Collaborative Approaches to Treating Pregnant Women with Opioid Use Disorders

Collaborative Approaches to Treating Pregnant Women with Opioid Use Disorders


Sharon Amatetti: Thank you for joining today’s
webinar. On behalf of the Substance Abuse and Mental
Health Service Administration, Center for Substance Abuse Treatment, I am happy to welcome
you to today’s discussion, and excited to share the newly published document, “A Collaborative
Approach to the Treatment of Pregnant Women with Opioid Use Disorders Practice and Policy
Consideration for Child Welfare, Collaborating Medical, and Service Providers.” My name is Sharon Amatetti. I am the Chief of Quality Improvement and
Workplace Development Branch at the Center for Substance Abuse Treatment. Today, on our call, we have representatives
from over 49 states and also some folks joining us from Canada and the territories, and we
are really pleased with their turn out. The webinar series and the document is a collaborative
effort between SAMHSA, the Administration on Children, Youth and Families, and our National
Center on Substance Abuse and Child Welfare. The support of leadership across our agencies
has been really valuable to the cross system efforts in addressing the opioid crisis. Many of you may have participated in the Child
Welfare League of America’s special topic conference on substance use, or ACYF’s 20th
National Conference on Child Abuse and Neglect last month. A national spotlight was put on issues during
these conferences and highlighted a need for a collaborative effort in truly improving
outcomes for families and children affected by opioid and other substance use disorders. President Obama officially proclaimed September
18th through September 24th, 2016 Opioid Epidemic Awareness Week, so it’s timely that we’re
having this webinar today. The collaborative guidance document is intent
to support and provide concrete resources and tools in developing collaborative practice
among the primary systems that typically come into contact with pregnant women with opioid
use disorders and their infants and families. Over a two year time period, a work group
of 40 professionals from across the systems met on a regular basis to discuss and define
promising and best practices in working with the population. The document is available in the link on the
screen, and we’ll also be sending it out following this webinar. The outcome of the work group was a collaborative
guidance document that discusses national trends in opioid use and best practices in
the treatment of opioid use disorders and neonatal abstinence syndrome. The best practices are recommendations made
by major professional organizations including the American College of Obstetricians and
Gynecologists, the American Society of Addiction Medicine, and the World Health Organization. Perhaps what many of you will find most helpful
is the Guide for Collaborative Planning which is part of the document and also a case study
on the CHARM Collaborative in Burlington, Vermont. The document and guide were developed with
the intent of being very hands on and easy to translate into practice. The second webinar in this series will feature
six sites that are participating in our In Depth Technical Assistance Substance Exposed
Infants program. The six sites are developing a comprehensive
service array across systems and working with pregnant women with opioid and other substance
use disorders and their infants and families. The Collaborative Guidance Document was largely
informed by the experience of the six sites. The opioid crisis has highlighted a need to
identify best practices in working with families affected by substance use disorders. Since the passage of the Adoption and Safe
Families Act, a body of knowledge is understood on what works best for families affected by
substance use disorders. The opioid crisis underscores the need for
collaborative practice. It’s clear that any one system alone can’t
fix the issues. There are some challenges that are unique
to the opioid crisis. Evidence based treatment of opioid disorders
may require a medication assisted treatment component. This component and understanding why it is
a best practice is often one of the most challenging issues faced by communities, particularly
for pregnant women and infants. Other challenges such as a perception of who’s
the primary client of a system are not so unique to this crisis, but these factors call
for the development of the Collaborative Guidance Document. I want to stop here and ask a couple of polling
questions. Our first question really, if you could let
us know, speaking of the issues that we’re covering, are you familiar with the passage? Are you familiar with the Comprehensive Addiction
and Recovery Act of 2016, Section 503, Infant Plan of Safe Care? I see they’ve gone ahead and posted where
you can vote, yes or no. We’re trying to get a baseline of your familiarity
with the legislation that was recently passed. If you could indicate yes or no, I’ll give
you a few minutes to respond. No. Most of you are not familiar with this Comprehensive
Addiction and Recovery Act. We’re going to be going over that in a little
bit and give you a sense of what that’s all about. Let’s go to the second polling question. The question is, in your state jurisdiction
or community, is a notification to Child Protective Services made when an infant is identified
as being prenatally exposed to substances? Most of you know, yes or no, whether or not
this happens. Most of you are saying that, yes, it is happening
in your communities. The next question, please. In your state jurisdiction or community is
a Plan of Safe Care developed for infants who have been identified as prenatally exposed
to substances? Good, most of you “yes” or uncertain, not
so many “no.” We’ve heard from many states about a need
to understand what exactly is a Plan of Safe Care. Is it a safety plan? How’s it different from a discharge plan? We’ll talk a little bit about that as well. We’re going to go on and introduce some of
the topics that the polling questions were pertaining to and hopefully, we’ve whetted
your interest in that Comprehensive Addiction and Recovery Act. It was just passed by Congress in July of
this year. Section 503 of CARA, we call it CARA, the
acronym, addresses the Plan of Safe Care that was created as part of Keeping Children and
Families Safe Act of 2003. The 2003 act created new conditions for states
to receive state allocation under the Child Abuse Prevention and Treatment Act, or CAPTA. The intent of these conditions is to improve
outcomes for pregnant women with substance abuse disorders and their infants. The CAPTA conditions include a notification
to Child Welfare by healthcare providers who are involved in the care of delivery of substance
exposed infants. Most of you said that this was, in fact, the
practice in the jurisdiction that you’re familiar with. It also required the development of a Plan
of Safe Care. Then, in 2010, the conditions were updated
to clarify the definition of what substance exposed infant meant. One of the things that happened with the 2016
CARA changes is that it further clarified the definition. Infants who were identified as being affected
by substance abuse, CARA removed the term illegal. It used to say illegal substance use. It also clarified about infants having withdrawal
symptoms or experience of fetal alcohol spectrum disorder. The second thing that CARA does is strengthen
the Plan of Safe Care to address the needs of not just the infant but also the mother
and father or an affected caregiver. Then the third thing CARA does is stipulate
that the Plan of Safe Care is implemented so that families are able to access appropriate
services. Part of the monitoring of the implementation
will include reporting by state for the development of the Plan of Safe Care and how many referrals
to services were made. States have a couple of years yet to prepare
for these changes. I want to talk a little bit about Plans of
Safe Care. What is a Plan of Safe Care? The Plan of Safe Care provides a way to operationalize
