments for OUD during the postpartum period, as well as provides recommendations for the future. Methods: PubMed and PsycINFO were searched in July 2018 using combinations of 28 keywords. Eligibility criteria included: (1) coverage of postpartum period, (2) use of nonpharmacological treatment for OUD, (3) conducted in clinical samples, and (4) written in English. Results: A total of 4 out of 38 identified articles met eligibility criteria. Two of the studies offered weekly on-site group counseling, with one also offering monthly social worker meetings. The third study offered four sessions with a patient navigator during the postpartum period. The last offered an employment intervention. All four reported favorable effects on OUD at end of follow-up (range: 30 days postpartum to 1 year postpartum). However, the details of the interventions, methodologies, and abstinence rates were sparse. Discussion: Few published studies examine nonpharmacological OUD treatments specific to the postpartum period. Identification of adjunctive nonpharmacological treatments designed to the unique needs of postpartum women is of critical public health importance, and further research is needed.
1. Introduction Nationally, since 2005, the prevalence of opioid use disorder (OUD) during pregnancy has increased by over 400% (Haight, Ko, Tong, Bohm, & Callaghan, 2018). While pregnancy brings a strong motivator to obtain and comply with OUD treatment, the postpartum period contains unique substantial triggers for relapse, such as sleep deprivation, increased stress, heightened risk of mood disorders, loss of health insurance, and threat of loss of child custody (Committee on Obstetric
⁎
Practice, 2017). Consequently, the risk of discontinuation of OUD treatment and, subsequently, relapse is extremely high during the postpartum period (Krans & Patrick, 2016). For example, 56% of women discontinued treatment within the first six months after childbirth (Wilder, Lewis, & Winhusen, 2015). Similarly, less than half (44%) of women using opioids or medication assisted therapy (MAT) attended their postpartum clinic visits (Parlier, Fagan, Ramage, & Galvin, 2014). Discontinuation of treatment increases the risk of relapse, which places both mom and infant at risk for a wide variety of negative health (e.g.,
Corresponding author. E-mail address: [email protected] (A. Allen).
https://doi.org/10.1016/j.addbeh.2020.106323 Received 21 May 2019; Received in revised form 16 December 2019; Accepted 16 January 2020 Available online 20 January 2020 0306-4603/ © 2020 Elsevier Ltd. All rights reserved.
Addictive Behaviors 105 (2020) 106323
A. Martinez and A. Allen
overdose, infections, depression) and social (e.g., foster care placements, poor academic performance) consequences (Reddy, Davis, Ren, & Greene, 2017). In July 2017, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted an expert workshop with American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP), Society for Maternal-Fetal Medicine (SMFM), Centers for Disease Control and Prevention (CDC), and March of Dimes which focused on perinatal opioid use and childhood outcomes. This expert workshop recommended medication assisted therapy (MAT) as the standard of care, as well as “Access to adequate postpartum psychosocial support services, including substance use disorder treatment and relapse prevention programs…” (College (The College), 2019; Committee on Obstetric Practice, 2017; Reddy et al., 2017). However, to-date, the identification of effective adjunctive nonpharmacological interventions is lacking. This is particularly concerning for the postpartum period given the substantial triggers that arise during this unique time. The goal of this review is to synthesize scientific literature on nonpharmacological care for OUD during the postpartum period. Specifically, we sought to examine the following aspects of the nonpharmacological treatments: (1) content of nonpharmacological interventions, (2) inclusion of multidisciplinary team members, and (3) opioid use outcomes. The identification of effective adjunctive nonpharmacological interventions will inform clinical care by allowing for the compliance with clinical recommendations, as well as increase treatment compliance rates and decrease relapse rates; ultimately improving the life of both the mother and her child. 2. Methods In July 2018, we searched PubMed and PsycINFO for the following search terms: “addiction,” “behavior(al) therapy,” “counseling,” “comprehensive health care,” “drug abstinence,” “drug abuse,” “drug usage,” “nonpharmacolog*,” “opiates,” “opioid,” “opioid related disorders,” “physician patient relations,” “pilot program,” “postnatal,” “post natal,” “postnatal care,” “postpartum,” “post partum,” “postpartum period,” “program,” “recovery,” “rehabilitation,” “relapse prevention,” “self help,” “social support,” “substance abuse treatment centers,” “therap*,” “treatment.” To capture all relevant articles, [MeSH] for Medical Subject Headings and [Explode, Major Concepts] were applied in PubMed and PsycINFO, respectively, for all key terms recognized. Searches were not restricted by date. The first author completed a two-stage review of eligibility criteria by reviewing abstract first, followed by full-text review. Inclusion criteria included: (1) postpartum/postnatal, (2) treatment of OUD, (3) inclusion of nonpharmacological treatment for OUD, (4) written in English, and (5) original research of human subjects. Articles were excluded if they focused on treatment of a specific comorbidity (i.e., post-traumatic stress disorder, hepatitis C, and/or tobacco use) or did not include any results specific to the nonpharmacological intervention. The authors’ intended to categorize the content of nonpharmacological treatment interventions, develop common themes of nonpharmacological treatment for OUD, and summarize the outcomes of the nonpharmacological treatment in postpartum women with OUD. Upon selection of eligible articles, the first author reviewed all articles in detail to pull relevant information. Rationale for selections were discussed with and confirmed by the second author.
