I. INTRODUCTION
Though many think prescription opioids are safer than intravenously administered opioids, the consequences of such medications are in no way benign and can’t be overlooked. While non-injection opioid addiction has fewer severe medical complications than injection drug use, overdose deaths as a result of opioid analgesics recently surpassed heroin and cocaine, rivaling mortality rates from automobile accidents according to by the Center for Disease Control and Prevention. In fact, an increasingly common path taken by users is to change to intravenous or smoked heroin from prescription opioids. This is due in large part to limitations in supply and demand of the unintended consequences of tighter regulation of prescribing opioids by doctors.
The reasons behind prescription drug abuse in the United States is varied and complicated. The driving forces change based on different factors such as age, gender, race, ethnicity, geography, socioeconomic factors and diagnosed medical conditions. There are also many forces driving the increase in opiate use and abuse such as provider clinical practices, insufficient oversight to curb inappropriate prescribing; insurance and pharmacy benefit policies; and a belief by people that prescription drugs are not dangerous. In 2011 over 200 million prescriptions were dispensed for opioid analgesics, nearly a 200% increase since 1991. Also in 2011, over 11 million people reported taking opioid prescription drugs for non-medical reasons.
Alongside the rise in prescriptions, there has been an increase in the average dose per prescriptions, and daily and cumulative supply given. In 2010 there was such high number of prescriptions with large enough dosage levels to give every adult in the United States the equivalent of five milligrams of hydrocodone every four hours for an entire month. During this period there also was shown to be an increase in opioid overdoses as well as people entering substance abuse treatment for opiates.
From an issue affecting mostly lower class inner city women using intravenous heroin, a far larger, demographically diverse population addicted to prescription opioids has become prevalent throughout smaller urban and rural regions of the United States. This increase in prescription opioid use disorder is characteristic of Southeastern states, like Tennessee. Tennessee ranks as the state with the second highest rate of prescriptions written for opioid pain relievers, with 1.4 per person in 2012. In this paper, I will discuss the issues facing pregnant women in Tennessee that are addicted to opiates. I will also attempt to go over multiple public health approaches to remedy the obstacles faced by these women.
II. WOMEN
Over the last decade, rates of opioid pain reliever prescribing grew considerably within the United States affecting several segments of the population, as well especially women. Women of any race, age, or income are prescribed opiates more often than men regardless of type or duration of pain.
The reasons behind the large numbers of women using prescription opioids are multi-dimensional. Women tend to visit the doctor more often than men for pain since women are more likely to have a chronic pain condition. Drug use escalates into addiction faster even when using the same dose or smaller as men due to physiological differences in a slower metabolism and fat to water ratio. Sex-specific differences have been found in opioid receptors, leading to slower onset and offset of morphine among women than men and the need for greater doses to achieve similar effects. Thus women’s bodies can hold onto the drugs longer increasing the risk of abuse. Women are also more reluctant to get help for substance abuse than men due to stigma and social factors. Further incidents of prescription medication borrowing and sharing are higher (36.5%) among women of reproductive age than any other group.
A. Pregnancy
As a result of the increase in women taking prescription drugs, there is also a growth of women that use opiates during pregnancy and might not realize the potential risk of opioid consumption. This increasing amount of drug use throughout pregnancy within the past decade has led to a corresponding growth of incidences of maternal and infant complications, neonatal abstinence syndrome, and health care prices.
Across the country opioid use disorder, both via prescription medications or street drugs complicates approximately 54,000 pregnancies annually. Data indicates that 5.9% of pregnant women between the ages of 15 and 44 are illicit drug users. Opioid use during the 1st trimester of pregnancy grew from 8% to 20% from 2005 to 2009 in Tennessee. In Tennessee, 29% of pregnant women enrolled in Medicaid filled opiate scripts in 2009, though not all scripts are associated with abuse.
B. NEONATAL ABSTINENCE SYNDROME
Neonatal abstinence syndrome (NAS) is a postnatal withdrawal syndrome, initially represented in opiate-exposed newborns shortly after they are born. The syndrome most typically happens when there is prenatal exposure to opioids, though different medications have also shown to have an effect on NAS. NAS presents with an array of clinical signs, such as feeding issues, lack autonomic control, and behavioral distress.
