New York State (NYS) Opioid Use

Disorder (OUD) in Pregnancy &

Neonatal Abstinence

Syndrome (NAS) Project

Coaching Call Webinar

September 10, 2019

Welcome & IntroductionsMarilyn Kacica, MD, MPH

Medical Director

Division of Family Health

New York State Department of Health

Agenda12:00 PM –

12:10 PM

Welcome & Introductions

▪ Marilyn Kacica, MD, MPH

Medical Director, Division of Family Health

New York State Department of Health

12:10 PM –

12:55 PM

Accessing Consultation Services &

Warmline Assistance for OUD

▪ Mishka Terplan, MD, MPH, FACOG, FASAM

Adjunct Faculty, Clinical Consultation Center, University of

California, San Francisco

Consultant, National Center on Substance Abuse and Child

Welfare

12:55 PM –

1:00 PM

Next Steps

▪ Kelly Gilchrist

Manager, Executive Office/Medical Education

American College of Obstetricians and Gynecologists (ACOG)

District II

Accessing Consultation Services & Warmline Assistance for OUD

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1OHA30039-03-03 (AIDS Education and Training Centers National Clinician Consultation Center) in partnership with the HRSA Bureau of Primary Health Care (BPHC) awarded to the University of California, San Francisco.

September 10, 2019National Clinician Consultation Center

Mishka Terplan, MD, MPH, FACOG, DFASAM

Clinician Consultation Center:Who we are,what we do,and more…

- National tele-consultation/education arm of AETC Program: have offered free clinical decision support to health care providers for 25+ years

- Multi-disciplinary, inter-professional teams → 500+ years of collective experience on viral hepatitis, HIV, and substance use

- Point-of-care/”one-stop” resource for individually-tailored consultation

- Practical, compassionate assistance (“options, not answers”)

Who is the CCC?

Our mission is to improve health outcomes by building the capacity of healthcare providers through expert clinical consultation and education.

What does the CCC do?

• Consultation Goals:

– Provide up to date and evidence-informed, guidelines-based tele-consultation that can help optimize patient health outcomes

– Share expert opinion and best practices in “gray-zone” or “data-free” areas

– Provide useful references and resources

– Build provider capacity to manage similar cases in the future

• Care that is convenient, confidential, tailored, practical

CCC offers a different type of “clinical decision support”

How do the Warmlines work?

‘Live’ hepatitis C, HIV, and substance use tele-consultation available 9am – 8pm ET, Mon-Fri (Perinatal HIV Hotline 24/7)

Calls ring into San Francisco General Hospital offices during usual hours (voicemail available after hours). Clinicians can also submit electronic consultation request via CCC portal any time: nccc.ucsf.edu. All messages returned within 1 business day.

No patient identifiers are collected or stored in CCC case notes: all consultations are confidential(organized under caller/practice). Caller registration takes 2-3 min.

Multi-disciplinary, inter-professional consultant teams

Generalist- and specialty- trained physicians (all with experience in hepatitis C, HIV, and/or substance use); advanced practice nurses; clinical pharmacist specialists

“We learn a lot from our callers, and our callers learn a lot from their patients and communities”

11

Persistent stigma associated with some health conditions

“Share the care”: task-shifting and

integration within non-specialty settings

Resources (e.g.,navigator, tele-health, specialty pharmacies,

CCC, ECHO)

“Care cascades”: bridging gaps between diagnosis and treatment, creating low-threshold services

Convenient, accessible: co-located, multi-disciplinary services

Safe, non-judgmental

education and counselling,

risk/harm reduction interventions

Patient, community, and provider

education

Simple, highly effective medications: how can use of these be shared with, and/or

complement traditional healing approaches?

Substance Use Warmline (7/1/2017-6/30/2018)

• 7% relate to substance use in pregnancy

• 6% calls relate to reproductively-aged patients

• OUD>>>>AUD>>Benzo – stimulants rare

• 16% documented co-occurring mental health condition

• Depression, anxiety, trauma, PTSD

Substance Use Warmline and Pregnancy: Data from Calls

• Substance Use Warmline

• Pregnancy specific

Examples of CCC Case Consultations

• Contacted by addiction medicine provider, patient 28 weeks stable on 8mg BID buprenorphine, wants to taper off medication during pregnancy to prevent NAS/NOWS

• Provider knows that medication continuation is recommended

• Question: 1) Any additional information to share w her 2) How to taper

Case 1

• Additional information: Pt adherent w PNC and addiction treatment; and plans to resume medication after delivery

• We discussed:

– Data supporting medication for OUD

– Patient autonomy and right to refusal

– Reviewed literature on taper

– Discussed taper strategies if needed

Case 1

• Call to HCV line from medical student covering L+D re recently postpartum patient w +HCV screening test (question re management)

• During call – noted that pt had presented in opioid withdrawal and had been started on buprenorphine, currently receiving 2mg BID, no withdrawal, being discharged for follow up in 2 weeks w local bupe prescriber

