Substance Use Disorder (SUD) is characterized by tolerance, cravings, inability to control use of a substance, unsuccessful efforts to cut down on use, and the continued use of a substance despite consequences and loss of relationships (ACOG, 2017). Pregnant moms and their infants are a unique population that is hard hit by the current Opioid epidemic. This specialized population but in these case when a mom uses substances in pregnancy she is not only impacted her own health, but also the health of her unborn infant. Addiction is a complex, multifactorial disease that involves physical, emotional and mental health issues. More than 30% of pregnant women in SUD treatment program screened positive for moderate depression, in addition many have histories of abuse and trauma (ACOG, 2017). Pregnancy is a particularly difficult time to get treatment because Obstetricians (OB) are not trained to prescribe the Medication Assisted Treatment (MAT) regimen for SUD treatment that is done traditionally managed by Psychiatrists. However, while the Psychiatrists are trained to prescribe the MAT regimen, they rely on recommendations for the OB when prescribing medication to pregnant women. This leaves a gap in care and unfortunately many pregnant women cannot stop using in pregnancy which leads to the birth of infants that suffer from Neonatal Abstinence Syndrome (NAS)
The increase in SUD in pregnant mothers has led to a 5 -10 fold increase in the cases of NAS from 2000-2012 (variations dependent on reporting regions) (Kramlich et al, 2018). NAS has clinical symptoms that include hyper-irritability and irregularity of the nervous system, gastrointestinal system, and respiratory system with symptoms that include mild to moderate tremors, irritability, high pitched crying, difficulty being consoled, diarrhea, weight loss, seizures and can even lead to death. NAS infants may have to be started on pharmacologic treatment such as Morphine to manage the symptoms of NAS, and are traditionally monitored and cared for in the NICU. This care process interrupts maternal-infant bonding and in many of cases, breast feeding. NAS infants are difficult to console and a great deal of patients is required to get through the irritability and crying that is so common with this disorder. Then add a mom that has used substances in pregnancy that feels guilty, scared and judged, likely with poor coping mechanism (with drug use being a main source of coping). This scenario is too much for many moms, so some visit less and less frequently, and some don’t come back at all.
While acute treatment is important and recommended when SUD is identified, the relapse statistics highlights the need to shift from acute care treatment to focus on long-term recovery. That is exactly what some organizations are doing. An organization in Texas found success in implementation of community based Peer Recovery Coaches. The results following a 12 months of relationship with Peer Recovery Coach was a decreased inpatient, outpatient and ED admissions. Other outcomes included 83% of patients reporting reduced use or total abstinence from drug use; 54% reported owning/renting their own home compared to 32% when they enrolled; and 57% reported being employed compared to 27% when they enrolled (States News Services, 2017). Other organizations have also found success in Addiction/Recovery focused peer support programs in the ED. Outcomes after a pilot program in one ED from 2014-2016 saw a reduction in readmission rate and decrease in number of patients that left AMA. Other exciting results of peer support programs implemented in the healthcare setting is the education provided to healthcare workers that have improved empathy by physicians, nurses and care coordinators when working with patients with SUD (News Report, 2018). With the implementation of peer recovery support programs being done in organization’s Emergency Departments, and in the community’s settings, an idea emerged from NICU staff to apply that concept to their vulnerable population.
The idea of a NICU Peer Recovery Coach was born. There are times in our lives that are turning points, times of true crisis when people make decisions to change their lives. The ED’s have realized that following an overdose is one of those times and we believe that having a baby is another one of those times. It has been said that the opposite of addiction is not treatment and recovery, it is connections. The main goal of the NICU Peer Recovery Coaches (PRC) are to create connection through a shared lived experience of addiction. The PRC for the NICU go through specific training as a PRC but also education specific to NAS and the NICU environment. The PRC walk the path with a mom who has a baby in the NICU with NAS, and then maintains the relationship after discharge. This program has been successfully implemented with the on-boarding of 4 NICU specific Peer Recovery Coaches currently working with our patients with SUD that have infants with NAS.
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