Caring for Families Impacted by Opioid Use: A Qualitative Analysis of Integrated Program Designs

"If We Didn't Have Our Babies, We Wouldn't Be Here Right Now": A Qualitative Exploration of New Motherhood While Navigating Substance Use Disorder Recovery

BACKGROUND

Postpartum women with substance use disorder (SUD) are at heightened risk of adverse health outcomes problems. The current understanding of early motherhood while managing SUD is poorly understood, as the transitional period following delivery has been a neglected area within research. This qualitative study examined how postpartum women balance new motherhood while navigating early recovery from SUDs.

METHODS

The primary aim was to elicit individual experiences in the context of maternal functioning (social support, psychological well-being, infant care, self-care, mother-child interaction, management, and adjustment). In 2023, we purposefully recruited a sample of postpartum women receiving residential services for SUD (N = 22) and conducted semi-structured individual interviews. Interviews were audio-recorded and transcribed verbatim, and codes were analyzed using deductive and subsequent inductive analysis to identify themes unique to each functioning domain among postpartum women with SUDs.

RESULTS

Participants were predominately white (81%), single (86%), and between 20 and 40 years of age and were the primary caregivers for their children, and half were less than 3 months postpartum. Balancing infant care and self-care was cited as a significant challenge. Several participants expressed a need for more early parenting support and assistance in navigating social services and life after leaving residential treatment. Pregnancy catalyzed entering and remaining in treatment while remaining engaged in recovery and sustaining sobriety was a form of self-care. The social network gained as part of the treatment was frequently described as crucial for new moms to care for their children while navigating early recovery.

CONCLUSIONS

This study highlights the importance of exploring the postpartum experience and needs among postpartum people in SUD recovery. Maintaining recovery through sustainable sobriety was considered a form of self-care, indicating that the postpartum period is a critical point in both a mother's life and a unique intervention point for postpartum women with SUD.

Challenges for Antepartum Care of the Individual with Perinatal Substance Use: An Empirical Integrative Review of Novel Approaches to Improve Care

INTRODUCTION

Perinatal substance use continues to rise across the United States presenting unique challenges to providing antepartum care. Polysubstance use, limited and late engagement in health care, co-occurring mood disorders, and several social barriers are well documented. This review seeks to summarize these barriers and present novel approaches to caring for this high-risk population.

METHODS

Inclusion criteria for this study focused on peer-reviewed articles that explicitly detailed a direct impact on the provision or receipt of antenatal care in the setting of substance use within the United States that were published in the last 5 years. PubMed and Web of Science were used to find applicable articles. Of the 156 articles found, 10 relevant articles were selected for the final empirical integrative review that entailed data evaluation using the Mixed Methods Appraisal Tool (MMAT) and thematic analysis.

RESULTS

10 review articles met inclusion; 3 were qualitative, 6 were quantitative and nonrandomized, and one was quantitative descriptive. Six articles met MMAT quality criteria, and there were significant limitations in every article. Topics included opioid use disorder (n = 6), general substance use (n = 3), and tobacco use (n = 1). Themes included integrated models of prenatal care, colocated care, resource coordination, and peer support along with the role of the perinatal health care professional and consistent use of a substance use screening tool.

DISCUSSION

A comprehensive and multidisciplinary care model is necessary to meet the complex and urgent needs of individuals with perinatal substance use that not only meets recommendations for opioid maintenance therapy or substance use cessation but the important areas of accessibility and interpersonal support. Future research should focus on the development, implementation, and evaluation of new models of care for this vulnerable population.

High Engagement in Care in a Pediatric Medical Home for Children Impacted By Parental Substance Use

The opioid epidemic has heavily affected adults of childbearing age, leading to thousands of children impacted by parental substance use. Few programs provide longitudinal support to these children. This article describes an innovative pediatric medical home model for substance-impacted children and their families, at an urban safety-net hospital. The team-based program directly serves children, and also devotes significant resources to parental health and recovery. In the program's first 3 years, 95% of enrollees were engaged in care, meeting the American Academy of Pediatrics' recommended periodicity schedule for preventive health visits. On-time receipt of childhood vaccines ranged from 95% (pneumococcal conjugate) to 100% (human papilloma virus). The program's high engagement in care shows promise in engaging vulnerable families over time. Future work should explore how to engage children from more diverse backgrounds, and should examine whether the model impacts other indicators of health and well-being for children impacted by parental substance use.

Improving health and well-being for infants with prenatal substance exposure

Substance use disorders (SUD) among caregiving adults has inexorable linkage to the health and well-being of millions of children in the U.S. This piece provides an overview of such linkages, examples of relevant policies and regulations, and the role of pediatric healthcare within the health trajectories of children and families at this intersection. A commonality throughout this work is need for non-stigmatizing engagement and support to facilitate connections to care and reduce barriers.