services to mothers and babies. It’s clear that the needs of this population’s
multi layered and comprehensive. The Plan of Safe Care provides a vehicle to
coordinate across systems so that all the different service needs can be met. Ideally, it’s developed prior to the birth
of the infant so that all systems and partners, including the family, is prepared for the
birth of an infant who may have special needs. Having a plan in place prevents a crisis and
surprises at birth. After birth, the plan assures that services
continue beyond pregnancy and the birth event. The often forgotten fourth trimester or postpartum
period is critical. It’s a time of major stress. The life changes for the mother and mothers
are particularly high risk for relapse and postpartum depression. Of course, the needs of the infant who’s prenatally
exposed must be identified and addressed. The Plan of Safe Care is a fluid document
that needs to be updated as needs of the mother and baby are identified and should include
coordination, access to, and help with engagement and services. That’s a little bit about Plans of Safe Care. I, now, would like to turn things over and
introduce Dr. Nancy Young, the Director of the National Center on Substance Abuse and
Child Welfare, who will walk us through the contents of the guidance document. Many of the resources and tools will be helpful
to your communities in implementing CARA and CAPTA provisions. Nancy, I’ll turn it over to you. Dr. Nancy Young: Thank you so much, Sharon,
and welcome to all of our audience today. Sharon, thank you so much for your leadership
in ensuring that this document was envisioned and constructed, and now in the dissemination
mode. We appreciate, again, your leadership in making
sure that this happened. I don’t think that it’s news to anybody in
the audience today about the prescription pain medication epidemic that we have. In 2012, 259 million prescriptions were written
for opioids. It just seems like a mind boggling number
when you think about a bottle for every American adult to have access to. Not surprisingly, the number of prescription
opioids that were sold being quadrupled means that there is also an increase in the number
of individuals who’ve recorded what is referred to as “non medical use” of prescription opioids,
those that aren’t taking them as prescribed. 10.3 million individuals reported non medical
use. About 10 percent of those, or 1.9 million,
met the criteria for opioid use disorder. Those are data from the National Survey on
Drug Use and Health. What’s been particularly helpful, I think,
is an article written by Doctors Compton, Jones, and Baldwin, that looked at this relationship. We’ve certainly seen a lot in the popular
press about the number of individuals that start using or misusing non medically used
opioids, and turn to heroin when policies were put into place to help identify misuse
of opioids. We know now that those non medical users of
opioids that are prescribed develop a heroin use disorder, just about four percent of the
time. The circle goes back that if you look at the
data about the person with the heroin use disorder, they are 19 times more likely to
have non medically have used prescription opioids. It is a bit of a circle, that while not everyone
that uses opioids develops a heroin use disorder if you have developed a heroin use disorder,
you’re more likely to have misused prescription opioids. I particularly thought that was a very useful
article, you see the reference that I would refer you to, to understand more fully about
this connection between prescription opioids and the heroin overlap. We know in our media, and particularly in
certain areas of the country, that the sharp increase in heroin and opioid death rates
in recent years is terribly troubling. Something that is unique in this particular
epidemic, we didn’t see these kinds of numbers of overdoses certainly in the cocaine epidemic,
the methamphetamine epidemic, over these last 30 years. The unique attributes of opioids were suppressing
respiration, meaning that is what was driving that opioid death rate. As we look at that, we also look at the number
of children being placed in out of home care. That number came down quite dramatically,
from about 500,000 to a much smaller number that were coming into care. We’ve just captured this last five years of
data, to look at since 2010, so 2010 and ’11, really the low point of the number of kids
being placed, then the increase that has started in the more recent years. This asterisk on the 2015, those were data
that were discussed at the National Conference on Child Abuse and Neglect, although we have
not yet had the public access to that data file to make sure that we’ve got that correctly
from that actual data analysis, I just wanted to note that. Very troubling, when you see that we had been
making such progress in our country, at ensuring that kids were not coming into care over this
long period of time. A lot of policy and practice changes that
have gone on in child welfare to really make sure that that was happening in our country. While we don’t have data that says that that
increase since 2012 is directly related to opioids. We do know that over the last 15 years, there’s
been a continuing increase in the number of parents that it is noted in the file in the
child welfare data system, that alcohol or another drug use was a reason for the removal
of the child across the country. In most states that we go to and ask the question,
does that seem like that’s a valid amount of percentage of the cases in which the children
have been removed? That about a third of them are related to
substance abuse? Invariably, we are told no, that’s not even
close to what people believe in their own jurisdiction is what’s happening in the number
of parents with an alcohol or drug use problem that ends up associated with child neglect
typically. Sometimes child abuse is the reason that children
are coming into care. Equally troubling is the number of infants. If you look at that removal by age, you see
that in 2014, about 45,000 children under the age of one were being placed in care. While we don’t have direct data that says
that this is attributed to opioid use during pregnancy or prenatal exposure being detected
at birth and the reason why the child is being removed. Understanding that the vast majority of children
who are being placed into care are infants is particularly troubling as we look at the
brain development and the importance of attachment and bonding during those first months of life. When we look by state, this is the part of
the graph that generates, how could that overall national average say that there are only a
third of parents identified with an alcohol or drug problem associated with a child’s
removal. You see this variation by state. Let me take a second, because it’s a very
complicated graph. The blue bars are those children that are
under the age of one, who were placed in care. You see in just about every single state that,
that factor is checked in the data system when the child is an infant, and that overall
almost 42 percent of infants who came into care in 2014 were associated with the parent’s
alcohol and drug use, well over one is the national average is about 30 percent. But this is part of the issue in terms of
identification of the families in child welfare with a parent with an alcohol or drug use
problem as well as state policy and practice guidance about how to record those data in
the information system. We think that there are two things going on,
in your community, do you have a standard protocol about how to identify that parents
with an alcohol or drug use problem are associated with the child’s removal, and then secondly
how does that get recorded into your state information system so that you can be monitoring
over time. Is this variation evident in your community
or are there guidance or policies that need to be put in place to make sure that we are
identifying infants who may need extra intervention, another component of the Child Abuse Prevention
