Population Management

PMH Care Pathway - Management of Substance Use in Pregnancy

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Webinar Slides: Management of Substance Use in Pregnancy – PMH May 2015

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Webinar: Management of Substance Use in Pregnancy – PMH May 2015

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Management of Opioid Use in Pregnancy

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Urine Drug Screening Guidance for PMH Providers

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Pain Contracts/Treatment Agreements

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Use of the North Carolina Controlled Substances Reporting System

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Strategies and Scripts for Brief Interventions for PMH Providers

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CAPTA, reporting of substance-exposed pregnancies, and sample script for PMH providers

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Disclosure of information related to substance use for PMH providers

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Patient education resources – Substance Use in Pregnancy

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Provider resources – Substance Use in Pregnancy

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Reimbursement and coverage of substance abuse services for pregnant women

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NC Perinatal & Maternal Substance Abuse Initiative

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Prescribing buprenorphine in pregnancy

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PMH Care Pathways: Management of Substance Use in Pregnancy

April 2015

Background
Substance use is a persistent challenge in our society across all demographic groups and raises specific concerns and complications in pregnancy. Screening, brief intervention and referral to treatment (SBIRT) is an evidence-based approach to addressing substance use in clinical practice and is endorsed in the obstetric setting. Brief interventions in the prenatal care setting serve as teachable moments and may help women with substance use in pregnancy to reduce or eliminate use. For some women, the SBIRT approach will lead to treatment and recovery. The benefits of the pregnant woman’s behavioral change have proven to be effective in improving birth outcomes for the newborn.

1. Use universal verbal/written screening with patients at the initial prenatal visit and across pregnancy1. Urine drug screening is not recommended universally.

a. Establish a non-judgmental approach to addressing substance use. See Appendix E for sample language. 

b. Complete the PMH Risk Screening Form with new OB patients at the beginning of the first prenatal visit. Questions 8-13 on the “patient” side of the form are standardized substance abuse screening questions, adapted from the Modified 5 P’s instrument . i. A clinician (nurse, nurse practitioner, midwife, physician assistant or physician, per DMA Policy 1E6, Section 5.3.1) should review both sides of the screening form with the patient before the patient leaves and follow up on any positive responses in detail. 

c. Gather additional information to assess the patient’s risk for problems with drugs or alcohol from the following sources or others as appropriate:
Review the patient’s current medication regimen with the patient, including asking her about any misuse of prescription medications.
Check the NC Controlled Substances Reporting System (NC CSRS) and CCNC’s Provider Portal for prescription fill history to identify potential misuse of prescription drugs. See Appendix D for information about the use of the NC CSRS.
Ask about any past or current substance abuse treatment, including residential, outpatient, medication-assisted therapy for opioid use disorder, 12-step programs or other treatment modalities.

d. Record relevant information in the medical record. See Appendix G for guidance related to the documentation and disclosure of substance use information.i. Federal regulations restricting the disclosure of substance abuse treatment information do not apply to patient self-disclosure to her provider or substance abuse information gathered from other medical providers. ii. Providers should only include medically necessary and accurate information with no subjective comments when documenting and disclosing information related to substance use. 

e. Refer to the Pregnancy Medical Home Care Pathway on Perinatal Tobacco Use for guidance on the management of patients who report tobacco use during pregnancy on the PMH risk screening form.

2. Complete further assessment based on information gathered above: If patient answers “yes” to Risk Screening Form questions about current use of drugs or alcohol (question 13), about use of drugs or alcohol prior to pregnancy (question 12) or about past problems with drugs or alcohol (question 11), or screening findings indicate any potential concern about the patient’s use of drugs or alcohol or misuse of prescription drugs:

a. Ask the patient to specify what substance(s) she was referring to when responding to these questions.

b. Ask about frequency of use (“What do you mean by rarely, sometimes, or frequently?”)
i. Ask the patient how many days per week on average she uses or was using each substance and about times when she may have used more.
ii. Ask the patient to specify how much of each substance she uses or was using at one time.
iii. Ask when the last use was for each substance.

c. For patients who report past problems with drugs or alcohol:
i. Ask the patient to describe her past difficulties with substance use
ii. Ask the patient to describe her experience with substance use in previous pregnancies
iii. Offer support and referral for further substance use assessment or treatment as needed.
iv. Encourage the patient to disclose to you any concerns about substance use at this time or during the pregnancy and let her know that you will be checking in with her about substance use during the pregnancy