Integrating Care for Mother-Infant Dyads After Preterm Birth: A Qualitative Study of Clinician Perspectives on Feasibility

Objective

There are gaps in receipt of maternal preventive services in the interconception period. Yet mother-infant dyads have frequent health care visits. Health systems have opportunities to better capitalize on existing visits to address dyad needs, but this possibility has not been fully explored.

Methods

In this qualitative study we conducted semistructured interviews with clinical team members involved with birthing parents or infants after preterm birth. We conducted snowball sampling from teams in pediatrics, obstetrics, and family medicine at two geographically adjacent health systems. Interviews explored perspectives on existing barriers and facilitators to integrating dyad care across adult and infant teams. Interviews were audio-recorded, professionally transcribed, and coded using an integrated approach.

Results

We interviewed 24 physicians, nurses, midwives, and social workers (March-November 2021). Participants identified barriers to integrated care including infrequent communication between clinical teams, which was generalizable to care of the birthing parent or infant as individuals, and additional barriers related to privacy, credentialing, and visit design that were specific to dyad care. To improve integration of dyad care, clinicians proposed adapting a variety tools and procedures currently used in their practices, including electronic health record tools for communication, dedicated roles to support communication or navigation, centralized information on resources for dyad care, referral protocols, identifying dyads for proactive outreach, and opportunities for clinicians to connect face-to-face about shared patients or families.

Conclusions

Clinicians believe existing health care structures and processes can be adapted to address current substantial barriers to integrated dyad care.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Maternal Childhood Maltreatment, Internal Working Models, and Perinatal Substance Use: Is There a Role for Hyperkatifeia? A Systematic Review

The parent-infant relationship is critical for socioemotional development and is adversely impacted by perinatal substance use. This systematic review posits that the mechanisms underlying these risks to mother-infant relationships center on 3 primary processes: (1) mothers' childhood maltreatment experiences; (2) attachment styles and consequent internal working models of interpersonal relationships; and (3) perinatal substance use. Further, the review considers the role of hyperkatifeia, or hypersensitivity to negative affect which occurs when people with substance use disorders are not using substances, and which drives the negative reinforcement in addiction. The authors performed a systematic review of articles (published 2000-2022) related to these constructs and their impact on mother-infant relationships and offspring outcomes, including original clinical research articles addressing relationships between these constructs, and excluding case studies, reviews, non-human animal studies, intervention studies, studies with fewer than 30% female-sex participants, clinical guidelines, studies limited to obstetric outcomes, mechanistic/biological studies, and studies with methodological issues precluding interpretation. Overall 1844 articles were screened, 377 were selected for full text review, and data were extracted from 157 articles. Results revealed strong relationships between mothers' childhood maltreatment experiences, less optimal internal working models, and increased risk for perinatal substance use, and importantly, all of these predictors interacted with hyperkatifeia and exerted a marked impact on mother-infant relationships with less data available on offspring outcomes. These data strongly support the need for future studies addressing the additive impact of maternal childhood maltreatment experiences, suboptimal internal working models, and perinatal substance use, with hyperkatifeia as a potential moderator, and their interacting effects on mother-infant socioemotional outcomes.

Commentary on Nowakowski et al.: Bringing the participants' own words into addictions research-a win-win for patients and investigators

Bringing the participant’s own words into the design of clinical investigations, such as with qualitative and mixed methodologies, should be prioritized in addictions research across the translational science spectrum.

An Integrated Care Model for Pregnant and Postpartum Individuals Receiving Medication for Opioid Use Disorder

OBJECTIVES

Perinatal opioid use disorder is increasing. Integrated obstetric/addiction care models likely optimize parent-infant dyad outcomes, but the ideal combination of services is unknown. This study (1) describes pregnancy-to-postpartum service utilization by people receiving buprenorphine at an integrated Obstetric/Addiction Clinic and (2) explores the association between service utilization and postpartum buprenorphine continuation.

METHODS

This retrospective medical record review study uses research registry data from an outpatient Obstetric/Addiction Clinic. All patients are invited to participate in the research registry. For patients who consent, monthly medical record abstractions are conducted beginning with their first clinic visit to collect demographic, obstetric, and substance use disorder treatment variables. Present analyses included patients who delivered an infant between June 2019 and June 2021, started buprenorphine during pregnancy, and were receiving buprenorphine at delivery. Overall service utilization was the number of services (range 0-12) used between 28-weeks gestation and 12-weeks postpartum. Bivariate analyses and multivariable logistic regression assessed associations between service utilization and buprenorphine continuation.