Fig. 1. Article identification flow diagram.
women with OUD (n = 4), or both (n = 10). The subsequent review of full text resulted in nine more articles excluded due to missing nonpharmacological treatment-related results (n = 4) or primary focus on the following topics: parenting (n = 2), pain management (n = 2), and perinatal care without direct reference to the postpartum period (n = 1). The remaining 4 eligible articles are included in this review (Table 1), including (1) the Dartmouth-Hitchcock Medical Center Perinatal Addiction Treatment Program, a descriptive study of their integrative model of care intervention for substance use treatment (n = approximately 40) (Goodman, 2015), (2) the Toronto Centre for Substance Use in Pregnancy (T-CUP), a retrospective cohort study (n = 121), which was part of the family medicine program at St. Joseph’s Health Centre in Toronto, Canada (Ordean & Kahan, 2011), (3) the Therapeutic Workplace, a stratified randomized control study (n = 20 each group, n = 40 total), which was conducted at the Center for Addiction and Pregnancy, a comprehensive treatment program at Johns Hopkins Bayview Medical Center in Baltimore (Silverman, Svikis, Robles, Stitzer, & Bigelow, 2001), and (4) Optimizing Pregnancy Treatment Interventions for Moms (OPTI Mom), a one-group repeatedmeasures pilot study (n = 21), which was conducted at the outpatient University Pittsburg Medical Center Magee-Women’s Hospital Pregnancy Recovery Center (Cochran, Hruschak, & Abdullah, 2018).
3. Results 3.2. Content of nonpharmacological interventions 3.1. Article selection Two of the studies (Goodman, 2015; Ordean & Kahan, 2011) utilized their integrated intervention programs to stress the importance of providing services in a single visit, at a single location. T-CUP included family medicine services, withdrawal management, maintenance
Thirty-eight articles were identified from PubMed and PsycINFO (Fig. 1). After the initial review, 25 were excluded for lack of nonpharmacological treatment (n = 11), not addressing postpartum 2
3
• 1 year • Timepoint: • % abstinent not reported
buprenorphine, weekly addiction recovery group meetings, individual and/or family counseling, prenatal and postpartum care, neonatal education sessions. Monthly services included meetings with social worker.
services included perinatal addiction clinic • Weekly appointments, medication assisted treatment with
• • • • • • • • Not reported
“approximately 40” Inclusion Pregnant with OUD > 18 years old Receiving MAT treatment English speaking Exclusion Pregnancy loss or termination Psychiatric disorder or suicide risk
1
variable • Timepoint: • Decreased drug use; % abstinent not reported
•
maintenance pharmacotherapy, and relapseprevention counseling. Weekly group counseling provided.
visit provided services for family • Single medicine, withdrawal management,
years-old ± 5.5 (SD) • 29.4 White • 78.5% • 65.3% = high school education
• •
2
121 Inclusion Pregnant with substance use disorder Exclusion Pregnancy loss or termination
T-CUP
Goodman (2015). 2Ordean and Kahan (2011). 3Silverman et al. (2001). 4Cochran et al. (2018).
Primary Opioid-Use Outcomes
Intervention
Demographics
Sample Size Eligibility
Dartmouth-hitchcock
Table 1 Summary of studies evaluating nonpharmacological treatments for opioid use disorder during the postpartum period.
6 months • Timepoint: 52% ( ± 8%) abstinent • Treatment: • Control: 33% ( ± 6%) abstinent
family planning services.
• • • • • • 31.9 years-old ± 2.5 (SD); • Treatment: Control:31.6 years-old ± 4.8 (SD) Black • 83% • 65% = high school education for three hours per day, upon receipt of negative • Work urine screen (n = 20). (n = 20) received usual multidisciplinary care, • Control including individual and group therapy and obstetric and
3
40 Inclusion Pregnant with OUD > 18 years old Receiving MAT treatment Currently unemployed Positive urine screen for opioid or cocaine in < 6 weeks Exclusion Psychiatric disorder or suicide risk
Therapeutic workplace
30 days postnatal • Timepoint: • 95% abstinent
resources.
with patient navigator.
covered education, • Content support, and referral to other
years-old ± 5.77 (SD) • 29.7 White • 95% < = high school • 81% education • 62% employed during pregnancy • 10andsessions 4 postpartum sessions
• •
4
21 Inclusion Pregnant with OUD Exclusion None
OPTI mom
A. Martinez and A. Allen
Addictive Behaviors 105 (2020) 106323
Addictive Behaviors 105 (2020) 106323
A. Martinez and A. Allen
During the 24-week Therapeutic Workplace study, approximately 45% of participants attended the Workplace per day. Of the $3126 total potential voucher earnings, participant earnings averaged at $1013. Using an intent-to-treat analysis, the percentage of urine specimens negative for opioids and cocaine was almost twice as high in the Workplace group versus the control (50% (SE ± 9) versus 27 (SE ± 6), respectively). For opioids alone, percentage of urine specimens negative for the Workplace group versus the control were 52 (SE ± 8) and 33 (SE ± 6), respectively. Workplace attendance and drug abstinence were significantly correlated (r = 0.99, p < 0.01). Lastly, with regards to the OPTI Mom study, postpartum participants reported increased abstinence from illicit opioid use with > 90% days abstinent in the past 30 days at postnatal follow-ups (early discharge: 95%, SD = 0.02; no early discharge: 96%, SD = 0.01) in comparison to baseline with approximately 60% days abstinent in the past 30 days prior to intervention. Adjusting for treatment sessions and discharge status, there was a significant increase in percent of days abstinent (B = 0.15, 95% confidence interval [CI] 0.1–0.2) and decrease in drug use ([opioid or any other drug] odds ratio [OR] 7.62, 95% CI 2.8–21.0).