3. Offer a brief intervention to raise awareness of the risks of drug and alcohol use in pregnancy and to increase the patient’s motivation to acknowledge and address any problems related to use of these substances.3   Include a clear recommendation delivered in a non-judgmental, caring, and respectful manner to discontinue use of drugs and alcohol immediately for patients with any current use. See Appendix E for guidance on how to conduct a brief intervention. Patients on opioid therapy for chronic pain management or medication-assisted treatment for opioid dependence should not be advised to discontinue treatment; those using opioids illicitly should be referred for medication-assisted treatment. See Appendix A for further guidance on management of opioid dependence in pregnancy.

a. Provide clear, accurate information to all patients on possible effects of all common substances on the fetus.
i. Offer easy-to-read written materials and links to websites with reliable information for patients on substance use in pregnancy (see Appendix H for patient education resources)
ii. Encourage patients to bring questions about substance use to future prenatal visits.

b. For patients without current or recent substance use and without a history of significant problems with drugs or alcohol:
i. Reinforce positive behavior of abstaining from alcohol and drug use during pregnancy.
ii. Reinforce benefits of avoiding drug and alcohol use during pregnancy and for women’s health generally at subsequent visits.
iii. Reassess drug and alcohol use once per trimester and at post-partum visit, or if potential risk indicators are noted that warrant reassessment (see Appendix B for risk indicators). 

c. For patients who have a history of problems with drug or alcohol abuse but no current use:
i. Provide support for ongoing non-use and reinforce positive behavior of abstaining from alcohol and drug use during pregnancy.
ii. Consider further assessment or treatment, if warranted.
iii. Schedule more frequent prenatal visits.
iv. Consider referral to pregnancy care manager, especially if there are concerns about the potential for relapse.

d. For patients who have stopped using drugs or alcohol recently or since learning of the pregnancy:
i. Provide support for ongoing non-use and reinforce positive behavior of abstaining from alcohol and drug use during pregnancy.
ii. Consider further assessment or treatment, especially for patients who have only recently discontinued substance use.
iii. Schedule more frequent prenatal visits.
iv. Ensure that the patient has a pregnancy care manager.
v. Discuss referral options with the patient; see Section 4, Referral, below.

e. For patients with current substance use (see Appendix A for guidance specific to patients with current opioid use):
i. Assess the patient’s perception of problem and readiness to change her behavior, including her desire to stop using drugs or alcohol and her willingness to accept a referral for substance abuse assessment and/or treatment.
ii. Ensure that the patient has been referred to a pregnancy care manager.
iii. Schedule more frequent prenatal visits.
iv. Discuss referral options with patient; see Section 4, Referral, below.
v. For patients who do not agree to abstain from use and who do not want a referral for substance abuse assessment or treatment:
1. Utilize motivational interviewing techniques to engage the patient in ongoing discussion about her substance use.
2. Focus on strategies to reduce risk, such as decreasing use, increasing safety around use, and promoting optimal self-care.
3. Regularly reassess the patient’s readiness to change and adjust the plan of care accordingly, including offering referral for substance abuse assessment and/or treatment again.

f. Consider the use of urine drug screening for patients with a history of or with active substance abuse (see Appendix B for urine drug screening considerations).
1. Elicit the patient’s permission to perform urine drug screening randomly during the pregnancy.
2. Conduct urine drug screening once per trimester or more often for patients with active use during pregnancy.

4. Referral for Substance Abuse Assessment and Treatment: Patients who may benefit from a referral to a behavioral health provider for a substance abuse assessment include:
• those who have tried to stop using alcohol or drugs in the past without success,
• those who are currently using alcohol or drugs during pregnancy and are not confident in their ability to stop, and/or
• those who are not ready to stop but who are willing to meet with a behavioral health provider for assessment.
For patients who are ready to enter a substance abuse treatment program or who are in need of acute stabilization, see Sections 5d and 5e below.

a. Make a referral for substance abuse assessment for any patient who would benefit from this service. Explain that a substance abuse assessment with a behavioral health provider is a consultation with a specialist, as with any medical consultant, rather than a requirement that she enter substance abuse treatment. 

b. For outpatient or community behavioral health referrals for a substance abuse assessment, if a behavioral health provider is known to the practice, make a referral directly to that provider, preferably by phone with the patient present, or using whatever existing local referral process is already in place.
i. When speaking with the behavioral health provider, request an appointment for the patient to receive an assessment and for service recommendations (which are to be reported back to the prenatal care provider, per signed written consent).
ii. Prenatal care providers should establish pathways for referral and for coordination of care with local substance abuse treatment providers.