RESULTS

Participants (n = 42) were primarily non-Latinx White (67%) with comorbid psychiatric diagnoses (95%). On average, participants used 6 services; prenatal care, mental health care, and postpartum contraception were most utilized. Overall, 69% of participants continued buprenorphine at 6 months postpartum. This did not differ by level of service utilization (bivariate [ P = 0.07], multivariable [ P = 0.16]).

CONCLUSION

Integrated care with a harm reduction focus supports pregnancy-to-postpartum service utilization and buprenorphine continuation in a patient sample at high risk for medication for opioid use disorder discontinuation. Further work is needed to identify evidence-based methods to individualize integrated obstetric/addiction care.

Opportunities to Increase Well-Child Care Engagement for Families Affected by Maternal Opioid Use Disorder: Perceptions of Mothers and Clinicians

OBJECTIVE

Previous research suggests gaps in well-child care (WCC) adherence, quality, and effectiveness for children impacted by parental opioid use disorder (OUD). The objective of this study was to gather in-depth information regarding maternal and clinician-reported factors that enhance ("facilitators") or hinder ("barriers") WCC engagement as well as mothers' experiences during WCC visits.

METHODS

Thirty mothers who were in treatment for OUD and 13 clinicians working at a pediatric primary care clinic participated in this qualitative study. All participants completed one data collection telephone session which involved a brief questionnaire followed by a semi-structured interview. Thematic analyses of the interview transcripts were conducted using an inductive approach.

RESULTS

Three broad themes were identified as facilitators of WCC by mothers and clinicians, including: 1) continuity in care, 2) addressing material needs, and 3) clinician OUD training and knowledge. Themes identified as barriers to WCC included: 1) stigma toward mothers with OUD, 2) gaps in basic parenting knowledge, 3) competing specialized health care needs, and 4) insufficient time to address all concerns.

CONCLUSION

WCC programs or clinical pathways designed for families affected by maternal OUD should consider these barriers and facilitators of WCC engagement and affect experiences of WCC for mothers and clinicians.

Psychiatric comorbidities and their treatment predict buprenorphine continuation among postpartum people with opioid use disorder

Background

Opioid use disorder (OUD) is a growing crisis among pregnant and postpartum people. Psychiatric comorbidities are common, yet how they impact OUD treatment outcomes is not well characterized. The aim of this study was to assess the association of psychiatric comorbidities and receipt of psychiatric treatment with buprenorphine continuation through one year postpartum among a sample of people with OUD.

Methods

A subsample was identified from a larger retrospective cohort of patients receiving buprenorphine for OUD at the time of delivery from an academic medical center between 2017 and 2020. Medical record abstractions were conducted during pregnancy through one year postpartum. Independent variables included any psychiatric diagnosis and postpartum receipt of psychiatric treatment (medication or behavioral health). The primary outcome was week of buprenorphine discontinuation. Cox Proportional Hazard models were used.

Results

Of 138 patients, 71.8% had a psychiatric condition and 35.5% continued buprenorphine for a full year postpartum. Postpartum buprenorphine continuation was associated with (a) Psychiatric co-morbidity (buprenorphine discontinuation HR 0.49; 95% CI 0.29, 0.82), (b) Receipt of psychiatric medications in weeks 39-52 postpartum (buprenorphine discontinuation HR 0.21; 95% CI 0.06, 0.83), and (c) Receipt of behavioral health therapy in weeks 9-38 postpartum (buprenorphine discontinuation HR 0.40; 95% CI 0.18, 0.90).

Conclusion

Our work suggests a dynamic relationship between OUD treatment outcomes, psychiatric comorbidities and receipt of psychiatric treatments through the highly vulnerable postpartum period. Clinicians and researchers alike should work to advance patient-centered engagement in integrated care models tailored for this unique population.

Redefining Child Protection: Addressing the Harms of Structural Racism and Punitive Approaches for Birthing People, Dyads, and Families Affected by Substance Use

There has been growing attention on the effect of substance use, including opioid use disorder, on pregnant and birthing people and their infants. Although effective medication treatment for opioid use disorder is the standard of care, racial disparities are evident in access during pregnancy. Structural racism affects treatment access and approaches to reporting to child welfare services. Black people and their newborns are more likely to be drug tested in medical settings, and Black newborns are more likely to be reported to child welfare services. Child welfare models often focus on substance use as being the dominant issue that drives risk for abuse or neglect of a child, and current reporting practices, which vary by state, contribute to these disparities. This commentary proposes an alternate way of thinking about family-based support. We suggest changes to law, institutional policy, clinical care, and ideology. Specifically, we propose realigning around shared goals of supporting the birthing person-infant dyad and recognizing that substance use is not synonymous with abuse or neglect; creating an anonymous notification process outside of the child welfare system to meet federal data-collection requirements; limiting perinatal drug testing and requiring written, informed consent for parental and neonatal testing; and developing integrated care teams and hospital settings and policies that support dyadic care.