and Treatment Act, requiring that infants under the age of three are referred to developmental
assessment. Are those developmental assessments being
conducted in a way that acknowledges that this may have been an infant with prenatal
substance exposure that may need some fine tuning in the way in which those developmental
assessments are done? We would encourage you to look at your own
state data as well as your local community. What is the practice and the policy in your
community related to the very, very important data element and being able to monitor over
time drug use patterns and their impact on the child welfare system? When we think about infants with prenatal
substance exposure, it’s important to place it in the context of which substances. Now you may say well obviously we are not
going to have policy in our state that says that tobacco or alcohol use during pregnancy
would be something that would meet the criteria for notification to child welfare. The reason why we include that in this table
is to note that those legal substances, tobacco associated with low birth weight babies, tobacco
associated with the severity of neonatal abstinence syndrome and heavy alcohol use during pregnancy. I think we are all aware of the warning labels
on alcohol bottles and that is because there are neuro developmental effects that can be
present if the baby is exposed to alcohol during pregnancy. Those much larger numbers in part also sets
out the values discussion that you may need to have in your community. If the community is in an area of the country
that has a large number, a higher concentration of opioid use and a higher concentration of
parents with opioid use disorders and that are being identified at birth. What are the values questions about the identifications
of those infants in the context of the legal substances that also have a potential effect
on the developing fetus and on the infant? Now we are not trying to say that again, that
those meet the criteria of the comprehensive addiction and recovery act that says very
specifically, affected by withdrawal symptoms, and we would refer you back to that exact
language. But we would also want to make sure that we
are placing that in the context. These are hard issues for communities to deal
with, and we want to make sure that we are providing this national data and if you are
interested in those data for your local community, how you could use those national estimates
to be able to be monitoring. If you know that there are very small number
of infants who are actually getting a notification to child protective services, does it match
with how many infants were potentially exposed in your particular community? We would invite you to be in touch with us
if you would like some assistance with helping with monitoring some of those data. But let’s turn our attention to some of the
things that we know about the treatment of opioid use disorders. This is from the director of the National
Institute on Drug Abuse and a couple of co authors that thought that the just recently
since the 2016 publication in the New England Journal of medicine, and again, I would encourage
you to get that article and to get the most updated information about treatment and addiction
and recovery. They state in this article that we know now
that addiction is a brain disease, it affects both the brain and the way in which the person
behaves. It has both biological and environmental factors
and that those researchers at NIDA, or the National Institute on Drug Abuse are searching
for those genetic variations that contribute to the development and the progression of
the disease. Now, sometimes I hear when I travel around
the country, “Oh, yeah, it’s a brain disease, but it’s not really like other kinds of diseases
that are real diseases, that this isn’t the same.” What we know is that the brain imaging study
show that there are physical changes in areas of the brain that are critical to judgment,
decision making, learning and memory and behavioral control. Those changes alter the way in which the brain
works, it helps to explain the compulsion and continued use despite the individual experiencing
negative consequences. If you are a child welfare caseworker or a
supervisor, you might be struggling with parents that are exhibiting this kinds of symptoms
of not having good judgment, of making bad decisions, of not being able to remember what
they promised in their case plan, not remembering their next appointment, not being able to
recognize what they had gone through the day before is somehow misplaced in trying to think
about what they have learned and moved forward. Now, these kinds of effects happen early in
active period, it happens during the active youth period, we know that the brain is miraculous
in the ability to recover, and to have those kinds of judgment, decision making, learning,
and memory, and behavior control come back into play. But I think that it’s important to think about
how our practice looks, because if we have someone who has this altered brain chemistry
in early abstinence, in early recovery, what do we need to be doing, as case workers to
be sure that we’re providing the kinds of services that are needed in order to address
this particular individual that has a brain disease. I often say if we had someone that has a brain
injury of any other kind, we would adapt the way in which we are interacting. But too often I do see in communities that
those adaptations haven’t necessarily been made when it’s an individual that has a brain
disease with altered brain chemistry as a result of substance use disorder. I would encourage you again to look at what
kinds of practice changes, what kinds of supervision, what kinds of guidance can be given to both
child welfare workers and the courts and attorneys and others that are interacting with families
particularly during the time of early abstinence, early recovery period. The good news is that we also know that this
brain disease is treatable, that it is preventable, that the discoveries in the science of addiction
have led to better treatment, that people do recover and resume life, but that we need
to have more of a chronic disease management approach, rather than a one time event. Again, practice protocols that sometimes looks
like will send us parents over to the treatment agency and have them send us back when they
are ready to resume their parenting role. It takes much more of a team effort to be
sure we have the approach in place, that recognizes it’s a disease in the reward system of the
brain, and that the way in which we treat that, may need to look different. Again, take this keen approach that crosses
over between the child welfare agency, the hospital and the medical community, the courts
and the child welfare agencies, so altogether. As we get into the talking about the guidance
document itself, that’s the recognition that we heard from practitioners across the country,
that this team has been able to look at this brain disease as a treatable chronic disease,
and how to have the systems in place, to respond to that individual so that whenever possible
we are making sure that the children have access to their parents and that they are
part of that treatment component. What we know from many, many years of study
of what works in treatment is that medications are an important element of treatment for
many patients, particularly important that they are combined with counseling and other
behavioral therapy. It’s difficult to say that there could be
good news in the era of this opioid epidemic affecting our country, but we do have medications
that are specific for opioid use disorders. We detail those in just a minute in the guidance
document. Broadly, medication assisted treatment is
a variety of medication that are used to complement those behavioral approaches and the other
kinds of counseling approaches that are important in treatment. Specifically, there are medications for tobacco,
for alcohol use disorders and opioid use disorders. Now this is a pretty detailed chart. We don’t expect you to be able to copy all
