The opioid epidemic has led to an increased number of pregnant women

The opioid epidemic has led to an increased number of pregnant women utilizing opioids in pregnancy and in the postpartum period. According to the CDC, that number has quadrupled from 1999-2014 from 1.5 per 1,000 births to 6.5 (Centers for Disease Control and Prevention, 2018). Per the Substance Abuse and Mental Health Services Administration, in 2016 over 20,000 pregnant women reported using heroin or opioids (Substance Abuse and Mental Health Services Administration, 2018). Opioid use disorder has a known association with adverse outcomes for both mothers, their fetus, and newborn. Some of these risks include maternal death, preterm birth, abruption, stillbirth, low birth weight, respiratory issues in newborns, feeding problems in newborns, and neonatal abstinence syndrome (CDC, 2018). The medication-assisted treatment (MAT) model of care for opioid use disorder in pregnancy and postpartum has been proven effective with early recognition, intervention, and continuation with follow-ups in the postpartum period. However, it has been found 56% of postpartum women discontinue MAT treatment within six months (Drug and Alcohol Dependence, 2015). Improving discontinuation rates of medication-assisted treatments for opioid use disorder in postpartum women is imperative in fighting the opioid crisis. BackgroundPubMed was used to review the literature by utilizing the advanced search option. Searches included MeSH terms such as hospitals rural, rural health, rural health services, rural population, medically underserved area, pregnant, postpartum, antepartum, analgesics, opioid-related disorder, opioid, opiate substitution treatment, medication assisted treatment, retention, buprenorphine, and/or methadone. A total of 22 published systematic reviews resulted and if “rural” was removed from the search, results increased to 1594. Results from the past five years dropped the number of publications to 365. For this research proposal, data was reviewed from 8 of the 22 articles based on the lack of research in relation to postpartum retention in medication-assisted treatments in rural and underserved areas. These articles were selected based on best understood treatments for opioid use disorder in pregnant women, identification of decreased rates of retention in MAT programs for pregnant and postpartum women, and conclusions based on needing larger studies to understand management of opioid use disorder in pregnancy and postpartum.Available KnowledgeKelty & Hulse (2017) found that methadone and buprenorphine were better options for MAT in pregnancy and postpartum over the use of implant naltrexone. However, Zedler et al. (2016) found that buprenorphine treatment during pregnancy compared with methadone treatment let to a lower risk of preterm birth and no greater harms. Dooley et al. (2016) found that buprenorphine-naloxone is safe for use in pregnancy for opioid substitution however larger studies are needed to understand management of opioid use disorder in pregnancy and postpartum. Wilder, Hosta, & Winhusen (2017) found that primarily Caucasian women in an urban setting taking >60mg methadone during pregnancy were more likely to remain in opioid treatment at delivery and 60 days postpartum. Parlier, Fagan, Ramage, & Galvin (2014) found that only half of white women in their study using MMT or opioids received prenatal counseling about postpartum contraception. Alternative strategies for providing postpartum care should be explored in women using opioids or MMT during pregnancy (Parlier et al., 2014). Sproule et al. (2018) found that women who used MAT during pregnancy had a fourfold increase in the odds of social services removal at the hospital compared with those who were stabilized on MAT prior to conception. Additionally, Wilder, Lewis, & Winhusen (2015) found that the postpartum period is a time of increased risk for discontinuation of MAT. According to Wilder et al. (2015), the MAT discontinuation rate at 6 months postpartum was 61.9% which consisted of 97.8% Caucasian women. More research, development, and testing of interventions is needed to encourage early enrollment in MAT and improve postpartum retention (Wilder et al., 2015). Target ImprovementThe purpose of this project is to improve discontinuation rates of medication-assisted treatments for opioid use disorder in postpartum women up to six months postpartum. The staff who work in the trenches to take care of the patients include case management, mental health, social services, certified nurse midwives, registered nurses, physicians, and primary care providers. There is a multidisciplinary approach to improve access to care for success in the postpartum period. There are a lack of treatment plans and processes in place in the postpartum period for medication-assisted treatment women with opioid use disorder. This leads to discontinuation of medication-assisted treatment in postpartum women. Per Drug and Alcohol Dependence (2015), there is a 56% discontinuation rate of medication-assisted treatment within six months in the postpartum period. Specific AimThe aim of this project is to improve discontinuation rates of medication-assisted treatments for opioid use disorder in postpartum women from 56% to 25% through early recognition and intervention in pregnancy and six months postpartum by 2021.FrameworkThe