Maternal Perspective of Inpatient Methadone Initiation: Opportunities to Increase Retention in Treatment

OBJECTIVES

Recent trends demonstrate increases in the rates of opioid use among pregnant and parenting women. Treatment for pregnant people with opioid use disorder (OUD) includes medications for OUD, like methadone, as well as comprehensive support services. Still, inpatient treatment engagement is suboptimal and treatment drop out is common. There is little research examining the maternal perspective of the inpatient methadone initiation experience. The primary aim of this qualitative methods study was to explore patient experience and perspective of the inpatient methadone initiation period.

METHODS

All participants were recruited from a single urban university affiliated hospital and OUD treatment program. Data were collected from 30 maternal participants in OUD treatment about their inpatient methadone initiation experience while pregnant using semistructured interviews. Thematic analyses were conducted using an inductive approach after an iterative process of code development and application among a multidisciplinary team of 3 coders. Validity was accounted for through 2 participant feedback interviews and study team review and discussion of findings.

RESULTS

Four themes emerged from the maternal interview data: (1) Barriers to Inpatient Methadone Initiation, (2) Facilitators to Inpatient Methadone Initiation, (3) Transition From Hospital Inpatient to Outpatient or Residential OUD Treatment Services, and (4) Opportunities for Enhanced Clinical Support.

CONCLUSION

Maternal participants reported multiple barriers and facilitators to inpatient care during methadone initiation, highlighting opportunities for improvement to effectively engage pregnant individuals in treatment.

Pediatric Primary Care Diagnoses Among Children with Intrauterine Opioid Exposure

BACKGROUND AND OBJECTIVES

Characterizing common concerns for children with intrauterine opioid exposure (IOE) can inform tailored primary care.

METHODS

Retrospective analysis of primary care data of children with IOE from birth to age two years within one multi-state pediatric health system. Well child care (WCC) and problem-based visit diagnoses were categorized, and descriptive statistics were tabulated.

RESULTS

Three hundred and eighty-five (385) children with IOE had 3,622 primary care visits, of which 51.4% were WCC and 48.6% were problem-based. Most frequent visit diagnoses were upper respiratory complaints (14.8% of visits), feeding difficulties (12.2%), and perinatal viral exposure (9.8%). Although visit type (WCC vs. problem-based) varied across diagnostic category, frequent utilization of both visit types were documented for several diagnoses in infancy (e.g., fussiness/colic, feeding difficulties).

CONCLUSIONS

Well child care visits for children with IOE are key opportunities for anticipatory guidance with an emphasis on problems that may contribute to acute health care utilization, particularly in early infancy.

Doula engagement and maternal opioid use disorder (OUD): Experiences of women in OUD recovery during the perinatal period

BACKGROUND

Pregnant women who have substance use disorders (SUDs) are at increased risk of preterm birth, fetal mortality, and inadequate prenatal care and have higher rates of childhood trauma than their counterparts without SUDs. Doulas have been utilized with other vulnerable populations who experience trauma to increase perinatal healthcare utilization, provide emotional support, and improve birth outcomes. The objective of the current study was to examine, in women with opioid use disorder (OUD), perceptions of working with a doula in the perinatal period.

METHODS

Eligible participants were ≥ 18 years old, in OUD treatment, and were pregnant or recently delivered (child ≤ 3 months of age). Semi-structured interviews were used to collect tacit data on the woman's experience working with a doula during the perinatal period. All one-hour interviews were conducted over the phone and transcribed verbatim by a HIPAA compliant transcription service. Transcripts were reviewed independently by 4 coders using open coding procedures, constant comparative method of grounded theory, and inductive thematic analysis. Demographic data and history of childhood trauma information (Adverse Childhood Experiences Tool) were collected with a phone survey prior to the interview.

RESULTS

Participants' (N = 23) were 32.5 years of age (4.1 SD), with the majority Caucasian (71.4%), Non-Hispanic (71.4%) and Medicaid recipients (100%). Participants reported a mean of 5.61 (SD=2.93) adverse childhood experiences, indicating a significant trauma burden. Major themes uncovered in the interview transcripts revealed emotional and OUD recovery support provided by the doula and increased maternal health literacy and self-advocacy. The presence of a doula during labor/delivery reduced maternal perceptions of stigma they perceived from their healthcare providers.

