TWO PATIENTS IN ONE
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I learned of the neurobiology of addiction early in my self-study program . This area of study gave me a better understanding of the brain dysfunction leading patients to continue destructive behavior and to relapse . This was the first lesson shared with my residents , and this knowledge led to greater understanding , empathy and patient engagement . Before studying , I was dumbfounded when patients reported that a friend or relative ’ s fatal overdose prompted their relapse . An understanding of the changes in the amygdala and limbic system leads to a more informed approach to treatment and counseling . The neurobiology of addiction continues to be the first topic of discussion when I mentor new students , nurses and residents .
MOVING FROM DETOXIFICATION AND REFERRAL TO OFFICE CARE :
We quickly developed some proficiency with initial evaluation and stabilization . However , outpatient substance use disorder ( SUD ) treatment resources were very limited for pregnant women . There was only one methadone treatment program that would expedite care for pregnant OUD patients by prioritizing intake regardless of ability to pay . Most buprenorphine clinics did not accept pregnant women , and all were cash-pay enterprises . The Mental Healthcare Parity and Affordable Care Acts eventually facilitated greater access to care , but there was an immediate need for additional options for pregnant women in crises . My initial response was to obtain a waiver to prescribe buprenorphine and to provide medication-assisted treatment ( MAT ) during prenatal visits in order to remove the financial barrier . Patient acceptance and satisfaction was high ; neonatal outcomes were improved . However , there were several challenges inhibiting long-term recovery .
1 . Authorization for buprenorphine prescriptions required patients to have Behavioral Health Services , a necessary component of recovery . Behavioral Health Services remained difficult to arrange in a timely fashion . It was difficult to obtain documentation of compliance because attendance sheets from Alcoholics Anonymous or Narcotics Anonymous meetings are not easily verified and communication with various outside Behavioral Health Programs was laborious ( CFR 42 Part 2 authorization consents are required , and most centers were unaccustomed to communicating with medical providers ). Patients were often non-compliant with visits , citing lack of child care , work hours and lack of transportation .
2 . Few patients continued MAT after delivery . We promised to provide MAT during the pregnancy and directed patients to make pre-payments to a buprenorphine provider for MAT after delivery . Many were “ hustling ” for daily cash to support their addiction prior to entering treatment . Continuation of illegal activities for the purpose of obtaining medical care was undesirable . If they didn ’ t have financial resources for MAT during pregnancy , they were unlikely to have them after the delivery ; babies are expensive .
3 . Follow up for postpartum medical services was poor . The challenges of newborn care and the chaos brought from failure to continue MAT made family planning and hepatitis C treatment impossible .
AN INTEGRATED CARE MODEL FOR PREGNANCY AND BEYOND :
The Maternal Opiate and Substance Treatment ( MOST ) Program was created at Norton Women and Children ’ s Hospital in July 2015 . In addition to improving perinatal outcomes , our goal was to facilitate long-term recovery and health . A nurse navigator coordinated admission for stabilization , communication with outside providers and behavioral health centers as well as post-MAT induction follow up appointments . Initially , a single maternal-fetal medicine doctor provided MAT and a single Licensed Clinical Social Worker ( LCSW ) provided individual counseling . At the time of the program ’ s inception , MAT providers for pregnant women on Medicaid was still scarce . Access to care for these women was difficult because buprenorphine providers would not accept pregnant women who did not have an obstetrician and obstetricians were reluctant to assume care for OUD pregnancies that didn ’ t already have addiction medicine care . The MOST program ’ s initial goal was to expedite care by starting the obstetrical care and MAT induction as soon as possible . Some patients continued obstetrical and / or MAT care with the MOST program . Most were referred out for obstetrical and MAT care depending on geography , access to transportation and patient preference . The program was successful . We noted reduced Neonatal Opioid Withdrawal Syndrome ( NOWS ) and as word spread , patients were initiating care earlier in gestation .
The MOST program has continued to evolve and stretch toward the goal of facilitating long-term recovery with improved lifelong prospects for mother and child . The most prominent changes have been :
1 . The addition of a second LCSW counselor . This has allowed the program to provide twice weekly group meetings ( telemedicine during the COVID-19 pandemic ). We also added an after-hours group meeting to better accommodate those who work .
Methamphetamine addiction has become much more prevalent in the last several years . We are now able to offer individual and group counseling for those patients . The integration of counseling
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