that down. But this chart is in our guidance document
and it is just updated with the Comprehensive Addiction and Recovery Act that makes two
important changes when we looked at Buprenorphine as a medication that is used in opioid disorders. Probably most people are very familiar with
Methadone and the requirements of an opioid treatment program about how individuals get
access to daily Methadone dosing. Buprenorphine is more recent, but it has been
available for many years and many of you are probably familiar with Buprenorphine. Up until the Comprehensive Addiction and Recovery
Act, physicians that were licensed, that had been through a certification for prescribing
Buprenorphine could only have up to 100 patients. CARA, the Comprehensive Addiction and Recovery
Act, expanded that to 275 patients for those physicians that have been certified as prescribers. It also expanded that access for being able
to prescribe Buprenorphine to nurse practitioners and the physician’s assistant. As Sharon mentioned, it just came into play
in July that it was signed into law. Communities are just beginning to adjust to
that. But many of you that may be in communities
that have not been able to get access to a physician, or often had waitlist for your
Child Welfare involved families in order to get Buprenorphine, this is good news and we
would encourage you to reach out to your medical community and to the opioid treatment program
in your community to make sure that you’re getting access when needed for a parent. Two pages of charts that give information
specific to the different medication that are available for opioid use disorders. Important to note the Narcan, first responders
and family members are so important for them to have that. It is Nalaxone, which reverses…it actually
blocks the receptors in the brain so that it can reverse the overdose. Folks who have administered that say it is
a miracle to see that the person who is in the midst of an overdose, that are administered
Narcan can get an immediate reversal of that overdose. It has saved countless lives already. It may be important for Child Welfare to be
aware of that ensuring that family members of a person with an opioid use disorder get
trained in the administration of Narcan and to be aware of the potential of reversing
those overdoses. Particularly if you are in sections of the
country that have higher rates of opioids and opioid overdose death. Another that is newer that we want to make
sure that Child Welfare agencies and courts are familiar with, Vivitrol, which is an extended
release Naltrexone, that locks the effects of the opioids. It’s for maintenance, it’s not like Narcan
which is an immediate reversal of an overdose. It is a maintenance medication that is a once
a month injectable, reduces some of that barrier to Methadone and to Buprenorphine by providing
that injection once a month. Many of the formularies for prescriptions
for Medicaid access now include Vivitrol. I’ve added something that we would encourage
you to look at in your own state to know if that is something that is available as a medication
in your particular community. The point is not that we expect that Child
Welfare workers and court staff and attorneys be experts in these medications, certainly,
you need an awareness of them, but each of those medications varies in its intent and
about the ability of what it actually does. The important part is that there is a network
of physicians and those that can make these determinations about what is the appropriate
medication for each individual person based on their specific biology, their addictive
history and severity, and their life circumstances and needs. These are decisions to be made by medical
professionals and hopefully that this would urge you to create that partnership with the
medical professionals who are able to prescribe the medication for the parents in your caseloads. There are specific prescribing requirements. I won’t go through all these requirements. You’ll find those in the documents on the
guidance, and want to make sure that the different issues related to access to Methadone and
Buprenorphine are understood by Child Welfare practitioners and Child Welfare system so
that you can build those partnerships. I mentioned already that the maximum of 100
clients was extended to 275 by CARA in July and the expansion to who can actually prescribe. What’s important is that those medications,
you have an awareness of them and also that medication is that the treatment is well researched
for decades about what does the effect of having access to medication do in treatment
outcome. It increases the retention in treatment, it
decreases the illicit use, it decreases criminal activity, decreases drug related HIV risk
behaviors and decreases complications in pregnancy, which is what we’re really talking about today,
when we talk about pregnant women and how these medications and other behavioral and
counseling approaches can be put in place to ensure that parents in the Child Welfare
systems have access to a comprehensive treatment program. When we think a bit about this sub population
of Child Welfare involved families and pregnant women with opioid use disorders, there’s really
a unique set of needs that they have that effect both their obstetrics care as well
as the pregnancy outcome and what is needed during treatment. We use this guide quite often, to graphically
show what’s happening to the developing fetus during pregnancy if the mother is not receiving
medication assisted treatment and is using opioids, in just a way to say that concentration
for the fetus, goes up and down just as it does for the mother. The goal of medication assisted treatment
is to improve that fetal environment by smoothing out those ups and downs and importantly, preventing
mom’s return to illicit use and changing that concentration for the infant. Providing medication assisted treatment avoids
the erratic maternal opioid levels, protects the fetus from those repeated episodes of
use and withdrawal. It also decreases the risk to the fetus for
infection from HIV, hepatitis, other transmitted diseases. It reduces the incidence of obstetric complications
and fetal complications at birth. When we look at the guidance document, you’ll
see many quotes from the American College of Obstetrics and Gynecologists and the American
Society of Addiction Medicine that speak to this issue of why medication during pregnancy. We also know when we think about Child Welfare
practice, that different populations of women can give birth to an infant that displays
neonatal abstinence syndrome symptoms. Women who are receiving opioids because of
a medical condition, who is being maintained on opioids for chronic pain or other medical
condition, mothers who are actively abusing or dependent on heroin, mothers who may be
in that category of misusing a prescribed medication, they may be misusing non prescribed
medication in addition to the opioids. They may be in recovery from an opioid usage
disorder and maintained on Methadone or Buprenorphine, exactly what we’re advising that moms should
be doing during pregnancy. Receiving medication assisted treatment, participating
in counseling, participating in other behavioral kinds of effective strategies, yet we often
find in communities that all of the different kinds of condition are lobbed together as
one and that there isn’t good differentiation between which mom are we talking about, in
particular, moms that are in that half right circle if you will. Moms who are stable on opioid treatments,
meaning they are receiving medication assisted treatment, are not differentiated from those
that may be actively abusing or dependent on heroin. The reason for that differentiation is not
the use in and of itself, but how that use plays out in safety and risk assessment. The Comprehensive Addiction and Recovery Act
says that a plan of safe care is required when babies display a withdrawal syndrome,
and part of that plan of safe care needs to be differentiating the potential risk or safety
