Renee Maloney, RN, was working at the Pregnancy Care Center at Catholic Medical Center in Manchester, NH, when she noticed a disturbing trend about seven years ago.
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Renee Maloney, RN[/caption] The trend was a steady increase in the number of newborns experiencing symptoms such as diarrhea, shaking, breathing problems and excessive fussiness. The infants were suffering from neonatal abstinence syndrome, or withdrawal from drugs they had been exposed to in the womb from opioid use disorder.
The trend was fueled by a surge in the number of moms who had gotten hooked on opioids, and Maloney felt compelled to find a way to help these women with their addictions earlier in pregnancy.
She and Nicole Pendenza, BSN, RNC-NIC, director of maternal, child and women's health at the hospital, proposed a plan for a program to provide addiction treatment and recovery services to pregnant women in the area. Hospital leaders were supportive, and the facility opened Roots for Recovery in 2017. Women in the program have access to prenatal care, individual counseling with a social worker, recovery support groups and a provider who can prescribe medication like buprenorphine, a medication-assisted treatment to help patients reduce or quit using heroin or other opiates. The program is helping many pregnant women overcome addictions that started after physicians prescribed opioids to treat pain.
"I've been surprised to see women from all walks of life," Maloney said. "The addiction may have started after medication was prescribed for pain following a tooth extraction or athletic injury, and they became physically dependent."
In some cases, women start buying heroin off the street after prescriptions run out. Catholic Medical Center is among a growing number of hospitals launching programs specifically geared to help pregnant women who are struggling with opioid use disorder. The number of these women more than quadrupled from 1999 to 2014, according to the Centers for Disease Control and Prevention. Researchers found the national prevalence of opioid use disorder increased from 1.5 per 1,000 hospital deliveries in 1999 to 6.5 in 2014. The annual rate increases were highest in Maine, New Mexico, Vermont and West Virginia.
Innovative approaches to treating withdrawal from opioid use disorder
At Catholic Medical Center, new patients initially meet with Maloney and a social worker, who gather information about the patient's history and collect a urine sample to screen for drugs. Then patients meet with a nurse practitioner, who can prescribe medication-assisted treatment. The staff completed a four-month training to learn about motivational interviewing, trauma-informed care and how to provide care to newborns with neonatal abstinence syndrome. One common misconception the providers address with patients is the belief that women should stop using illegal opioids during pregnancy, according to Maloney.
"Stopping abruptly could cause withdrawal and potentially put the pregnancy at risk," she said. "Instead, we encourage women to come in and get the support they need to start taking prescribed medication that can help with the cravings."
The Roots for Recovery staff also have been trained to use the eat, sleep, console approach for infants with neonatal abstinence syndrome. In this model of care, these babies can stay with mothers rather than transferring to the neonatal intensive care unit, where they often receive morphine to treat withdrawal symptoms. Instead, nurses encourage breastfeeding, skin-on-skin contact, supplemental feeds and other comfort measures to help the babies through the withdrawal period. The model has been so successful that 86% of babies with neonatal abstinence syndrome did not require medication in 2018 -- compared to 18% seven years ago. The length of stay for the infants also has dropped from 15 days to six days in the hospital.
Creating a safe place for pregnant moms with opioid use disorder
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Emily Brayton,RN[/caption] When leaders at Dartmouth-Hitchcock Medical Center in Lebanon, NH, were interested in starting an addiction recovery program for pregnant patients, Emily Brayton, BSN, RN, nurse manager of the birthing pavilion, knew it was critical to be aware of the shame many women experience.
"They feel an immense amount of guilt, and many who come into the healthcare setting feel so much judgement," she said. "It was important to break down the barriers between moms and the healthcare team."
To facilitate trust with patients, nurses emphasize that moms play an essential role in caring for their babies, and nurses are partners in supporting the babies. "A lot of the women have been beaten down for years, and they do not think they are worth anything," Brayton said. Many did not have loving parent models, and they do not know what to do. Brayton shows patients how babies react differently to moms than to healthcare providers, and she affirms their decisions to keep their babies safe by getting help. By participating in the program, women have access to:
- Medication-assisted treatment
- An intensive outpatient program
- Group therapy with other moms and pregnant women
- Individual counseling
- Support to find housing, transportation, insurance and employment resources
The patients also meet pediatricians who are trained to work with moms in recovery once the babies are discharged from the hospital.
How to reach more women facing opioid use disorder
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Brenda Baker, RN[/caption] Although hospitals are increasingly developing programs to help pregnant women with opioid use disorder, researchers such as Brenda Baker, PhD, RN, CNS, are finding evidence that many of these women are not accessing programs to get help.
In a recent study, Baker reviewed literature related to incarcerated pregnant women from 2006 to 2016, and the results showed babies had longer gestational periods and higher birth weights if their mothers entered the prison system earlier in the pregnancy.
More than two-thirds of women in state prisons enter the system with drug dependence or abuse, according to the Bureau of Justice Statistics. Mothers who enter the correctional system earlier deliver healthier babies because these women receive the food, shelter and safety they may not have access to in the community, said Baker, an assistant professor at Emory University's Nell Hodgson Woodruff School of Nursing in Atlanta. "It's shameful that our society is not reaching these women," said Baker, who provides prenatal education for incarcerated women through the Motherhood Beyond Bars program. Many of the pregnant women have multiple children who are in foster care or living with family members. "The class in prison is often the first time they've had any type of prenatal education," Baker said. "If they were using, they want to know if the drugs will hurt their babies. This is an opportunity to be a healthcare provider who can give them hope."
Take these courses on opioid use disorder:
Opioid Use Disorder and Pregnancy: What Does Evidence-Based Care Look like? (1 contact hr) Perinatal opioid use is a serious public health challenge in the United States which, if untreated, is associated with morbidity and mortality for both mothers and their infants. Maternity care providers are uniquely positioned to assist by facilitating access to treatment and comprehensive care. What does research tell us about optimal screening approaches for prenatal substance use? What kinds of treatment programs are available for pregnant women who struggle with opioid use disorders? Which resources should be provided prenatally to promote the safety of mother and baby? Listen to this webinar to learn more. Patient Counseling: Preventing and Combating Opioid Misuse (1 contact hr) Education is a key component of healthcare for which we could all use more time. In the midst of competing demands for planning care, implementing clinical interventions, and documentation, healthcare professionals find themselves trying to carve out quality time for patient education. With the current opioid epidemic, what is critical information professionals need to know to assess the nature of patient's and client's opioid use, provide education and/or counseling for opioid use, and refer persons to applicable resources for substance misuse or abuse. Substance Abuse and Women (1 contact hr) Substance abuse alert! Women have unique and particular risk factors for substance abuse that are different from risk factors for men! Did you know that a women can progress to a substance abuse disorder more quickly than a man? With the opioid epidemic, reproductive concerns, and the majority of women who don't receive treatment for drug and alcohol problems, do you know how to help the women in your life?
