Using a collaborative care model, Dr. Schauberger and his nonphysician colleagues will see patients together. “We’ll often have two or three staff members in the room – at least the social worker, the care coordinator, and myself,” he said. Recognizing that “the patient, not the doctor, is at the center of the care model” is critical for making things work, he said. “It’s important for everyone on the team to be aware of that.”
The collaborative model helps to address the many nonmedical challenges that can contribute to ongoing issues with substance use. Family dynamics and the presence – or absence – of a support system can make a big difference in adherence to a treatment plan during pregnancy and in the postpartum period. “The social, political, and legal issues are really what are important. … We try to get them into the system as soon as possible,” he said. His practice has a close connection with the addiction team at Gundersen Health, which dispenses methadone, as does a private addiction clinic in town, said Dr. Schauberger, who prescribes buprenorphine.
Wisconsin is one of the three states where pregnant women can be committed for coerced treatment, said Dr. Terplan. Dr. Schauberger has a good connection with his legal system locally, and he views any possibility of incarceration or commitment for substance use in pregnancy as “a serious problem that we need to avoid.”
Not all physicians practice in an environment where they have the luxury of specialization, and Dr. Schauberger said that the demand is too high in many places for primary care providers not to manage the care of pregnant women with substance use disorders. Though these women are high risk, “it is a type of high risk that a family medicine doctor should be able to take care of without problem. Primarily the risks are premature labor and intrauterine growth retardation, which are both problems that most family medicine doctors that do obstetrics should be able to identify and follow,” he said.
This fits with the mission of family practice, said Dr. Filer. As a specialty, “family practice is tied in to community resources,” she said. “Knowing your referral network is vital.” She also sees a growing trend of AAFP members who have completed addiction medicine fellowships. “This reflects a practice need – and a community need,” she said.
One family practice physician’s rural southeast Nebraska practice necessitates a creative and flexible approach to caring for pregnant women with opioid use disorder. Robert Wergin, MD, the only physician in the small town of Milford, Neb., has a cradle-to-grave practice that includes obstetrics. When on call, he’s also the emergency physician at the 25-bed critical-access hospital that serves his area. The opioid epidemic touches his pregnant patients frequently.
Dr. Robert Wergin
Dr. Wergin is the current board chair of AAFP, as well as a past president of the organization. A Nebraska native, he draws his resources from the community, often tapping local pastors for help. He recently referred a pregnant woman to a church food pantry, since her food aid for the month had run out and she had another 10 days to face with an empty larder. “You’ve got to look at the comprehensive picture, and really know the patient to understand barriers to care, such as transportation problems and poverty.”
The area has no methadone clinic, and the few buprenorphine prescribers in the area usually have full practices and waiting lists. This means that optimal MAT may not be achievable. When he can, he sends patients to Lincoln, Neb., about 30 miles away, for treatment. If that’s not feasible, and the problem is identified early in the pregnancy, Dr. Wergin may help patients taper to eliminate or reduce opioid use.
An opinion reaffirmed in 2014 by ACOG recognized that MAT may not be accessible to all. ACOG’s Committee on Health Care for Underserved Women, together with the American Society of Addiction Medicine, wrote, “If the alternative to medically supervised withdrawal is continued illicit drug use, then a medically supervised withdrawal in the first trimester is preferable to waiting until the second trimester.”
Dr. Wergin also works hard to incorporate family supports into his care of substance-using pregnant women. “Comprehensive care is really important,” he said. “Somehow, you have to get a buy-in from the patient,” and sometimes a supportive mother or partner can make a big difference in maternal and neonatal outcomes, he explained. Rapport and trust are critical, and his career-long presence in the community has helped build that trust with the families for whom he cares, he said.