The incidence of NAS has grown considerably within the United States between 2000 and 2009. In 1999 the number of babies born with NAS was .7% per one thousand however by 2011 that number had increased to 8.5%. NAS has become well known as a significant health care expenditure that is related to opioid use disorder throughout pregnancy. As a result, NAS has been targeted as a central focus for prevention efforts.
In 2013, the Tennessee Department of Health required NAS reporting to be mandatory. Tennessee created the first statewide surveillance system for NAS to allow the study of prevention of this serious complication of prescription opioid dependence. The Tennessee NAS surveillance system identified a high rate of NAS cases throughout the state (11.6 per 1,000 live births), demonstrating a 16-fold increase in the syndrome since the year 2000. A total of 921 cases were reported in 2013 (among 79,954 births), with the majority of cases clustered in eastern Tennessee. In 63% of cases where NAS occurred, the baby was born to a mother who was using at least one substance that had been prescribed to her by a health care provider. While 33% of cases occurred among women using illicit drugs or medications prescribed for somebody else.
Among neonates exposed to opioids in utero, withdrawal signs will develop in 55% to 94% of them. Beyond initial withdrawal symptoms that first present after about a day or two – breathing problems, convulsions, vomiting, diarrhea, tremors, sweating, fever, mottled skin, jitteriness, irritability, feeding difficulty, necrotizing enterocolitis, seizures, risk for jaundice and sepsis, high-pitched crying and Low birth weight
i. Long Term Effects of NAS
While hospital stays for NAS babies are on average three weeks, there is no research yet into the long-term effects of infant opioid withdrawal that has been published. Opiates have been shown to decrease brain growth and cell development in animals, but studies of their effects on neurotransmitter levels and opioid receptors have produced mixed results. Moreover, long-term effects on height and weight of the child have not been documented in opiate-exposed children yet. Hyperactivity and short attention span have been noted in toddlers prenatally exposed to opiates. Older opiate-exposed children have demonstrated memory and perceptual.
Longitudinal studies of prenatal opiate exposure have not produced consistent findings of cognitive/executive functioning. Though developmental scores tend to be lower in exposed infants, these differences no longer exist when appropriate medical and environmental controls are introduced. School achievement and language development have not been studied adequately yet for people prenatally exposed to opiates. There is insufficient data available to draw any conclusions about the effects of prenatal opiate exposure on the risk of tobacco, problem alcohol or illicit drug use later in life.
III. Multiple approaches to care
There is are many different types interventions and approaches to care available for parenting and pregnant women including intensive outpatient, inpatient, detox, and residential treatment plans. There are also options for parenting training, instruction about drug use, and individual development tasks. The best strategies tend to fall into the categories of removing barriers; education; monitoring; and criminal law. However, few programs have been specifically aimed at women of reproductive age and the majority of policies in place currently, do not address women-specific problems tackling opioid abuse. Tennessee lawmakers should create specific policies that place emphasis on expanding the access of care to women of reproductive age and those that are pregnant to combat the rising rate of NAS in the state. Effective methods to solve the problem within these categories of treatment and intervention will have to address the unique factors that affect substance-abusing women generally and the specific factors influencing pregnant and parenting women.
A. REMOVING BARRIERS
Successful programs should have the ability to address the unique characteristics of substance-abusing women in general and pregnant and parenting women specifically. The majority of women who misuse alcohol and illicit materials face huge obstacles to move beyond addiction. These challenges can include barriers at physical, social, and economic levels when seeking treatment. They exist as the women seek treatment and are continually pervading. Women are further challenged by how quickly they progress from use to abuse and addiction by comparison to their male counterparts.