pharmacotherapy, and relapse-prevention counseling (additional details were not provided). Onsite group counseling was also offered weekly. Further, referrals were made for local women-only treatment programs, as well as other community services and resources (i.e. housing). The Dartmouth-Hitchcock Medical Center achieves integrated care through the fusion of obstetrics and gynecology and psychiatric/addiction medicine departments. The program consists of weekly perinatal addiction clinic appointments, medication assisted treatment with buprenorphine, weekly addiction recovery group meetings, individual and/or family counseling, prenatal and postpartum care, neonatal education sessions, and monthly social worker meetings. In addition to providing multidisciplinary care, the Therapeutic Workplace intervention participants were invited to work three hours per day, Monday through Friday, over 6 months (timing during pregnancy was unspecified). Upon arrival, participants provided a urine specimen. If the specimen was negative for opioids and cocaine, participants were permitted to work that day. Participants were rewarded with vouchers for training, data entry, abstinence and attendance. Usual care consisted of services for pregnant drug-abusing women, including individual and group therapy and obstetric and family planning services. In addition to usual care, the postpartum women in the intervention group could receive vouchers up to 8 weeks after delivery without going to the Workplace if drug-free urine toxicology was provided on required days. This encouraged abstinence maintenance while permitting mother-baby bonding time. After the 8-week period, mothers were welcome to return to the Workplace or continue bonding time for an additional 4 weeks (per mother’s choice). After the 12-week period, predelivery Workplace expectations resumed. In contrast, the OPTI Mom study explored the use of patient navigation (PN) to link motivational interviewing, case management, medical care, and psychosocial services. During the 10 prenatal sessions and 4 postnatal sessions, the PN provided education (i.e. substance use treatment, healthcare), support (i.e. identification of goals, attendance at appointments), resources (i.e. psychosocial services), and plans for follow-up. The PNs assisted participants to identify their own goals (i.e. writing exercises) and establish care with providers and professionals, including preparation for appointments and overcoming barriers to care. Monetary compensation was given for travel and for completing the three assessments (baseline, prenatal, and postnatal).
4. Discussion There is a clear and consistent recommendation from numerous professional organizations to pair nonpharmacological interventions with pharmacological treatment for OUD during the postpartum period (Committee on Obstetric Practice, 2017; Lindsay & Burnett, 2013; Ramage, Ostrach, Fagan, & Coulson, 2018; Velez & Jansson, 2008). However, as this review demonstrates, the science in this area is severely lacking. We were only able to identify four studies that tested the effect of a nonpharmacological adjunctive treatment on opioid use outcomes. Further, none of the studies we identified tested an intervention designed to the unique and substantial needs of the postpartum period. This further emphasizes the gap in research on nonpharmacological interventions for women with OUD in the postpartum period. Despite the limited number of published studies available, those we did identify demonstrated significant decreases in drug use, suggesting promise of these interventions. The OPTI Mom study utilized patient navigation (PN) intervention specifically for pregnant and postpartum women with OUD; this approach may be an especially promising area of research as PN had favorable effects in a wide range of patient groups, including cancer, HIV, and mental health disorders (Freeman & Rodriguez, 2011; McDonald, Sundaram, & Bravata, 2007; Parker, 2011; Robinson-White, 2010). Similarly, the Sustained Patient-centered Alcohol-related Care (SPARC) protocol utilizes expert health coaches and clinician evaluations to address alcohol-use screening and intervention (Glass, Bobb, & Lee, 2018). However, the OPTI-Mom study relied on self-report, which has the potential for social desirability bias and, therefore, additional research is needed to replicate these findings. Specific treatment plans for postpartum women appear sparse. For future research, interventions similar to those reviewed could be implemented specifically for the postpartum period. The DartmouthHitchcock Medical Center, T-CUP, Workplace, and OPTI Mom already had postpartum specific protocols, and these interventions should be evaluated in fully-powered randomized controlled trials. Future research may also consider compiling a comprehensive list of potential specialists and clinicians to be involved in the care of postpartum women with OUD. With a comprehensive picture of the variations in interdisciplinary teams, organizations can visually compare their teams to others (similar to Table 2) and make adjustments according to their patient populations’ needs. Unfortunately, there was also a lack of consistency in terminology used in the description of professionals involved, with only counselors and nurses explicitly described in all four studies. This limited our ability to compare interdisciplinary teams by study.