factors for that particular infant and its family. Thinking through which parent, which family
are we talking about becomes a very important first step in Child Welfare practice to understand
the way in which our safety assessments are being developed or adjusted to reflect the
different kinds of situations for a particular family. Going back to guidelines that I mentioned
from ASAM or the American Society of Addiction Medicine, and others the American College
of Obstetrics and Gynecologists about treatment for opioid use disorders during pregnancy,
that is a decision made by a physician that balances the risks and benefits. An infant may, in fact, exhibit a withdrawal
syndrome from a mom who is doing exactly what her medical physician has advised her to do. Knowing that that is happening for a particular
mom is important in knowing the balance of the risks and benefits. The infant health and the mother’s health,
those that are not in treatment should be encouraged to start opioid agonist treatment
with Methadone or Buprenorphine as early in pregnancy as possible. You might say, “Well, gee, that just runs
counter to what my belief system is.” The reason why we’re spending a little more
time with that on the medical advice is because we need to make sure that we’re following
what does the research say and why would we make these decisions about having medically
prescribed opioids as treatment during pregnancy. We think that it’s been critical for each
community to understand that and for each physician to be able to balance those risks
and benefits with the individual woman and her family during pregnancy. The reason why you hear often that it’s not
advised to keep her off of opioids during pregnancy is a couple factors, the first really
being that evidence over many years that decrease in the medication assisted treatment can result
in the pregnant woman returning to her former use. We don’t want to see that and have that up
and down of the level of the opioids during that pregnancy and there can be an associated
preterm labor or fetal distress when there’s abrupt discontinuation of opioids. Just as the mother may be experiencing withdrawal
syndrome when it’s happening during pregnancy, the baby is not being medically managed as
you can if the baby has been born and is experiencing neonatal abstinence syndrome. Important to know what your medical community
advises and important to know how the medical community approaches medication assisted treatment
and what that policy or those guidelines may need to be in your state or in your community. This is another one that we get a reaction
to, when we’re presenting about information on medication assisted treatment during pregnancy,
the American Society of Addiction medicine in their practice guideline, medications in
the treatment of addiction encourage that mothers breastfeed. You’ll see a full discussion of that in the
guidance document. In part, that is because the benefits of breastfeeding
extend to all women and their infants. Knowing some of the situations for breastfeeding
for a mom who is stable on medication assisted treatment and encouraging breastfeeding is
very important. We want to back this up a second and ask you
to participate again. In your community, are best practices in the
treatment of infants who are prenatally exposed to opioids understood? From your perspective, is that something that’s
understood in your community? Interesting, about half said that best practices
in the treatment of infants are not understood in your community. Boy, do we have a ready made audience for
the guidance document, because we would encourage you again to look at that and to go to those
references that we mentioned in terms of the practice guidelines from the medical community
to ensure that those can be put in place in your particular community. Let’s turn then to what happens with neonatal
abstinence syndrome. We know that it is an expected and importantly
a treatable condition that follows prenatal exposure to opioids. Just briefly, some symptoms often begin within
one to three days after birth but it may take longer. You may have an infant who comes back into
the emergency room several days after birth after the baby has gone home. If this is something that wasn’t detected
during pregnancy, or after birth, you may have a baby that has difficulty with sleeping
and eating, the irritability, difficult to soothe, diarrhea, slow weight gain. There are tools that have been created to
monitor the severity of these symptoms to understand the severity and the treatment
approach for that particular infant. Not every baby displays all of those symptoms
and from a study called “The MOTHER Study” that was conducted some years ago, we understand
now that tobacco plays a role in the severity of the Neonatal Abstinence Syndrome or NAS
as well as the occurrence of the NAS. You see this wide variation, about infants
that actually have symptoms of NAS and not having a good way to say this particular infant
is going to have these kinds of symptoms versus those that do not. You can understand how sometimes babies are
not detected at birth, or sometimes babies may be going home and coming back into the
emergency room and perhaps Child Welfare was called at that point after the baby’s birth. There’s awareness of NAS symptoms may come
after the baby has gone home and that the management of that is important to make sure
that we understand when medication are necessary based on reliable assessment tool to understand
the severity of that particular symptom because studies, and we know, nonpharmacological treatment
should be put in place for all of the infants. For those of you who have had an infant, you
know that these are important kinds of conditions for all babies, not just those with NAS. We find sometimes that the values issue in
a particular community might interfere with the idea that the baby would room in with
the mother, the baby may be able to breastfeed. We’re talking about knowing the difference
between a mom who is stable on medication assisted treatment, versus those that may
be continuing to use other substances and advising breastfeeding. Those nonpharmacological treatment approaches
are very important to make sure that whenever possible, the treatment goal is about that
mother infant bond. When the severity of the symptoms are such
that the infant is experiencing those kinds of symptoms that are being monitored, they
have pharmacological treatment available for them. Again, that is a complex interplay between
the infant and the other kinds of conditions that were going on, if there were multiple
substances, alcohol, and tobacco, in particular, associated with the opioids, needing to have
that history and to understand that in the assessment of the NAS. Some of those challenges that have been reported
in the media are often attributed, again, to the legal substances that are independent
of other risk factors. Knowing the postnatal environment and the
stability for the family, particularly, if there are other family members that are available
to help care for the baby. I think most of us know when a baby is anticipated
in the family there’s always a discussion about, is grandma going to come and live there
for a couple of weeks, or is she going to stay in a hotel and come in and out, or is
grandma not somebody that would be helpful to care for that baby? Is there another family member? I see the mothers that are sitting in the
room with me smiling because they’ve all gone through these decisions also about who’s the
right person to offer help to this couple with a newborn. Those same kinds of decisions need to be made
hopefully in advance with this particular mom of understanding the family characteristics
and what other kind of medical and psycho social factors that may have an impact on
long term outcomes, again, making sure that we’re fostering that bonding whenever possible. That comes out in many different kinds of
systems and individuals that are involved in the life of this particular family. The guidance document is really premised on