Parenting and pregnant women encounter the same minefield of problems as those women without children, but take on added burdens like a heightened level of danger with regard to physical and sexual maltreatment, extensive societal stigma, and the intricacy of balancing their own often failing health, the health of their unborn child, and well as the wellbeing of their present children. More specifically, the affected women face private barriers to treatment for example fear of reprisal from significant others and household members. Anxiety about not being able to look after their children, anxiety about losing custody of their children is a constant worry for these women. Women also are worried about lifestyle changes, isolation, and confidentiality since stigma connected with using is much greater as a woman and it is especially heightened if pregnant.
Additionally, complicating this sense of isolation is the anxiety that their partners may become abusive either on account of the woman using or because the partners do not want the women to expose their use by seeking treatment. Evidence also indicates that women experience a greater amount of co-occurring psychosocial, psychiatric and medical difficulties as compared with their male counterparts. These variables serve as significant barriers to substance abuse services for pregnant and parenting women. Other obstacles include individual issues such as remorse, shame, too little understanding of dependence, and limited awareness of the methods to obtain health care and treatment.
The first aspect to adequately address women with opioid abuse problems it to tackle the personal barriers that they face in creating legislation and being aware of them. In general, there is a significant lack in women-focused programs for substance abuse and women in Tennessee. Women face many issues getting treatment to care, many logistical like lack of transportation and lack of child care that prevent women from getting proper help.
There is also evidence that indicates women who have issues with substance abuse are more likely to come from families that have drug abusers or are disorganized and often lack a healthy support system. Due to the unique circumstances of substance abuse during pregnancy, the ability to increase access to care for women needs to be targeted from multiple angles. Without implementing strategies that take into account the needs and barriers facing women no approach to combat NAS will be very useful.
i. Treatment centers that focus on pregnant women
To effectively combat NAS rates and opioid abuse there needs to be a much greater availability of complete and focused drug treatment for both pregnant and non-pregnant women. There are very few drug treatment programs that cater to the needs unique to women let alone women that are pregnant. By tailoring care to women’s needs, programs have been shown to be more efficient in treatment.
Pregnant women who are addicted to opiates have very different issues that need to be addressed by drug treatment as they often cannot be drug-free through the duration of their pregnancy. Not only that but fetal distress could easily occur due to a cycle of abuse and relapse. To prevent these harms, Opioid Medication Assisted Therapy is considered to be the best strategy to help pregnant opiate abusers. This is often by taking regulated amounts of methadone, buprenorphine or Subutex requiring very specific care.
Unfortunately, nationally there are less than 2,000 drug treatment facilities that offer services for pregnant women, out of 11,000. In Tennessee, there are 39 licensed residential detoxification programs, but only 11 of those programs will accept expectant mothers. When it comes to treatment programs willing to take on pregnant women many programs are reluctant to take on the liability of having such women enrolled and thus availability, development and implementation suffer. To allow for more access to treatment legislation that relaxes the liability of treatment centers may be helpful.
Furthering the problem is that there is extremely limited state funding for beds in these residential programs and long waiting lists to get into a detox center is typical. Many programs say that they will take in women who are pregnant on a case by case basis but generally that only applies to women who are between their eighth and 34th week of pregnancy.
They also require that the women be medically stable and have been seen by a high-risk obstetrician/gynecologist before admittance. Finding a treatment program in the state which also has access to a high-risk obstetrician/gynecologist is rare and places, even more, limitations on places pregnant women can get detox.
Legislation both at the state level and nationally has tried to address this by improving access to comprehensive treatment for pregnant women. Still, there are many systemic issues that face pregnant women and women who already have children which have yet to be overcome.
Successful treatment services for pregnant women must, as a result, be family-focused, multidimensional, caring, and unbiased. Research also confirms that a confrontational strategy does not work well with women. Additionally, providers of care must be aware of and incorporate a patient’s background, culture, and previous mental health issues or trauma. Research also suggests that increased attendance in treatment is essential to treatment success. So, any mechanism that may improve the length of stay is essential. In this regard, of important and overarching consequence is the research that suggests that programs that allow kids to remain with their mother in residential treatment are more successful in patient outcomes.