Matrix Model provides a framework for opioid users in treatment in order to help them achieve abstinence (National Institute on Drug Abuse, 2018). Utilizing this model, patients learn about addiction, relapse, and receive direction and support from programs, therapy, and counseling (National Institute on Drug Abuse, 2018). Through drug testing, coaching, encouraging relationships, and treatment sessions that promote self-esteem and positivity, this model helps to prevent relapse (National Institute on Drug Abuse, 2018). According to the National Institute on Drug Abuse (2018), a number of studies have demonstrated there has been a significant reduction in drug, alcohol use, and improvements in psychological indicators in patients treated using the Matrix Model. Therefore, utilizing the Matrix Model for treating medication-assisted postpartum women would be beneficial in decreasing discontinuation rates in the program. Flow chart processThere is a needed process to facilitate proper follow-up with postpartum patients in medication assisted treatment programs or with opioid use disorder. (See Appendix)Fish Bone DiagramChanges needed to accomplish the aim include appropriately screening all women for opioid use disorder at all appointments, admission to Labor and Delivery, at discharge, and postpartum follow-up. All women with opioid use disorder should be enrolled in a treatment program during pregnancy and postpartum. Easy access to care during pregnancy and postpartum should be provided for frequent counseling, education, and resources. Furthermore, all women should be enrolled in Medicaid during prenatal care or when deemed eligible. PDSAPlan: Screen 100% of women by utilizing an opioid use disorder tool during prenatal visits, labor and delivery, and during the immediate postpartum period before discharge. A screening tool, such as the Opioid Risk Tool, will be initiated in clinics and Labor and Delivery units. Upon admission and discharge, the screening tool will be utilized and continued indefinitely.Plan: Enroll uninsured, eligible patients in Medicaid as soon as possible during prenatal care. Screen uninsured patients for Medicaid eligibility at first healthcare visit. Enroll 100% of eligible patients with opioid use disorder in Medicaid during first prenatal visit.Plan: Enroll all opioid use disorder pregnant and postpartum women in a woman-centered treatment program in local community. Case management will follow-up with patients on the treatment program attendance for six months after delivery. 100% of patients will be enrolled in special treatment program for six months after delivery.Plan: Implement frequent counseling, education, and resources to mothers during prenatal, intrapartum, and postpartum periods on breastfeeding, contraception, pain management, and infant care. Enroll mothers in follow-up education prior to discharge and follow-up with frequent phone calls and appointments for six months. Require documentation of contraception prescription, placement, or refusal. Postpartum pain management guidelines must be followed—no narcotics for vaginal deliveries.Team and Tentative TimelineThe team leader includes the Nurse Manager of the OB/GYN clinic. Since it is a multidisciplinary team approach, mandatory training will be provided to the OB/GYN clinic, family medicine clinic, Labor and Delivery staff, Mother Baby Unit staff, and NICU staff. The team will include two midwives, two OB/GYNS, two Family Medicine Physicians, two Labor and Delivery nurses, two Mother Baby unit nurses, and two NICU nurses. Meetings will occur every two weeks starting May 2019 while establishing new guidelines and implementation of new admission and discharge processes along with the plan of action. The project begins June 2019 and the project possibly ends June 2021. MeasuresMeasures were chosen for studying the processes and outcomes of the interventions. Baseline data was collected by reviewing processes currently and determining the percentages of screening tools, enrollment in MAT, enrollment in Medicaid, and scheduled postpartum follow-up appointments. Measuring instruments for the study include data involving questionnaires and electronic data collection. The rationales for choosing these methods include that questionnaires provide information directly from the patient and electronic data collection allows viewing of screening, enrollment, and implementation. Both instruments make data easily accessible if properly utilized and documented. A process change included utilizing the Opioid Risk Tool to screen and document scores on all women during prenatal visits, labor and delivery, and postpartum (Webster, 2005). The Opioid Risk Tool is a patient self-administered five item questionnaire utilized in primary care settings and is collected at every prenatal visit and on Labor and Delivery. The ORT tool is an accurate tool to determine high and low risk patients in which a score of eight or higher indicates a high risk for opioid abuse (Webster, 2005). It is the nurse and providers responsibility to score, collect, and document the data for the project. Nurses will collect the ORT questionnaire from each patient at every visit. High-risk opioid abuse patients will be documented and followed closely. Patients will also be enrolled in Medicaid, if eligible, by the first prenatal visit when high risk opioid use was determined. Documentation