trying to lay out a step by step guide with tools about how you do this collaborative
planning. I know many communities have worked in a collaborative
effort between child welfare and substance abuse treatment and of course adding in the
house care system, adding in making sure that there is an opioid treatment program that
is available to child welfare and involves family complicates that collaborative planning. We’ve provided in this guidance a facilitator’s
guide about how you create those collaborative processes, a way in which we can look at what
point in the system, through a comprehensive framework, to coordinate across these multiple
systems and how to make that possible, again, a guide to building and sustaining the collaborative
team. We’ll talk about that in just a minute. Strategies to measure progress over time,
we don’t want you meeting endlessly in collaborative meetings without a way to make sure that you’re
monitoring, is this really having an effect in how we’re handling this approach to parents
with opioid use disorders and some tools to develop a collaborative action plan. Some of you may have seen this framework. The National Center on Substance Abuse and
Child Welfare has been talking about these five points of intervention for probably at
least a decade, now. What it tries to show is that there are multiple
points in which the prevention, intervention, and treatment for families with an infant
with prenatal substance exposure can take place, and that the sooner we’re able to recognize
that there is an awareness that there is a potential substance use disorder in this community
among this set of families, the more preventive we can be. I mentioned those labels on alcohol bottles. That is an awareness of substance use effect
at pre pregnancy. It is a public education campaign that says,
“We need to be aware of this, the effects on a developing fetus.” How we make sure that our communities know
that this is something that is going on, how we are able to best protect moms and to identify
during pregnancy those moms who have not been able to get over their substance use disorder
in a way that allows them to participate fully in making sure that they are getting access
to treatment. During that prenatal period, a second point
of intervention, that screening and assessment. One of the things that we’re going to ask
you is to understand how your public health clinics, how your obstetricians in your community,
identify substance use during pregnancy. Is there a way we can back up into pregnancy,
to understand that this is going on and that we can initiate some enhanced prenatal services? Again, that medication assisted treatment
when needed, the kinds of counseling, and other strategies that have been shown to be
effective, to be put in place in treatment during that prenatal period. If that doesn’t happen during the prenatal
period is that waiting until the identification at birth, at which point we understand that
this has been an infant with prenatal substance exposure. That we need to make sure that the infant’s
needs are being taken care of, as well as the parent’s needs, and that those treatment
responses are responding to the parent’s needs. Again, CARA, the Comprehensive Addiction and
Recovery Act, and the changes in the Child Abuse Prevention and Treatment Act say specifically
that we need to make sure that there is a plan of safe care that responds to the family
and caregivers needs. This is a way to think about it, which points
in this framework are we putting our practice and policy emphasis to make sure that we have
each of these points? The pre pregnancy, the prenatal care, the
identification at birth, the notification to child welfare, and the postpartum care,
to ensure that the infant safety responding to the infant’s needs and responding the parent’s
needs is being put in place. Then it doesn’t stop, as we know that these
may be families that would be very appropriate for a home visiting model. We often find in states that this particular
set of families have not been prioritized for home visiting services. Do you know in your community who gets offered
and who gets follow ups in home visiting, to make sure that we’re again responding to
the needs of the infant and then as that individual child develops over time, to make sure that
those neurodevelopment potential effects are being tended to? The guidance is built on this framework and
specifies this step by step process that sets the stage for collaboration. What is the collaborative structure that you
have in place in your community or your state? How do you understand the baseline of what
is going on right now, in terms of any gaps or barriers? What each of your different partners in the
collaborative have in terms of their particular mandate and have to set this broad area of
action to prioritize work in this particular area. How do you engage those key stakeholders and
establish work groups, again, that are setting the stage for collaboration? Who’s involved? Do you have a public health clinic, or do
you have your local stakeholders that identify women during pregnancy or the hospitals that
maybe identifying infants at birth? How do you know what each individual organization
contributes to this collaborative process? There are cross system guides to help differentiate
that. What is standard practice now? In order to create these action plans, how
do know you have systems in place at present? Or perhaps, and frankly, we find frequently
that a system is not in place at present. How do you understand that baseline of what
is going on right now across all these systems to define the shared goal about how each system’s
policies and procedures, how those values issues might be playing out in practice, in
order to develop the goals that the collaborative will set together? Again, some system specific guides. We encourage you to actually do a walk through. How does the individual parent, how does the
individual pregnant mother, get from one system to another, both physically as well as getting
that admission criteria, the feedback loop. How do you go from the mother may be in the
public health clinic and may need access to treatment, or maybe this didn’t happen, the
identification, until first? How do you understand the needs for the infant
and said caregiver and family members? Some system specific guides about understanding
how that practice works, that presence and how to develop those strategies to be able
to create change in your system and to monitor those outcomes. Some guidance on developing a work plan that
details that work. We think that this is not a one time event. Just like assessment in families, it’s not
a one time event. This is something that is monitored over time. That you come back and revisit those guides
to understand how practice may have changed over time and when you need to revisit your
goals and revisit those strategies and monitoring of those outcomes. Who does look at the outcomes? Who monitors how many infants you believe
are prenatally exposed that may be exhibiting withdrawal symptoms or other effects of prenatal
exposure? How do you know the number of individual infants
that are being identified and the notification going to Child Protective Services? The collaborative guidance document is an
inclusive tool so it facilitates the answering of these questions across the system. Let’s talk about that governance structure. This is something that the National Center
on Substance Abuse and Child Welfare has been developing, again, over the last 15 years
of understanding what are the structures and the membership, how often they need to meet,
and what their primary functions are of these three different levels of collaborative work. We find that if you have just that middle
section of the management team, that is critical to understand what the barriers are and put
to practice changes in place. If it’s not supported by the director level
of what we refer to as the Oversight Committee, that sometimes you can’t get the changes made
that you’ve identified that this is a barrier to practice. This is the barrier to our collaborative effort. This is the barrier to getting pregnant women