Similarly, for outpatient services it has been found that treatment for moms is frequently more efficient when organized with prenatal care and transport services, as well as child care, mental health services, and support services. Additionally, other research on treatment strategies for pregnant and parenting women signals that contingency management strategies are successful in improving retention rates and reducing illicit drug use among pregnant women in drug treatment.
ii. Health Centers
One option to expand access to care is by regulating the creation and regulation of health centers. Health Centers are non-profit clinics in medically underserved areas that provide comprehensive primary care to patients regardless of insurance status. Health centers improve access to care while lowering costs associated with poor coordination and limited communication among the different providers of care. Also, health centers perform many roles other than primary care such as patient education, informal counseling and coaching, care coordination and other essential services all within a patient’s community.
Legislatures, medical schools, and social work programs can also help with the growth of such centers by creating programs that would provide incentives such as scholarships, tuition assistance or loan repayment for those who practice in health centers.
iii. Telehealth
. Mothers and pregnant women who use illicit substances frequently have difficulties finding health care, treatment programs, and counseling and traveling to them. This is a particularly severe issue in rural areas. Because Tennessee is mostly rural, there are fewer doctors and places to get care. Fewer doctors mean fewer options for treatment has been shown to be a factor in regions with high opioid prescriptions. When locating a treatment plan, one source of the problem is the lack of variety and availability various kinds of services present in an area or a city. To obtain these services, the woman must decide which treatments and programs are relevant to her needs and then she needs to figure out if those plans even have space for her. When there\’s space, then she then has to locate ways to get there, for childcare, and how to deal with jobs absence if the care is any distance from her house.
Due to the difficult in access due to location and travel, telehealth care is another option that’s being explored to treat people with substance abuse problems. Telehealth attempts to combat the barriers women face such as difficulty in transportation, childcare, and stigma when trying to access care. Telehealth is the use of medical information exchanged from one site to another, generally though it refers to remote physician-patient care. Allowing for patients to be able to get proper medical advice and consultations remotely. Telehealth Supports rural providers as well as patients by facilitating continuing education as well as communication and collaboration among different providers in different locations. Telehealth initiatives can be vital to residents of more rural areas such as Tennessee as well as substance abusers.
Lawmakers can help telehealth growth in some ways such as by allowing private payer reimbursement for telehealth care. Since doctors are required to have a license in each state in which they practice lawmakers can also facilitate telehealth growth by expanding portable licensure policies to remove practice barriers for health care providers that offer telehealth residency programs and training and rotation opportunities in rural hospitals.
iv. Non-Traditional Health Care Providers
Lawmakers can facilitate an increase in primary care access by redefining and expanding the scope and standards of practice for non-physician and non-traditional practitioners, like the telehealth providers mentioned. This would allow these types of providers to independently provide a full range of primary care services, especially when dealing with substance abuse users such as counseling and family planning.
One potential approach to relieving pressures on the primary care workforce is greater use of physician assistants and nurse practitioners, which could both increase the number of primary care providers and potentially free up doctors to care for patients that are more complex. Another component of such legislation should specifically define and recognize community health workers as currently there is no law in Tennesee recognizing or limiting the scope of their practice. Additionally, this bill needs to establish standards or credentials for community health workers and a method to assess training and certification.
Legislatures and medical schools should create software that would support workforce development policies that offer incentives for providers who practice in rural communities. Financial incentives including tuition aid scholarships or loan repayment to help health students to continue a career in primary care are all ways to get outside more physicians to underserved areas.
There are pharmacy specific laws also being explored. One idea is to create a law that authorizes all appropriately trained state-licensed pharmacists to exclusively supply additional services including furnishing routine vaccinations, hormonal contraception, nicotine replacement medications, and certain prescription drugs.
The legislation would also establish a new level of skill for pharmacists who with specified advanced training and expertise, can have board recognition to work in collaboration with a patient’s primary care provider. They will be allowed to assess and refer patients; start, stop, and correct drug therapies; purchase and interpret drug therapy-associated evaluations, and participate in the assessment and management of diseases and health states.
Such provider status laws could allow more pharmacists to be able to use the full degree of their training and schooling, with a potentially important effect on payment and practice models.
2016-12-19-1482127932