Reports From the Field

Addressing Maternal Mortality Through Education: The Mommies Methadone Program

Journal of Clinical Outcomes Management. 2020 November;27(6):e4-e9 | 10.12788/jcom.0032

References

1. Centers for Disease Control and Prevention. Opioid painkiller prescribing: where you live makes a difference. CDC website. www.cdc.gov/vitalsigns/opioid-prescribing. Accessed October 28, 2020.

2. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network, 2011: national estimates of drug-related emergency department visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville (MD): SAMHSA; 2013. www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf. Accessed October 28, 2020.

3. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374:154-63.

4. National Center for Health Statistics. NCHS data on drug-poisoning deaths. NCHS Factsheet. https://www.cdc.gov/nchs/data/factsheets/factsheet-drug-poisoning-H.pdf. Accessed October 28, 2020.

5. National Institute on Drug Abuse. America’s addiction to opioids: heroin and prescription drug abuse. Bethesda (MD): NIDA; 2014. www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed October 28, 2020.

6. Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: SAMHSA, 2011 Contract No.: HHS Publication no. (SMA) 11–4658.

7. Maeda A, Bateman BT, Clancy CR, et al. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes. Anesthesiology. 2014;121:1158-1165.

8. Whiteman VE, Salemi JL, Mogos MF, et al. Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. J Pregnancy. 2014;2014:1-8

9. Pregnancy Mortality Surveillance System. www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm#trends. Accessed February 4, 2020.

10. Macdorman MF, Declercq E, Cabral H, Morton C. Recent increases in the U.S. maternal mortality rate. Obstet Gynecol. 2016;128:447-455.

11. Texas Health and Human Services. Maternal Mortality and Morbidity Task Force and Department of State Health Services Joint Biennial Report, September 2018. www.dshs.texas.gov/legislative/2018-Reports/MMMTFJointReport2018.pdf

12. Virginia Department of Health. Pregnancy-associated deaths from drug overdose in Virginia, 1999-2007: a report from the Virginia Maternal Mortality Review Team. Richmond, VA: VDH; 2015. www.vdh.virginia.gov/content/uploads/sites/18/2016/04/Final-Pregnancy-Associated-Deaths-Due-to-Drug-Overdose.pdf. Accessed October 28, 2020.

13. Maryland Department of Health and Mental Hygiene. Maryland maternal mortality review 2016 annual report. Baltimore: DHMH; 2016. https://phpa.health.maryland.gov/Documents/Maryland-Maternal-Mortality-Review-2016-Report.pdf. Accessed October 28, 2020.

14. Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol. 2014;123:997-1002.

15. Reddy UM, Davis JM, Ren Z, et al. Opioid use in pregnancy, neonatal abstinence syndrome, and childhood outcomes. Obstet Gynecol Survey. 2017;72:703-705.

16. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35:650-655.

17. Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction during pregnancy. In: Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series, No. 43. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005:211-224.

18. Wojnar-Horton RE, Kristensen JH, Yapp P, et al. Methadone distribution and excretion into breast milk of clients in a methadone maintenance programme. Br J Clin Pharmacol. 1997;44:543-547.

19. Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015;10:135-141.

20. Sachs HC. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Committee on Drugs. Pediatrics. 2013;132:e796-809.

21. Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract. 2014;9:19.

22. Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. Obstet Gynecol. 2017;130:488-489.

23. Gopman S. Prenatal and postpartum care of women with substance use disorders. Obstet Gynecol Clin North Am. 2014;41:213-228.

24. Mitchell M, Severtson S, Latimer W. Pregnancy and race/ethnicity as predictors of motivation for drug treatment. Am J Drug Alcohol Abuse. 2008;34:397-404.

In addition, maternal mortality reviews in several states have identified substance use as a major risk factor for pregnancy-associated deaths.^12,13 In Texas between 2012 and 2015, opioids were found in 58% of maternal drug overdoses.¹⁰ In 2007, 22.8% of women who were enrolled in Medicaid programs in 46 states filled an opioid prescription during pregnancy.¹⁴ Additionally, the rising prevalence of opioid use in pregnancy has led to a sharp increase in neonatal abstinence syndrome (NAS), rising from 1.5 cases per 1000 hospital births in 1999 to 6.0 per 1000 hospital births in 2013.¹⁵ Unsurprisingly, states with the highest rates of opioid prescribing also have the highest rates of NAS.¹⁶

Methadone combined with counseling and behavioral therapy has been the standard of care for the treatment of OUD in pregnancy since the 1970s. Methadone treatment prevents opioid withdrawal symptoms and increases adherence to prenatal care.¹⁷ One of the largest methadone treatment clinics in the San Antonio, TX, area is the Center for Health Care Services (CHCS). University Health System in San Antonio (UHS) has established a clinic called The Mommies Program, where mothers addicted to opioids can receive prenatal care by a dedicated physician, registered nurse, and a certified nurse midwife, who work in collaboration with the CHCS methadone clinic. Pregnant patients with OUD in pregnancy are concurrently enrolled in the Mommies Program and receive prenatal care through UHS and methadone treatment and counseling through CHCS. The continuity effort aims to increase prenatal care rates and adherence to methadone treatment.

Once mothers are off illicit opioids and on methadone, it is essential to discuss breastfeeding with them, as many mothers addicted to illicit opioids may have been told that they should not be breastfeeding. However, breastfeeding should be encouraged in women who are stable on methadone if they are not using illicit drugs and do not have other contraindications, regardless of maternal methadone dose, since the transfer of methadone into breast milk is minimal.^18-20 Breastfeeding is beneficial in women taking methadone and has been associated with decreased severity of NAS symptoms, decreased need for pharmacotherapy, and a shorter hospital stay for the baby.²¹ In addition, breastfeeding contributes to the development of an attachment between mother and infant, while also providing the infant with natural immunity. Women should be counseled about the need to stop breastfeeding in the event of a relapse.²²

Finally, the postpartum period represents a time of increased stressors, such as loss of sleep, child protective services involvement, and frustration with constant demands from new baby. For mothers with addiction, this is an especially sensitive time, as the stressors may be exacerbated by their new sobriety and a sudden end to the motivation they experienced from pregnancy.²³ Therefore, early and frequent postpartum care with methadone dose evaluation is essential in order to decrease drug relapse and screen for postpartum depression in detail, since patients with a history of drug use are at increased risk of postpartum depression.

In 2017 medical students at UT Health Long School of Medicine in San Antonio created a project to educate women about OUD in pregnancy and provide motivational incentives for sustained abstinence; this project has continued each year since. Students provide education about methadone treatment and the dangers of using illicit opioids during and after pregnancy. Students especially focus on educating patients on the key problem areas in the literature, such as overdose, NAS, breastfeeding, postpartum substance use, and postpartum depression.