into treatment or babies into appropriate developmental assessment. Or making sure that a plan of safe care is
being implemented. Each of these levels of the system have responsibilities
for work groups to give that day by day practice knowledge about how things are really going
on in the community. The core team to identify the patterns of
those barriers and to identify solutions. The Oversight Committee to ensure that there’s
the long term sustainability and that the implementation of those practice and policy
changes are being met. We spend a little bit of time on this structure
with each of the groups that we meet with as we work in a collaborative way because
what we have found, again, over the 15 years is that when one of those levels is left out,
the collaborative tends to go away over time. It’s important because of the changes in personnel
of project directors leaving or child welfare directors leaving or the presiding judge has
left. Unless this is really codified in a structure
that’s in place, then those individuals may be changing their positions means that the
collaborative doesn’t become sustained over time. We offer some tips and some practical guidance
about how to keep the leaders and other members engaged, how to facilitate the decision making
among these partners representing the different systems. We’ve heard from communities over and over
about we didn’t really understand what was going on in the child welfare system or the
treatment system or the court or the hospital, the healthcare system. Until we really sat down and tried to understand
how families that were supposed to interact in each of these systems and how you can sustain
this practice of collaboration over time by making sure that you have the leadership in
the various positions. This is what those process from guides look
like. The question for each of the systems, the
mother’s medical providers, infant’s medical providers, substance abuse treatment, and
medication assisted treatment providers as well as child welfare. Each have a guide to understand what practice
looks like now so that they can then come together and define these shared goals to
know what you share in common, how each of the systems operate at present. How families, again, if there’s a system walk
through about how that’s supposed to work? Then, having people at the front line that
can say, “Does it work that way?” You might even want to ask some families,
“Is that what your experience was?” In defining those shared goals understanding
how you might look at the barriers or the patterns of the gap or the patterns of successes
to be able to really map what’s going on in the community to create these practice and
policy changes. Again, the mother’s medical providers with
some key questions, the infant’s medical providers and how they need to respond to say, “What
does practice look like in our hospitals and in our clinics?” What does the substance abuse medical treatment
and medication assisted treatment providers? What does that look like? Where are they located? How do families get access to those services? Is there a way in which that access is facilitated
for this population? How is care coordinated? Is there case management that’s provided? Then, again, in the child welfare arena, how
are the response workers that take the hotline calls? What kind of awareness do they have of the
different kinds of populations that we’re talking about? What is the emergency response for families
with substance abuse disorders? What is the response for the social worker
who’s carrying the case, etc.? The guidance document allows you to look at
each of those different components, including the courts and family drug courts to understand
what practice is and how you set some goals about how to change that practice. There’s also some guidance on sequencing,
that cross system guide of what should you do first. How do you know where you get a handle on
all of these various players that are involved in the life of these families? How you get some calculations to analyze the
results? Are you having an effect on how you might
be able to operationalize those results and to practice some policy changes? Step four in identifying the strategies and
to monitor those outcomes. Walking through that process of the vision,
mission, goal, strategy, and action plan. Being very concrete at each of these multiple
intervention points during pregnancy, to postnatal infancy, and early childhood, and adolescence. How your community is responding to this set
of families. Strategies for developing those shared outcomes,
identifying again ways to measure over time. Importantly, then how to communicate that
progress to key stakeholders in your community. We certainly have seen an increased amount
of attention to the media. Is there a media strategy that you need in
your community to make sure that both that pre pregnancy awareness is getting out? Also so that the community knows that this
is an approach that’s being taken to ensure that we’re helping families that have opioid
use disorders and that we’re protecting the safety and well being of children and their
families. Strategies to engage other stakeholders. Then importantly, again, in the guidance documented
the case studies from the CHARM Collaborative. CHARM stands for Children in Recovering Mothers. It was first in place in Burlington, Vermont. We became aware of this some decade ago of
the high risk pregnancy clinic. The hospital reaching out to say that they
were seeing a lot of mothers with opioid use disorders and needing access to medication
assisted treatment. In that case, they have put in place some
very important changes in the way in which they engaged mothers and their families with
shared understanding among their partners. Regular opportunities to share information
about particular needs for family members and to ensure that mom is engaging in medication
assisted treatment and substance use treatment services. How the prenatal care is being managed with
this particular changes that may be needed in her obstetric care. One of the things that we think is incredibly
important and it had a very major impact in their community is working through the involvement
of child welfare. How they were able to look at their state
law and determine that child welfare could be involved, like with the pregnant woman,
in the 30 days prior to birth in an assessment track, if you will. That prior to the infant’s birth, the assessment
is conducted so that they’ve eliminated almost completely the surprise or the crisis at birth
for child welfare. That prior to that there is an understanding
of where is the baby going to go? Who is the helper that can come into the home
if the baby is going home? If the baby can’t go home that there is an
immediate safe place for the baby knowing who, perhaps, that person might be or if this
child is going to go into foster care. Having those decisions prior to birth allows
the birth mother to be engaged in understanding the rating of Neonatal Abstinence Syndrome,
understanding the kinds of nonpharmacological as well as pharmacological treatment approaches
for NAS. It completely eliminates for the vast majority
of infants with prenatal opioid exposure that crisis that is created in child welfare for
finding where’s the baby going to go, where’s the right placement, getting the court reports
filed. Now, they tell us that there are still occasionally,
maybe about one pregnant woman that delivers a month that they may not have identified
and know exactly what is going to happen for the plan to safe care or the placement of
that infant before the infant is born. In a community the size of Burlington, Vermont
to have reduced that, to have a plan in place in advance, we think is critically important. We would encourage you to read the CHARM Collaborative
case study. Know then how that could operate potentially
in your community. The policy drivers that are available in Vermont
