Improving Neonatal Outcomes: Multidisciplinary Treatment Approach to Caring for Pregnant Persons With Opioid Use Disorder

Sunday, 17 November 2019: 3:15 PM

Nancy S. Goldstein, DNP, ANP-BC, RNC-OB1
Erica Nichole Ramirez, MSN, RN2
Lauren Elizabeth Greenwood, MSN, RN3
Kodiak Ray Sung Soled, MSN, RN4
Laura Stinnette Lucas, DNP, APRN-CNS, RNC-OB1
(1)School of Nursing, Johns Hopkins University, Baltimore, MD, USA
(2)Neonatal Intensive Care Unit, Harris Methodist Children’s Hospital, San Antonio, TX, USA
(3)4th Pegau, Inspira Medical Center Woodbury, Woodbury, NJ, USA
(4)School Of Nursing, The Program of the Study of LGBT Health, Columbia University, New York, NY, USA

Background: The United States has experienced an epidemic of opioid addiction over the past decade. Unfortunately, this disease has not spared pregnant persons. The rate of opioid use during pregnancy quadrupled from 1.5 to 6.5 per 1,000 hospital live births per year from 1999 to 2014 (Haight, Ko, Tong, Bohm, & Callaghan, 2018). Opioid use disorder (OUD) in pregnancy can lead to a host of adverse outcomes including an increased likelihood of preterm birth, decreased birth weight, and increased chance of the newborn being admitted to the NICU, especially for complications such as neonatal abstinence syndrome (NAS) (Krans, Cochran, & Bogen, 2015; Kramlich & Kronk, 2015; Sutter, Gopman, & Leeman, 2017). Furthermore, NAS infants are more likely to experience respiratory diagnoses, feeding difficulties, and seizures, among other challenges (Patrick et al., 2015). From 2004 to 2013, the percentage of NICU days attributed to NAS rose from 0.6% to 4.0% (Tolia et al., 2015). This is not only dangerous for the neonate but weighs a heavy burden on healthcare resources, including the annual $1.5 billion in hospital charges that are associated with the rise of NAS (American College of Obstetricians and Gynecologists [ACOG], 2017).

The current first-line treatment for childbearing individuals with OUD, is opioid agonist treatment (OAT). OAT involves the use of medications such as buprenorphine and methadone. The goal of OAT is to prevent illicit opioid use known to cause morbidity and mortality to a fetus. However, a common contributor to opioid abuse is past trauma and co-occurring mental health disorders (ACOG, 2017). In fact, 50-80% of women with OUD have experienced some sort of trauma leading to OUD and 45% of women with OUD have a co-occurring mental health disorder (Saia et al., 2016). This necessitates a trauma-informed care framework that considers the impact of victimization and trauma, leading to opioid-use activity. Preliminary evidence suggests multidisciplinary treatment (MDT) services within a trauma-informed care approach may improve perinatal outcomes for gestating individuals with OUD (Sutter et al., 2017). A valuable model implementing this approach is the Dartmouth-Hitchcock Medical Center’s Perinatal Addiction Treatment Program in Lebanon, New Hampshire (Goodman, Milliken, Theiler, Nordstrom, & Akerman, 2015).

Purpose: The purpose of this literature review is to establish whether a multidisciplinary team approach within a trauma-informed care approach improves neonatal outcomes for pregnant persons with opioid use disorder.

Methods: An internet search was performed to determine the efficacy of the current gold-standard treatment for OUD in pregnancy compared to an MDT approach. A systematic literature search was conducted based on the identification of three main concepts: neonatal outcomes, multidisciplinary treatment, and opioid use disorder in pregnancy. Four databases were searched using the PRISMA-P checklist to frame the search. These databases included PubMed, CINAHL, Embase, and ProQuest. The inclusion criteria included articles published in English within the last 10 years, contained the keywords from the search strategy and were from peer-reviewed journals and government reports. In vitro research, animal research, expert opinions and editorials, and case reports were excluded in order to appraise higher level evidence. Studies were also excluded that didn’t report the outcomes variables of the neonate. Mesh terms included maternal health services, interprofessional relations, opioid-related disorders, harm reduction, pregnancy complications, neonatal abstinence syndrome. Additional keywords included trauma-informed care, relapse rate, opioid-related, opioid use, opiate addiction, opioid abuse, substance use disorder, cross-disciplinary, harm minimization, reduction, perinatal substance use, postpartum, pregnancy, antenatal, opiate abuse, risk behavior, maternal health, opiate dependence, opioid agonist, interdisciplinary, multidisciplinary, communication, harm, reduction, and minimization. A total of 89 articles have been found through the search strategy and 11 have met the inclusion criteria for analysis. The 27 item PRISMA checklist is being utilized to appraise the evidence, summarize key findings, and synthesize those findings into evidence-based recommendations for current clinical application. Emerging evidence shows the overall strength of the evidence is good and consistent. Gaps in the evidence are being identified to provide a roadmap for future research priorities.

Results: Emerging evidence of clinical research shows the use of a trauma-informed, MDT approach improves neonatal outcomes. Mental health treatment, trusting patient-provider relationships, and an MDT approach each correlate with regular antenatal care which reduces relapse rates and thus poor neonatal outcomes (Kramlich & Kronk, 2015; Krans et al., 2015; & Sutter et al., 2017). MDT services also increase the rates of sustained recovery for the childbearing individual, and combination therapy yields the best results for sustained recovery (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016; & Sutter et al., 2017). Positive outcomes of regular antenatal care included increased length of gestation, increased neonatal birth weight, decreased hospital interventions and shorter hospital stays (Kramlich & Kronk, 2015; Saia et al., 2016; & Sutter et al., 2017).


Implications: The literature review shows consistent evidence that an MDT approach yields better neonatal outcomes than OAT. This MDT team should include a local coalition of representatives from the community and all representatives must be trained to provide non-judgmental care when working with this population. MDT services should include family case management, access to OAT, psychiatric consultation, access to behavioral health counseling, resources for relapse prevention, specialized perinatal care, child care, and peer support. It is also recommended that providers use a trauma-informed approach when caring for pregnant individuals with OUD.

In order to evaluate the effectiveness of the MDT, it is important to examine a variety of patient and neonatal outcomes to allow for better between-study comparisons. Suggested variables include adherence to prenatal care, relapse rates, gestational age, birth weight, hospital stay length, and the number of hospital interventions. Future research should also assess which MDT services are most effective for improved outcomes for the childbearing individual. Cost-effectiveness analyses could further support the promotion of the MDT approach for pregnant persons and subsequently improve neonatal outcomes. As the death rate from opioids has increased every year for the past two decades and the costs of neonatal intensive care related to NAS has skyrocketed, this is a program of research that demands our attention and innovation.

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