3.3. Inclusion of multidisciplinary team members Professional members listed as part of each multidisciplinary intervention team can be seen in Table 2. The number of professionals on each team was not specified. While some roles may overlap, terms used by the articles were maintained. All four studies included nurses, counselors, and case managers/social workers as a part of their multidisciplinary teams. 3.4. Opioid use outcomes All studies reported improvements in opioid use outcomes. The Dartmouth-Hitchcock Medical Center subjectively reported improved care coordination, interdisciplinary communication, patient and provider satisfaction, and more prenatal visit recommendations. Provider attitudes about women in treatment also improved and, subsequently, perceived quality of care improved (additional details were not provided). For the other three studies, statistically significant results in support of the interventions were found, including a decrease in drug use. Of the 121T-CUP participants, 39 participated in formal treatment programs and 23 joined self-help groups. Drug use, including heroin and prescription opioids, decreased significantly (p < 0.05) from baseline use to follow-up (specific time-point varied) for those who attended T-CUP earlier in pregnancy. However, group-specific estimates were not provided. 4
Addictive Behaviors 105 (2020) 106323
A. Martinez and A. Allen
Table 2 Interdisciplinary care team members by study. Professional Addiction specialist Behavioral health provider Case manager Counselor - Drug and Alcohol Counselor - Family Counselor - Group Therapy Counselor - Individual Therapy Counselor Family medicine physician Family planning advisor Medication assisted therapy provider - Buprenorphine Provider - Methadone provider Maternal-Fetal Medicine Physician Midwife Nurse Obstetrician Patient Navigator Other Support Staff Pediatric Hospitalist Pediatrician Prenatal Care Provider Postnatal Care Provider Psychiatrist - Addiction psychiatrist Psychologist Social worker
Dartmouth-HITCHCOCK
1
T-CUP
2
Therapeutic workplace
3
OPTI mom
4
X X X X
X X X
X
X X X X
X X
X X
X X
X X
X X X X
X X
X X X
X X
X X X
X X X
X X X
X X
X
X X
Goodman (2015). 2Ordean and Kahan (2011). 3Silverman et al. (2001). 4Cochran et al. (2018).
The 2015 Federal Guidelines for Opioid Treatment Programs expound on recovery-oriented systems of care, which are an ongoing process where patients access resources to maintain recovery and rebuild wellbeing. Recovery-oriented systems of care contrast with previous traditions that focused on abstinence alone. Within this framework, opioid treatment programs have the potential to expand care from simply dispensing medications to patient-centered, patient-driven recovery. Recovery thus encompasses patient wellbeing rather than merely abstinence. Although MAT and opioid treatment programs are greatly underused, these guidelines detail nonpharmacological care that would be worthwhile to include in future programs and research. Since MAT is intended to be consistent, daily treatment, it is an ideal opportunity for counseling and nonpharmacological care integration. In conclusion, this review has identified a significant and critical gap in scientific literature regarding nonpharmacological treatment options for postpartum women with OUD. Given only four studies were identified for this review, we were unable to make any generalizable conclusions regarding the factors that lend to successful nonpharmacological interventions for OUD during the postpartum period. Without focusing on nonpharmacological aspects, critical components of treatment options are being overlooked. Postpartum women with OUD are a complex population due to their specific maternal, neonatal, and recovery needs. When disciplines deliver care separately, communication, care coordination, and follow-up are poor, and patients suffer. Additional research is needed to further identify and develop effective nonpharmacological treatment in adjunct with pharmacological treatment for women with OUD in the postpartum period.
Treatment Remains the Recommended Therapy for Pregnant Women - ACOG. https:// www.acog.org/About-ACOG/News-Room/News-Releases/2017/Medication-assistedTreatment-Remains-the-Recommended-Therapy–for-Pregnant-Women?IsMobileSet=false. Accessed February 1, 2019. Cochran, G., Hruschak, V., Abdullah, W., et al. (2018). Optimizing pregnancy treatment interventions for moms (OPTI-Mom): A pilot study. Journal of Addiction Medicine, 12(1), 72–79. Committee on Obstetric Practice (2017). Committee opinion no. 711: Opioid use and opioid use disorder in pregnancy. Obstetrics & Gynecology, 130(2), 81–94. Freeman, & Rodriguez (2011). History and principles of patient navigation. Cancer, 117, 3539–3542. Glass, J., Bobb, J., Lee, A., et al. (2018). Study protocol: a cluster-randomized trial implementing sustained patient-centered alcohol-related care (SPARC trial). Implementation Science, 13(1), 108. Goodman, D. (2015). Improving access to maternity care for women with opioid use disorders: Colocation of midwifery services at an addiction treatment program. Journal of Midwifery & Women's Health, 60, 706–712. Haight, S., Ko, J., Tong, V., Bohm, M., Callaghan, W., Opioid use disorder documented at delivery hospitalization – United States, 1999–2014 [CDC web site]. August 10, 2018. Available at: http://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm. Accessed 09. 09.18. Krans, E., & Patrick, S. (2016). Opioid use disorder in pregnancy: Health policy and practice in the midst of an epidemic. Obstetrics & Gynecology, 128(1), 4–10. Lindsay, M., & Burnett, E. (2013). The use of narcotics and street drugs during pregnancy. Clinical Obstetrics and Gynecology, 56(1), 133–141. McDonald, K. M., Sundaram, V., Bravata, D. M., et al. (2007). Closing the quality gap: A critical analysis of quality improvement strategies. AHRQ Technical Reviews, 04(07), 0051–0057. Ordean, A., & Kahan, M. (2011). Comprehensive treatment program for pregnant substance users in a family medicine clinic. Canadian Family Physician, 57(11), 430–435. Parker, Lemak (2011). Navigating patient navigation: Crossing health services research and clinical boundaries. Advances in Health Care Management, 2011(11), 149–183. Parlier, A., Fagan, B., Ramage, M., & Galvin, S. (2014). Prenatal care, pregnancy outcomes, and postpartum birth control plans among pregnant women with opiate addictions. Southern Medical Journal, 107(11), 676–683. Ramage, M., Ostrach, B., Fagan, B., & Coulson, C. (2018). Stabilizing the mother-infant dyad for better outcomes from OB to FM: Caring for patients with perinatal opioid use disorder through the 4th trimester. North Carolina Medical Journal, 79(3), 164–165. Reddy, U. M., Davis, J. M., Ren, Z., & Greene, M. F. (2017). Opioid use in pregnancy, neonatal abstinence syndrome, and childhood outcomes. Obstetrics and Gynecology, 130(1), 10–28. Robinson-White, et al. (2010). Patient navigations in breast cancer: A systematic review. Cancer Nursing, 2010(33), 127–140. Silverman, K., Svikis, D., Robles, E., Stitzer, M., & Bigelow, G. (2001). A reinforcement-based therapeutic workplace for the treatment of drug abuse: Six-month abstinence outcomes. Experimental and Clinical Psychopharmacology, 9(1), 14–23. Velez, M., & Jansson, L. (2008). The opioid dependent mother and newborn dyad: Nonpharmacologic care. Journal of Addiction Medicine, 2(3), 113–120. Wilder, C., Lewis, D., & Winhusen, T. (2015). Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug and Alcohol Dependence, 149, 225–231.
Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References American College of Obstetricians and Gynecologists (The College). Medication-Assisted
5
Contents lists available at ScienceDirect
Addictive Behaviors journal homepage: www.elsevier.com/locate/addictbeh
A review of nonpharmacological adjunctive treatment for postpartum women with opioid use disorder Alaina Martineza, Alicia Allenb, a b
T
⁎
College of Medicine, University of Arizona, 1501 North Campbell Ave, Tucson, AZ 85719, United States Department of Family & Community Medicine, College of Medicine, University of Arizona, 3950 South Country Club Drive, Suite 330, Tucson, AZ 85714, United States
H I GH L IG H T S
adjunctive treatments (NAT) are recommended during postpartum. • Nonpharmacological review identified 4 published papers on NAT during postpartum. • Our • Effective NAT for postpartum opioid use disorder treatment is severely lacking.
A R T I C LE I N FO
A B S T R A C T
Keywords: Opioid use disorder Women Postpartum Multidisciplinary treatment Nonpharmacological treatment
Introduction: Over the past decade, opioid use disorder (OUD) among pregnant women has increased by over 400%. Although medication assisted treatment (MAT) provides necessary care for women with OUD, effective adjunctive nonpharmacological treatments have not been systematically identified. This is especially concerning for the postpartum period, which includes several unique risk factors (e.g., sleep deprivation, mood disturbances) for MAT non-adherence and relapse. This review summarizes the existing knowledge regarding nonpharmacological treatments for OUD during the postpartum period, as well as provides recommendations for the future. Methods: PubMed and PsycINFO were searched in July 2018 using combinations of 28 keywords. Eligibility criteria included: (1) coverage of postpartum period, (2) use of nonpharmacological treatment for OUD, (3) conducted in clinical samples, and (4) written in English. Results: A total of 4 out of 38 identified articles met eligibility criteria. Two of the studies offered weekly on-site group counseling, with one also offering monthly social worker meetings. The third study offered four sessions with a patient navigator during the postpartum period. The last offered an employment intervention. All four reported favorable effects on OUD at end of follow-up (range: 30 days postpartum to 1 year postpartum). However, the details of the interventions, methodologies, and abstinence rates were sparse. Discussion: Few published studies examine nonpharmacological OUD treatments specific to the postpartum period. Identification of adjunctive nonpharmacological treatments designed to the unique needs of postpartum women is of critical public health importance, and further research is needed.
1. Introduction Nationally, since 2005, the prevalence of opioid use disorder (OUD) during pregnancy has increased by over 400% (Haight, Ko, Tong, Bohm, & Callaghan, 2018). While pregnancy brings a strong motivator to obtain and comply with OUD treatment, the postpartum period contains unique substantial triggers for relapse, such as sleep deprivation, increased stress, heightened risk of mood disorders, loss of health insurance, and threat of loss of child custody (Committee on Obstetric
⁎
Practice, 2017). Consequently, the risk of discontinuation of OUD treatment and, subsequently, relapse is extremely high during the postpartum period (Krans & Patrick, 2016). For example, 56% of women discontinued treatment within the first six months after childbirth (Wilder, Lewis, & Winhusen, 2015). Similarly, less than half (44%) of women using opioids or medication assisted therapy (MAT) attended their postpartum clinic visits (Parlier, Fagan, Ramage, & Galvin, 2014). Discontinuation of treatment increases the risk of relapse, which places both mom and infant at risk for a wide variety of negative health (e.g.,
Corresponding author. E-mail address: [email protected] (A. Allen).
https://doi.org/10.1016/j.addbeh.2020.106323 Received 21 May 2019; Received in revised form 16 December 2019; Accepted 16 January 2020 Available online 20 January 2020 0306-4603/ © 2020 Elsevier Ltd. All rights reserved.