CONCLUSION

Doula engagement was associated with perceptions of increased emotional support, health literacy and self-advocacy in maternal health among women with OUD, which is significant given this population's trauma histories. This preliminary research has significant implications for improving the health of the mother child dyad affected by maternal OUD.

Well-Child Care Adherence After Intrauterine Opioid Exposure

BACKGROUND AND OBJECTIVES

For children with intrauterine opioid exposure (IOE), well-child care (WCC) provides an important opportunity to address medical, developmental, and psychosocial needs. We evaluated WCC adherence for this population.

METHODS

In this retrospective cohort study, we used PEDSnet data from a pediatric primary care network spanning 3 states from 2011 to 2016. IOE was ascertained by using physician diagnosis codes. WCC adherence in the first year was defined as a postnatal or 1-month visit and completed 2-, 4-, 6-, 9-, and 12-month visits. WCC adherence in the second year was defined as completed 15- and 18-month visits. Gaps in WCC, defined as ≥2 missed consecutive WCC visits, were also evaluated. We used multivariable regression to test the independent effect of IOE status.

RESULTS

Among 11 334 children, 236 (2.1%) had a diagnosis of IOE. Children with IOE had a median of 6 WCC visits (interquartile range 5-7), vs 8 (interquartile range 6-8) among children who were not exposed (P < .001). IOE was associated with decreased WCC adherence over the first and second years of life (adjusted relative risk 0.54 [P < .001] and 0.74 [P < .001]). WCC gaps were more likely in this population (adjusted relative risk 1.43; P < .001). There were no significant adjusted differences in nonroutine primary care visits, immunizations by age 2, or lead screening.

CONCLUSIONS

Children <2 years of age with IOE are less likely to adhere to recommended WCC, despite receiving on-time immunizations and lead screening. Further research should be focused on the role of WCC visits to support the complex needs of this population.

Implementation of a Mindfulness Intervention for Women in Treatment for Opioid Use Disorder and Its Effects on Depression Symptoms

Background: Many women in treatment for opioid use disorder (OUD) also experience mental health co-morbidities. Mindfulness intervention has demonstrated effectiveness for improving mental health in the general population, but has not been tested with female populations in OUD treatment. The purpose of this study was to describe characteristics associated with participation in a mindfulness intervention provided to women in treatment for OUD, and also to evaluate the effectiveness of a mindfulness intervention on depression symptoms. Aims: To evaluate participation characteristics associated with a mindfulness intervention and to assess the impact of a mindfulness intervention on depression symptoms for women with OUD. Methods: A secondary data analysis of a mindfulness intervention with women in treatment for OUD was accomplished. Bivariate analysis was conducted to determine any sociodemographic variables associated with intervention participation. Depression scores were assessed pre and post intervention using paired samples t tests for the intervention group (n = 65) and the control group (n = 8). Results: A 45% of women in the study reported moderate to severe depression symptoms at baseline, and 63% reported high levels of childhood trauma. There was a significant decrease in depression scores (M = 3.6 [1.2,6.1]) following the mindfulness intervention for the intervention group (t(64) = 3.1, p = .003). Participants entering the intervention group with moderate to severe depression scores experienced the most significant decrease in depression symptoms (M = 6.6, SD = 13.5), (t(64) = -2.1, p < .05). Conclusions: Women in treatment for OUD experience high levels of depression symptoms and past trauma, and mindfulness is a feasible intervention for OUD populations which may improve depression symptoms.

Integrating childhood obesity resources into the patient-centered medical home: Provider perspectives in the United States

Pediatric primary care providers play a critical role in managing obesity yet often lack the resources and support systems to provide effective care to children with obesity. The objective of this study was to identify system-level barriers to managing obesity and resources desired to better managing obesity from the perspective of pediatric primary care providers. A 64-item survey was electronically administered to 159 primary care providers from 26 practices within a large pediatric primary care network. Bivariate analyses were performed to compare survey responses based on provider and practice characteristics. Also factor analysis was conducted to determine key constructs that effect pediatric interventions for obesity. Survey response rate was 69% ( n = 109), with the majority of respondents being female (77%), physicians (67%), and without prior training in obesity management (74%). Time constraints during well visits (86%) and lack of ancillary staff (82%) were the most frequently reported barriers to obesity management. Information on community resources (99%), an on-site dietitian (96%), and patient educational materials (94%) were most frequently identified as potentially helpful for management of obesity in the primary care setting. Providers who desired more ancillary staff were significantly more likely to practice in clinics with a higher percentage of obese, Medicaid, and Hispanic patients. Integrating ancillary lifestyle expert support into primary care practices and connecting primary care practices to community organizations may be a successful strategy for assisting primary care providers with managing childhood obesity, especially among vulnerable populations.

Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome

BACKGROUND

Current pharmacologic treatment of the neonatal abstinence syndrome with morphine is associated with a lengthy duration of therapy and hospitalization. Buprenorphine may be more effective than morphine for this indication.

METHODS

In this single-site, double-blind, double-dummy clinical trial, we randomly assigned 63 term infants (≥37 weeks of gestation) who had been exposed to opioids in utero and who had signs of the neonatal abstinence syndrome to receive either sublingual buprenorphine or oral morphine. Infants with symptoms that were not controlled with the maximum dose of opioid were treated with adjunctive phenobarbital. The primary end point was the duration of treatment for symptoms of neonatal opioid withdrawal. Secondary clinical end points were the length of hospital stay, the percentage of infants who required supplemental treatment with phenobarbital, and safety.

RESULTS

The median duration of treatment was significantly shorter with buprenorphine than with morphine (15 days vs. 28 days), as was the median length of hospital stay (21 days vs. 33 days) (P<0.001 for both comparisons). Adjunctive phenobarbital was administered in 5 of 33 infants (15%) in the buprenorphine group and in 7 of 30 infants (23%) in the morphine group (P=0.36). Rates of adverse events were similar in the two groups.

CONCLUSIONS

Among infants with the neonatal abstinence syndrome, treatment with sublingual buprenorphine resulted in a shorter duration of treatment and shorter length of hospital stay than treatment with oral morphine, with similar rates of adverse events. (Funded by the National Institute on Drug Abuse; BBORN ClinicalTrials.gov number, NCT01452789 .).

Patterns of gestational weight gain related to fetal growth among women with overweight and obesity

OBJECTIVE

Maternal obesity is associated with increased risk of large-for-gestational-age (LGA) and small-for-gestational-age (SGA) births. Both are related to childhood obesity. This study considers that the patterns of gestational weight gain (GWG) may help to disentangle these competing risks.

METHODS

Patterns of GWG were characterized among a cohort of women with overweight or obesity (n = 651). Polytomous logistic regression models were tested for associations between GWG patterns and birth weight outcomes: SGA (<10th) and LGA (>90th percentile).

RESULTS

Rates of SGA were higher than those for LGA (14.9% vs. 7.8%). Four GWG patterns were identified: consistently high (29%), early adequate/late high (33%), consistently adequate (18%), and consistently low (20%). Risk of LGA was highest in women with consistently high GWG (adjusted odds ratio [OR] 4.62 [1.53, 13.96]), and risk was elevated, but with lower magnitude, among women with early adequate/late high gains (OR 3.07 [1.01, 9.37]). High GWG before 20 weeks, regardless of later gain, was related to LGA. Low gain before 20 weeks accompanied by high gain later may be associated with reduced SGA risk (0.55 [0.29, 1.07]).

CONCLUSIONS

The pattern of weight gain during pregnancy may be an important contributor to or marker of abnormal fetal growth among women with overweight or obesity.

Project Northland in Croatia: results and lessons learned

As part of an international public health partnership formed in 2001 we assessed the impact of Project Northland in Croatia--an adolescent alcohol school-based prevention intervention implemented in Split--on students. The curriculum was implemented in 13 randomly selected schools with another 13 schools serving as controls. The evaluation included quantitative and qualitative methods, using pre/post-tests to compare intervention and controls and follow-up focus groups with parents and teachers. Quantitative data showed the intervention was more successful in changing attitudes in the first two years, but had less impact on older students. Qualitative data suggest benefits from the program overall. Given the intervention was successful in the earlier grades it should be initiated earlier to have a greater impact. Challenges and lessons learned are offered.