are not completely unavailable in most jurisdictions, most states in the country. It may be possible now or you may need to
have policy changes in your state so that you can better prepare for the birth of the
infant and to understand when that assessment can be conducted in order to have a plan ready
for the baby and the family prior the child’s birth. We would encourage you to download your copy
today. It’s available on our website. You see the link. It’s at ncsacw.samhsa.gov, National Center
Substance Abuse Child Welfare. There are many other resources that are available
to you on the website related to pregnancy and opioid use disorders treatment. We would encourage you when you get to the
website, look around a little bit and make sure that you’re looking at the other resources. We will be holding a part two of this webinar
series. The six states that have been working with
the National Center over the past, almost, two years now, are going to share their lessons
about using the guidance document about the policy tools, and the practice tools, the
kinds of changes that they have been trying to make in their state, and the progress that
they have made as well as the lessons that they learned. Again, I would encourage you to look when
you get to our website at the resource directory and the other kinds of things that are available
to you about the research. If you’re looking for the data that were presented
today, other kinds of training materials, examples for different sites. There are eight recorded webinars on various
aspects of opioid use disorders in pregnant women. Some explaining medication. Some that are specific to the treatment of
pregnant women with opioid use disorders. Some that are specific to managing NAS. We would encourage you to look at those webinars. If you’re just starting in your community
to try and get a handle on some of these practice and policy issues, we’d encourage you to look
at that library of webinars. Perhaps you look at and view the webinar in
your collaborative and then have the discussion about how that operates in your community. Use those as opportunities to engage your
partners. Then there is also a discussion guide. We’d appreciate your feedback if you look
at what’s in [inaudible 77:52] draft as what a plan of state care might look like
in your community. If you find that there are components of that
that you would like to give us feedback on, we would certainly encourage you and welcome
you to do that. We’re certainly looking for input from many
different jurisdictions around the country and what should be a plan of safe care for
this particular set of families. We also want to make sure that you’re aware
that there are online tutorials that come with free CEUs or Continuing Education Unit. Three different courses that were updated. Just about a year ago they were released. The new content included information on opioid
use disorders and treatment and recovery, as well as specific information family drug
court, about their effectiveness. The three different courses, you see the first
one, “A Guide for Child Welfare.” The second, “A Guide to Substance Abuse Treatment
Professionals.” That explains the dependency court and the
timing and what child welfare practice looks like when you have a family in treatment that
may be involved in child welfare. The third one, “A Guide for Legal Professionals”
for attorneys and judges, other court administrators that are running dependency or family court
that are seeing this concentration of families with substance abuse disorders that may need
some information about how to better work with this particular set of families. Also on the website are a series of monographs
and other kinds of guidelines and publications that have been created over the last decade
by the National Center on Substance Abuse and Child Welfare. If you don’t see a topic that you have a question
about on our website, there is a link that you can send us an email and ask your question. We have many staff that that’s what their
main part of their work week is responding to your emails and making sure that we’re
meeting your needs for information and for examples of how other jurisdictions may have
dealt with some of these very complex issues of substance use disorders and child welfare. Let me open things up. Let me just tell you that when you close out
of the webinar today there will be an opportunity to evaluate this webinar. We would encourage you to do that. We’d appreciate very much your feedback on
that survey so that we can improve our approach in disseminating this information. Then now let me see if there are some questions
that came in. I think perhaps more questions then we’ll
have time to cover in our remaining five minutes. We will take into consideration all of your
questions and try and make sure that we make that available to the individual who registered
for the webinar today. Claudia or Hanh, you have some questions? Hanh: Yeah. Dr. Young, can you talk to us a little bit
about how different communities have supported collaboratives in their communities? Particularly, are there funding sources that
communities have typically looked towards? Are there any, I guess, in the horizon? Nancy: There are some on the horizon but before
I speak to that let me just say that most communities have a child abuse coalition or
a children’s coalition. Many governor’s offices have a cabinet level
office on children and families. Many child welfare offices have advisory committees
or child abuse and neglect counsels. We would encourage you to look at the existing
structure in your community about how Child Abuse and Neglect collaboratives are supported. If you don’t, we certainly would like to hear
from you about how we might help you with some of that. We also know that there have been various
grant programs that have been put in place over the last 10 years now. The Regional Partnership Grants. If you’re interested in getting outside funding,
we would encourage you to look at Children Bureau’s announcement of new Regional Partnership
Grant funding that will be coming out in the spring for application. We are encouraged that there will be a new
ground, and that gives funding to communities to build these collaboratives. Claudia: Thanks Dr. Young, I think we time
for one more question. What is the role of early intervention partners
and working with this population? Nancy: That’s then something that has been
a difficult component all the way back to the cocaine epidemic. The assessment of early intervention that
needs to happen as a requirement, again, of the Child Abuse Prevention and Treatment Act,
sometimes these infants and toddlers may not score on the standardized tools in a way that
generate eligibility or early intervention. They critically need to be part of the collaborative
groups. There is technical assistance that’s available. If you need that in your community to make
sure that the developmental assessment that are being conducted, and the early intervention
that’s been put in place, specifically, has intervention for some of the effects that
may be evident from neuro developmental challenges. That infants may be exhibiting, again, from
the prenatal alcohol exposure, or other substance exposure, as well as some of the changes that
infants may be experiencing in their caregiving environment that can have effects that they
need to be attended too, specifically. While I may have not mentioned them specifically
in the collaborative group, we know that they are part of the needed system response and
practice response to ensure that that component for the infant’s development is addressed
appropriately and that the appropriate kinds of interventions are in place to ensure that
the baby, the infant has optimal development opportunities. I think that wraps up our time for today. We appreciate, again, so much your time to
participate with us. We would encourage you again to visit our
website and be in touch with us. We look forward to the opportunities to speak
with you during our next webinar coming up with part two. Thank you so much.

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