Addictive Behaviors 105 (2020) 106323
A. Martinez and A. Allen
overdose, infections, depression) and social (e.g., foster care placements, poor academic performance) consequences (Reddy, Davis, Ren, & Greene, 2017). In July 2017, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted an expert workshop with American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP), Society for Maternal-Fetal Medicine (SMFM), Centers for Disease Control and Prevention (CDC), and March of Dimes which focused on perinatal opioid use and childhood outcomes. This expert workshop recommended medication assisted therapy (MAT) as the standard of care, as well as “Access to adequate postpartum psychosocial support services, including substance use disorder treatment and relapse prevention programs…” (College (The College), 2019; Committee on Obstetric Practice, 2017; Reddy et al., 2017). However, to-date, the identification of effective adjunctive nonpharmacological interventions is lacking. This is particularly concerning for the postpartum period given the substantial triggers that arise during this unique time. The goal of this review is to synthesize scientific literature on nonpharmacological care for OUD during the postpartum period. Specifically, we sought to examine the following aspects of the nonpharmacological treatments: (1) content of nonpharmacological interventions, (2) inclusion of multidisciplinary team members, and (3) opioid use outcomes. The identification of effective adjunctive nonpharmacological interventions will inform clinical care by allowing for the compliance with clinical recommendations, as well as increase treatment compliance rates and decrease relapse rates; ultimately improving the life of both the mother and her child. 2. Methods In July 2018, we searched PubMed and PsycINFO for the following search terms: “addiction,” “behavior(al) therapy,” “counseling,” “comprehensive health care,” “drug abstinence,” “drug abuse,” “drug usage,” “nonpharmacolog*,” “opiates,” “opioid,” “opioid related disorders,” “physician patient relations,” “pilot program,” “postnatal,” “post natal,” “postnatal care,” “postpartum,” “post partum,” “postpartum period,” “program,” “recovery,” “rehabilitation,” “relapse prevention,” “self help,” “social support,” “substance abuse treatment centers,” “therap*,” “treatment.” To capture all relevant articles, [MeSH] for Medical Subject Headings and [Explode, Major Concepts] were applied in PubMed and PsycINFO, respectively, for all key terms recognized. Searches were not restricted by date. The first author completed a two-stage review of eligibility criteria by reviewing abstract first, followed by full-text review. Inclusion criteria included: (1) postpartum/postnatal, (2) treatment of OUD, (3) inclusion of nonpharmacological treatment for OUD, (4) written in English, and (5) original research of human subjects. Articles were excluded if they focused on treatment of a specific comorbidity (i.e., post-traumatic stress disorder, hepatitis C, and/or tobacco use) or did not include any results specific to the nonpharmacological intervention. The authors’ intended to categorize the content of nonpharmacological treatment interventions, develop common themes of nonpharmacological treatment for OUD, and summarize the outcomes of the nonpharmacological treatment in postpartum women with OUD. Upon selection of eligible articles, the first author reviewed all articles in detail to pull relevant information. Rationale for selections were discussed with and confirmed by the second author.
Fig. 1. Article identification flow diagram.
women with OUD (n = 4), or both (n = 10). The subsequent review of full text resulted in nine more articles excluded due to missing nonpharmacological treatment-related results (n = 4) or primary focus on the following topics: parenting (n = 2), pain management (n = 2), and perinatal care without direct reference to the postpartum period (n = 1). The remaining 4 eligible articles are included in this review (Table 1), including (1) the Dartmouth-Hitchcock Medical Center Perinatal Addiction Treatment Program, a descriptive study of their integrative model of care intervention for substance use treatment (n = approximately 40) (Goodman, 2015), (2) the Toronto Centre for Substance Use in Pregnancy (T-CUP), a retrospective cohort study (n = 121), which was part of the family medicine program at St. Joseph’s Health Centre in Toronto, Canada (Ordean & Kahan, 2011), (3) the Therapeutic Workplace, a stratified randomized control study (n = 20 each group, n = 40 total), which was conducted at the Center for Addiction and Pregnancy, a comprehensive treatment program at Johns Hopkins Bayview Medical Center in Baltimore (Silverman, Svikis, Robles, Stitzer, & Bigelow, 2001), and (4) Optimizing Pregnancy Treatment Interventions for Moms (OPTI Mom), a one-group repeatedmeasures pilot study (n = 21), which was conducted at the outpatient University Pittsburg Medical Center Magee-Women’s Hospital Pregnancy Recovery Center (Cochran, Hruschak, & Abdullah, 2018).
3. Results 3.2. Content of nonpharmacological interventions 3.1. Article selection Two of the studies (Goodman, 2015; Ordean & Kahan, 2011) utilized their integrated intervention programs to stress the importance of providing services in a single visit, at a single location. T-CUP included family medicine services, withdrawal management, maintenance
Thirty-eight articles were identified from PubMed and PsycINFO (Fig. 1). After the initial review, 25 were excluded for lack of nonpharmacological treatment (n = 11), not addressing postpartum 2
3
• 1 year • Timepoint: • % abstinent not reported
buprenorphine, weekly addiction recovery group meetings, individual and/or family counseling, prenatal and postpartum care, neonatal education sessions. Monthly services included meetings with social worker.
services included perinatal addiction clinic • Weekly appointments, medication assisted treatment with
• • • • • • • • Not reported
“approximately 40” Inclusion Pregnant with OUD > 18 years old Receiving MAT treatment English speaking Exclusion Pregnancy loss or termination Psychiatric disorder or suicide risk
1
variable • Timepoint: • Decreased drug use; % abstinent not reported
•
maintenance pharmacotherapy, and relapseprevention counseling. Weekly group counseling provided.
visit provided services for family • Single medicine, withdrawal management,
years-old ± 5.5 (SD) • 29.4 White • 78.5% • 65.3% = high school education
• •
2
121 Inclusion Pregnant with substance use disorder Exclusion Pregnancy loss or termination
T-CUP
Goodman (2015). 2Ordean and Kahan (2011). 3Silverman et al. (2001). 4Cochran et al. (2018).