Case 2

• HCV provider line called me. I discussed OUD management with the hospital team

• Reviewed current clinical care:

– Pt had received some opioid agonist in labor and postpartum

– 4mg/day – low and likely insufficient to achieve opioid blockade

– Rec: 1) titrate to cravings 2) shorter follow up 3) naloxone co-prescribing

Case 2

• Called by NP in addiction practice. Pt 34 weeks, receiving 24mg/day buprenorphine. Urine drug testing = +bupe otherwise negative. But pt often late (or early) to appointment, always has an “excuse”, is “rude and nasty”, no counseling. “If she weren’t pregnant, we would kick out of clinic”. Question: “are we assuming liability by continuing to care for her”

Case 3

• Accentuate the positive: Patient is taking medication and comes to clinic: Patient is stable in recovery but non-adherent w rules of treatment

• Discussed aspects of her life that make attendance more difficult (childcare)

• Focus on recovery – and reviewed research on counseling and medication

Case 3

• Opioid use disorder (OUD) is a treatable chronic brain disease

• FDA-approved medications to treat OUD are effective and save lives

• Long-term retention on medication for OUD is associated with improved outcomes

• A lack of availability or utilization of behavioral interventions is not sufficient justification to withhold medications

• Most people who could benefit from medication-based treatment for OUD do not receive it, and access is inequitable across subgroups of the population

• Confronting the major barriers to the use of medications to treat OUD is critical to addressing the opioid crisis

CONCLUSIONS OF THE NATIONAL ACADEMIES COMMITTEE

“The value of this type of high-level expertise for the practicing, busy clinician cannot be overstated. The Warmline has been such a helpful resource for me, as a doctor in a community setting where I really want access to evidence-based medicine and the ability to discuss challenging substance use issues with colleagues! Your service is greatly appreciated.”

“I called in for information on buprenorphine. We need this kind of service since this is new for many of us.”

“The consultant went above and beyond, providing me with some helpful discussion/counseling points for a patient on high doses of chronic opioids for pain. The patient was very upset about the idea of an opioid taper, and the consultant helped mediate differing points of views to come up with a reasonable and safe tapering strategy.

“Very thorough, up-to-date, balanced information with the rare gift of presenting all that without saying there is only one correct answer. Thanks very much for your help.”

Feedback

National HCV, HIV/PrEP, and Substance Use Warmlinesoperate 9am-8pm ET, Mon-Fri

(toll-free numbers listed at nccc.ucsf.edu)National Perinatal HIV Hotline available 24/7, 365 days/year

Call Us!

Thank you!

To learn more, please visit www.nccc.ucsf.edu

SUBSTANCE USE

WARMLINE

855-300-3595

Questions & Discussion

Next StepsKelly Gilchrist

Manager, Executive Office/Medical Education

American College of Obstetricians and Gynecologists (ACOG)

District II

NYSDOH Caregiver Education Tools for NAS – Coming Soon!

• Newborn Care Journal

o To be used by parents in the hospital (and after discharge to home)

and shared with their newborn’s providers to increase family-centered

care for opioid-exposed newborns (can also be used for non-opioid

exposed newborns)

o Adapted from Northern New England Perinatal Quality Improvement

Network

• Neonatal Abstinence Syndrome (NAS): What You Need to

Know

o Key message: Be with your baby: You are the treatment!

o To be used by parents in the hospital to better understand nine

strategies for non-pharmacologic treatment for NAS

o Adapted from Illinois Perinatal Quality Collaborative

HANYS Opioid Lunch & Learn Opioid Use Disorder in Pregnancy: Response & Reporting

• Thursday, September 12, 2019, from 12 PM to 1 PM

• This presentation focuses on the response and reporting sections

of the ACOG AIM bundle on Obstetric Care for Women with OUD.

Learn more and register here:

https://www.hanys.org/events/?event_id=1763

September Coaching Call Webinar

• Tuesday, September 17, 2019, from 12 PM to 1 PM

• Dr. Updike will present on the importance of being prepared to treat women with OUD and their infants, and his team’s experience with buprenorphine waiver trainings.

• This webinar is open to all NYS birthing hospitals and providers, so feel free to share this information with colleagues.

Pre-register here: https://nichq.webex.com/nichq/k2/j.php?MTID=t1e7a59b7c8fa2a7bf712ab52739a53fe

Post Event Survey

https://www.surveygizmo.com/s3/5195513/New-York-State-Opioid-Use-Disorder-OUD-in-Pregnancy-and-Neonatal-Abstinence-Syndrome-NAS-Project-

September-2019-Coaching-Call-Webinar-Evaluation-Survey

Contact

New York State Opioid Use Disorder in

Pregnancy & Neonatal Abstinence

Syndrome Project

Ph: 518/473-9883

F: 518/474-1420

NYSPQC@health.ny.gov

www.nyspqc.org