of patient enrollment will be provided by the clinic managers based on Medicaid numbers. Labor and Delivery will provide the number of patients enrolled in a woman-centered treatment program from case management at discharge. Close follow-up appointments with counseling, education, resources, postpartum contraception will be collected by electronic data collection review in the clinic and verification that 100% of postpartum patients at discharge went home with a follow-up appointment. The clinic and labor and delivery manager are responsible for collecting and disseminating the data. Methods employed for assessing completeness and accuracy of the data include verification of number of patients seen in the clinic, verification of number of patients with opioid use disorder, verification of number of patients enrolled in MAT, and verification of data through proper documentation. There will be ongoing assessment of contextual elements that contribute to the success, failure, efficiency, and cost. These include number of women refusing to participate in the study, enforcing clinic managers and staff to adhere to the new processes, understanding Medicaid has limitations for enrollment and specific time frames, preparing for lack of insurance for patient’s ineligible for Medicaid, follow-up appointments scheduled, and understanding after delivery women only have 60 days of coverage under Medicaid. This information will be analyzed weekly and distributed to the quality improvement project team. Analysis PlanQualitative and quantitative methods will be used to draw inferences from the data. A qualitative measure utilized will be an interview process to analyze why some postpartum women discontinued medication-assisted treatment and others did not. Quantitative measures will include reviewing records for numeric information and questionnaires. This includes reviewing how many patients were enrolled in MAT programs postpartum, how many discontinued the treatment, when it was discontinued, how many patients were enrolled in Medicaid, and how many MAT patients had a follow-up postpartum appointment.Change Project OutcomesThe outcome of this project will be a change in the professional practice processes as well as a decrease in discontinuation rates in MAT in postpartum women. Screening tools will be utilized at prenatal visits and on Labor and Delivery. If patients are high-risk for opioid use disorder, they are placed in a medication-assisted treatment program during pregnancy and postpartum. Women at their first prenatal visit are enrolled in Medicaid if eligible. Upon discharging from the hospital, close follow-up appointments are made and patient information is verified for home phone calls. These process changes are deemed necessary for process improvement.Ethical Considerations There are ethical aspects of implementing and studying the interventions associated with medication-assisted treatment in postpartum women. Patients must have informed consent, therefore requiring the patients to be competent at consenting for themselves. It must also be taken into consideration that the patients who need enrollment in medication-assisted treatment understand what they are agreeing to. These concerns will be addressed by having the project reviewed by an ethics committee board. Furthermore, patients will be evaluated for mental capacity by a provider who then will inform and consent the patient of the research project. Patients will sign an agreement understanding the implications and facts of the project presented to them. An informed consent will also be signed by the patient. A potential conflict of interest include providers and nurses with bias due to personal ties to law enforcement who may perceive drug addiction as a crime rather than a disease. ConclusionRecent review of the literature deemed it necessary to research the discontinuation rates of medication-assisted treatment among opioid use disorder in pregnant and postpartum women. This will allow providers and nurses to use proven processes to retain patients in medication-assisted treatments in order to combat the opioid crisis, especially in pregnant and postpartum women. Sustainability of the research project may depend on certain limitations. Limitations may include issues with insurance payment for six month treatment programs along with patient buy in. The screening tools, enrollment in Medicaid if eligible, as well as the close follow-up appointments and contact with case management are highly achievable in all healthcare settings. There is a potential to spread to other settings, to include implementing these same processes in other clinics, Emergency Departments, and so forth. Implications for practice include achieving better access to care, communication with patients, and relationship building with patients. Further studies are necessary to ensure insurance accessibility, pay out for treatment programs affect retention, and if MAT programs are more beneficial than counseling alone in postpartum women. Lastly, the suggested next step would be to study the onset of abstinence from opioid use after medication-assisted treatment is implemented in pregnant and postpartum women. It would also be beneficial to study the effects on insurance and discontinuation rates of MAT programs among postpartum women.

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