Primary Opioid-Use Outcomes
Intervention
Demographics
Sample Size Eligibility
Dartmouth-hitchcock
Table 1 Summary of studies evaluating nonpharmacological treatments for opioid use disorder during the postpartum period.
6 months • Timepoint: 52% ( ± 8%) abstinent • Treatment: • Control: 33% ( ± 6%) abstinent
family planning services.
• • • • • • 31.9 years-old ± 2.5 (SD); • Treatment: Control:31.6 years-old ± 4.8 (SD) Black • 83% • 65% = high school education for three hours per day, upon receipt of negative • Work urine screen (n = 20). (n = 20) received usual multidisciplinary care, • Control including individual and group therapy and obstetric and
3
40 Inclusion Pregnant with OUD > 18 years old Receiving MAT treatment Currently unemployed Positive urine screen for opioid or cocaine in < 6 weeks Exclusion Psychiatric disorder or suicide risk
Therapeutic workplace
30 days postnatal • Timepoint: • 95% abstinent
resources.
with patient navigator.
covered education, • Content support, and referral to other
years-old ± 5.77 (SD) • 29.7 White • 95% < = high school • 81% education • 62% employed during pregnancy • 10andsessions 4 postpartum sessions
• •
4
21 Inclusion Pregnant with OUD Exclusion None
OPTI mom
A. Martinez and A. Allen
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A. Martinez and A. Allen
During the 24-week Therapeutic Workplace study, approximately 45% of participants attended the Workplace per day. Of the $3126 total potential voucher earnings, participant earnings averaged at $1013. Using an intent-to-treat analysis, the percentage of urine specimens negative for opioids and cocaine was almost twice as high in the Workplace group versus the control (50% (SE ± 9) versus 27 (SE ± 6), respectively). For opioids alone, percentage of urine specimens negative for the Workplace group versus the control were 52 (SE ± 8) and 33 (SE ± 6), respectively. Workplace attendance and drug abstinence were significantly correlated (r = 0.99, p < 0.01). Lastly, with regards to the OPTI Mom study, postpartum participants reported increased abstinence from illicit opioid use with > 90% days abstinent in the past 30 days at postnatal follow-ups (early discharge: 95%, SD = 0.02; no early discharge: 96%, SD = 0.01) in comparison to baseline with approximately 60% days abstinent in the past 30 days prior to intervention. Adjusting for treatment sessions and discharge status, there was a significant increase in percent of days abstinent (B = 0.15, 95% confidence interval [CI] 0.1–0.2) and decrease in drug use ([opioid or any other drug] odds ratio [OR] 7.62, 95% CI 2.8–21.0).
pharmacotherapy, and relapse-prevention counseling (additional details were not provided). Onsite group counseling was also offered weekly. Further, referrals were made for local women-only treatment programs, as well as other community services and resources (i.e. housing). The Dartmouth-Hitchcock Medical Center achieves integrated care through the fusion of obstetrics and gynecology and psychiatric/addiction medicine departments. The program consists of weekly perinatal addiction clinic appointments, medication assisted treatment with buprenorphine, weekly addiction recovery group meetings, individual and/or family counseling, prenatal and postpartum care, neonatal education sessions, and monthly social worker meetings. In addition to providing multidisciplinary care, the Therapeutic Workplace intervention participants were invited to work three hours per day, Monday through Friday, over 6 months (timing during pregnancy was unspecified). Upon arrival, participants provided a urine specimen. If the specimen was negative for opioids and cocaine, participants were permitted to work that day. Participants were rewarded with vouchers for training, data entry, abstinence and attendance. Usual care consisted of services for pregnant drug-abusing women, including individual and group therapy and obstetric and family planning services. In addition to usual care, the postpartum women in the intervention group could receive vouchers up to 8 weeks after delivery without going to the Workplace if drug-free urine toxicology was provided on required days. This encouraged abstinence maintenance while permitting mother-baby bonding time. After the 8-week period, mothers were welcome to return to the Workplace or continue bonding time for an additional 4 weeks (per mother’s choice). After the 12-week period, predelivery Workplace expectations resumed. In contrast, the OPTI Mom study explored the use of patient navigation (PN) to link motivational interviewing, case management, medical care, and psychosocial services. During the 10 prenatal sessions and 4 postnatal sessions, the PN provided education (i.e. substance use treatment, healthcare), support (i.e. identification of goals, attendance at appointments), resources (i.e. psychosocial services), and plans for follow-up. The PNs assisted participants to identify their own goals (i.e. writing exercises) and establish care with providers and professionals, including preparation for appointments and overcoming barriers to care. Monetary compensation was given for travel and for completing the three assessments (baseline, prenatal, and postnatal).