c. If the practice does not know of a behavioral health provider, call the Local Management Entity/Managed Care Organization (LME/MCO) Screening, Triage, and Referral (STR) line with the patient present. The LME/MCO will conduct an assessment and link the patient to a behavioral health provider in the community. The LME/MCO STR phone numbers can be found here: http://www.ncdhhs.gov/mhddsas/lmeonblue.htm
i. Pregnant patients who are uninsured or on Medicaid and are using substances are a priority population for the state LME/MCO system.
ii. When speaking with the LME/MCO, request an appointment for the patient to receive an assessment and for service recommendations (which are to be reported back to the prenatal care provider, per signed written consent).

d. For patients requesting a substance abuse treatment program:
i. Contact the NC Perinatal Substance Use Coordinator through the Alcohol/Drug Council of North Carolina at 800 688-4232 for assistance identifying a program or managing the referral process. See Appendix K for more information.
1. The NC Perinatal and Maternal Substance Abuse Initiative and CASAWORKS for Families Residential Initiative coordinates 28 evidence-based, gender-specific substance abuse treatment programs for pregnant and parenting women across the state.
ii. Refer the patient directly to a community-based substance abuse treatment program if a program that can meet the patient’s current needs is known to the practice.
1. Prenatal care providers should be familiar with local substance abuse treatment providers, including having established pathways for referral to treatment and coordination of care.

e. For patients in need of acute stabilization prior to entry into a community-based and/or residential treatment program, utilize available inpatient options, including the state-operated Alcohol and Drug Abuse Treatment Centers (ADATCs) or tertiary centers that manage pregnant patients with acute substance use treatment needs.
i. The three state ADATCs all accept pregnant women from their catchment areas. Pregnant women are a priority population.
1. The Julian F. Keith ADATC serves patients in the western counties of the state, and the R.J. Blackley ADATC covers the central part of the state.
2. In addition to serving women from eastern Carolina, the Walter B. Jones ADATC in Greenville, NC accepts pregnant women statewide, including those with high-risk pregnancies, and is able to provide medication-assisted therapy for opioid use disorder on site.
ii. To refer to an ADATC, complete the Regional Referral Form available on the Department of State-Operated Healthcare Facilities website (http://www.ncdhhs.gov/dsohf/professionals/admissioncriteria-adatc.htm).
1. Fax the form to the number listed on the website for the ADATC to which the referral is being made, then follow up with a phone call to the Admissions Coordinator, whose number is also posted on the DSOHF website.
2. The NC Perinatal Substance Use Coordinator, who can be reached at 1-800 688-4232, can help facilitate referrals to these facilities.
iii. For patients needing induction of medication-assisted therapy for opioid use disorder, see Appendix A, “Management of Opioid Use in Pregnancy.” 

f. For all referrals, have patient sign consent/release of information forms in order to coordinate care with the behavioral health provider. To share information on substance use assessment and treatment, substance use treatment providers will have the patient sign a 42 CFR, Part 2- specific release of information form. See Appendix G. “Guidance on documentation and disclosure of information related to substance use and its treatment” for more information.

g. Identify and address potential barriers to the patient following through with the referral, such as transportation, childcare, or fears about how she will be treated in the behavioral health setting.

h. Refer the patient for pregnancy care management if she is not already working with a care manager.
i. Ensure the pregnancy care manager is aware of the referral for assessment/treatment in order to assist the patient to follow through, including assisting in addressing barriers to attending an appointment for substance use assessment.

5. Management of patients who are currently receiving substance use disorder treatment (for patients receiving medication-assisted therapy for opioid use disorder see Appendix A, “Management of Opioid Use in Pregnancy”): If patient is currently involved in substance use disorder treatment, the prenatal care provider should work closely with the substance abuse treatment provider to coordinate care. 

a. Ask the patient about participation frequency and quality of treatment received.
i. If current treatment is not meeting the patient’s needs, work with the pregnancy care manager, LME/MCO, and/or the treatment provider to explore alternative treatment options.

b. Have the patient sign consent for release of information forms in order to provide coordinated care. See Appendix G for information on release of information forms specific to substance use treatment.

c. Contact the treatment provider to coordinate care, including reviewing medications being prescribed in both the behavioral health and prenatal settings. 

d. Maintain contact with the treatment provider over the course of the pregnancy and postpartum period

e. Identify and resolve barriers to treatment adherence.

f. Ensure the patient has a pregnancy care manager.

Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L

1American College of Obstetricians and Gynecologists: At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. Committee Opinion No.422. Obstet Gynecol 2008: 112; 1449-60.

2Kennedy C, Finkelstein N, Hutchins E, Mahoney J. Improving screening for alcohol use during pregnancy: the Massachusetts ASAP program. Maternal Child Health J. 2004 Sep;8(3):137-47.

3American College of Obstetricians and Gynecologists: Motivational Interviewing: A Tool for Behavior Change. Committee Opinion No.423. Obstet Gynecol 2009; 113: 243-6.