PREVENTING ADDICTION
TWO PATIENTS IN ONE
Genes Prenatal Drug Exposure Environment ACE Scores
Present |
Not modifiable |
1 . Support continuation of naltrexone in pregnancy
2 . Reconsider “ MAT dose does not matter ” – TENS , massage , meditation ; exercise and coaching on measures to improve sleep
|
1 . Partner with family and friends for resources / assistance
2 . More residential beds and programs
|
1 . Assist partners with access to SUD care & social services
2 . Adoption vs . foster care ?
|
Future |
Future study of epigenetic influences including drugs , stress and nutrition |
Research prenatal and postnatal supplements to enhance neuronal health Improved maternal nutrition |
1 . Fund and develop more SUD programs with family housing
2 . Research brain imaging & functional testing followed by customized childhood therapy and recreational programs
|
Enhanced family monitoring , enhanced collaboration 1 . Peds + OB-GYN-MAT provider 2 . Buprenorphine waivers for IM / Peds specialists |
with obstetrical care removes barriers and encourages patients to engage in SUD treatment . We are also able to directly witness and document progress , obtain serial drug screening and quickly adjust treatment plans when poor attendance or urine toxicology suggests reinstatement .
2 . Additional group members have obtained buprenorphine waivers ( five physicians and five nurse practitioners ). Hence , we can provide office visits every day of the week and inpatient consults for pregnant patients presenting to the ER in acute withdrawal or with sepsis , abscess or endocarditis .
3 . The MOST program has always strived to engage patients expeditiously . We are now able to continue care well beyond delivery . The goal is to continue for one year , but some patients choose to remain longer .
LONG TERM ADVANTAGES OF AN INTEGRATED CARE MODEL
Substance use disorders are prevalent , and the condition is not confined to the poor and uninsured . At least one in 20 adults have an alcohol or drug use disorder . Many of these patients already have relationships with medical providers . Medical providers have an opportunity to discuss substance use in an environment of trust . Patients experience less shame and guilt when they see empathetic medical providers . Nothing communicates empathy and caring more than a commitment to provide continuing involvement and treatment .
Some important health maintenance and treatment interventions require multiple visits or do not occur until many weeks after delivery . Vaccinations ( e . g . hepatitis A & B , pneumococcal , meningitis , rubella , varicella , COVID-19 boosters ) are important for patients with SUD because they frequently have crowded living conditions and contact with at-risk friends and relatives . Hepatitis C treatment is usually delayed until after the patient completes pregnancy and recovery . Compliance with routine postpartum follow up visits is only 45 % among patients on Medicaid and even lower among women with SUD . However , the MOST program has seen improved rates of follow up as we have extended MAT care well beyond pregnancy . Most notable is the improved use of family planning . Two-thirds of SUD patients do not use contraception and those who do , use less reliable methods such as condoms or oral contraceptive pills . Two-thirds of our integrated care patients have chosen Long-Acting Reversible Contraception ( subdermal implants or IUD ) or tubal ligation .
CHALLENGES PRESENT AND FUTURE
The most immediate challenge is the conversion from use of true natural opiates to potent fentanyl analogs which have produced the recent spike in overdose deaths . Even the patients who believe they are taking oral opioids are often taking fentanyl derivatives produced to appear like prescription pain pills . The increased potency to these substances results in more rapid progression from abuse to addiction . Our MOST program has experienced an increase in Against Medical Advice discharges as patients are experiencing intolerable symptoms despite our use of multiple symptomatic agents in high doses . The same has been reported by other states and treatment programs . Fentanyl is initially metabolized to norfentanyl which also acts as a mu opiate receptor agonist . Some patients have reduced norfentanyl clearance which can predispose to severe withdrawal
( continued on page 16 ) MARCH 2022 15