4. Discussion There is a clear and consistent recommendation from numerous professional organizations to pair nonpharmacological interventions with pharmacological treatment for OUD during the postpartum period (Committee on Obstetric Practice, 2017; Lindsay & Burnett, 2013; Ramage, Ostrach, Fagan, & Coulson, 2018; Velez & Jansson, 2008). However, as this review demonstrates, the science in this area is severely lacking. We were only able to identify four studies that tested the effect of a nonpharmacological adjunctive treatment on opioid use outcomes. Further, none of the studies we identified tested an intervention designed to the unique and substantial needs of the postpartum period. This further emphasizes the gap in research on nonpharmacological interventions for women with OUD in the postpartum period. Despite the limited number of published studies available, those we did identify demonstrated significant decreases in drug use, suggesting promise of these interventions. The OPTI Mom study utilized patient navigation (PN) intervention specifically for pregnant and postpartum women with OUD; this approach may be an especially promising area of research as PN had favorable effects in a wide range of patient groups, including cancer, HIV, and mental health disorders (Freeman & Rodriguez, 2011; McDonald, Sundaram, & Bravata, 2007; Parker, 2011; Robinson-White, 2010). Similarly, the Sustained Patient-centered Alcohol-related Care (SPARC) protocol utilizes expert health coaches and clinician evaluations to address alcohol-use screening and intervention (Glass, Bobb, & Lee, 2018). However, the OPTI-Mom study relied on self-report, which has the potential for social desirability bias and, therefore, additional research is needed to replicate these findings. Specific treatment plans for postpartum women appear sparse. For future research, interventions similar to those reviewed could be implemented specifically for the postpartum period. The DartmouthHitchcock Medical Center, T-CUP, Workplace, and OPTI Mom already had postpartum specific protocols, and these interventions should be evaluated in fully-powered randomized controlled trials. Future research may also consider compiling a comprehensive list of potential specialists and clinicians to be involved in the care of postpartum women with OUD. With a comprehensive picture of the variations in interdisciplinary teams, organizations can visually compare their teams to others (similar to Table 2) and make adjustments according to their patient populations’ needs. Unfortunately, there was also a lack of consistency in terminology used in the description of professionals involved, with only counselors and nurses explicitly described in all four studies. This limited our ability to compare interdisciplinary teams by study.
3.3. Inclusion of multidisciplinary team members Professional members listed as part of each multidisciplinary intervention team can be seen in Table 2. The number of professionals on each team was not specified. While some roles may overlap, terms used by the articles were maintained. All four studies included nurses, counselors, and case managers/social workers as a part of their multidisciplinary teams. 3.4. Opioid use outcomes All studies reported improvements in opioid use outcomes. The Dartmouth-Hitchcock Medical Center subjectively reported improved care coordination, interdisciplinary communication, patient and provider satisfaction, and more prenatal visit recommendations. Provider attitudes about women in treatment also improved and, subsequently, perceived quality of care improved (additional details were not provided). For the other three studies, statistically significant results in support of the interventions were found, including a decrease in drug use. Of the 121T-CUP participants, 39 participated in formal treatment programs and 23 joined self-help groups. Drug use, including heroin and prescription opioids, decreased significantly (p < 0.05) from baseline use to follow-up (specific time-point varied) for those who attended T-CUP earlier in pregnancy. However, group-specific estimates were not provided. 4
Addictive Behaviors 105 (2020) 106323
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Table 2 Interdisciplinary care team members by study. Professional Addiction specialist Behavioral health provider Case manager Counselor - Drug and Alcohol Counselor - Family Counselor - Group Therapy Counselor - Individual Therapy Counselor Family medicine physician Family planning advisor Medication assisted therapy provider - Buprenorphine Provider - Methadone provider Maternal-Fetal Medicine Physician Midwife Nurse Obstetrician Patient Navigator Other Support Staff Pediatric Hospitalist Pediatrician Prenatal Care Provider Postnatal Care Provider Psychiatrist - Addiction psychiatrist Psychologist Social worker
Dartmouth-HITCHCOCK
1
T-CUP
2
Therapeutic workplace
3
OPTI mom
4
X X X X
X X X
X
X X X X
X X
X X
X X
X X
X X X X
X X
X X X
X X
X X X
X X X
X X X
X X
X
X X
Goodman (2015). 2Ordean and Kahan (2011). 3Silverman et al. (2001). 4Cochran et al. (2018).
The 2015 Federal Guidelines for Opioid Treatment Programs expound on recovery-oriented systems of care, which are an ongoing process where patients access resources to maintain recovery and rebuild wellbeing. Recovery-oriented systems of care contrast with previous traditions that focused on abstinence alone. Within this framework, opioid treatment programs have the potential to expand care from simply dispensing medications to patient-centered, patient-driven recovery. Recovery thus encompasses patient wellbeing rather than merely abstinence. Although MAT and opioid treatment programs are greatly underused, these guidelines detail nonpharmacological care that would be worthwhile to include in future programs and research. Since MAT is intended to be consistent, daily treatment, it is an ideal opportunity for counseling and nonpharmacological care integration. In conclusion, this review has identified a significant and critical gap in scientific literature regarding nonpharmacological treatment options for postpartum women with OUD. Given only four studies were identified for this review, we were unable to make any generalizable conclusions regarding the factors that lend to successful nonpharmacological interventions for OUD during the postpartum period. Without focusing on nonpharmacological aspects, critical components of treatment options are being overlooked. Postpartum women with OUD are a complex population due to their specific maternal, neonatal, and recovery needs. When disciplines deliver care separately, communication, care coordination, and follow-up are poor, and patients suffer. Additional research is needed to further identify and develop effective nonpharmacological treatment in adjunct with pharmacological treatment for women with OUD in the postpartum period.
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Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. References American College of Obstetricians and Gynecologists (The College). Medication-Assisted
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