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Date
IP Address
2024-03-02
54.84.95.243
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ClassC
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2025-03-03
3.233.166.20
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ClassC
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2025-11-18
18.211.28.121
(
ClassC
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Port 80
HTTP/1.1 301 Moved PermanentlyServer: awselb/2.0Date: Tue, 18 Nov 2025 02:58:20 GMTContent-Type: text/htmlContent-Length: 134Connection: keep-aliveLocation: https://nastoolkit.org:443/ html>head>title>301 Moved Permanently/title>/head>body>center>h1>301 Moved Permanently/h1>/center>/body>/html>
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100%;background-repeat:no-repeat}.partnerdata-v-27caccf1{min-height:8rem;display:flex;align-items:center;justify-content:center;padding:2rem 4rem}/style> /head> body > div data-server-renderedtrue id__nuxt>!---->div id__layout>div>div data-v-27caccf1>header data-v-27caccf1>div classgrid-bg data-v-27caccf1>div classcontainer mx-auto px-4 data-v-27caccf1>nav classflex items-center justify-between mb-8 py-4 data-v-5cbcef37 data-v-27caccf1>a href/ aria-currentpage classtext-xl noto-serif-jp-bold nuxt-link-exact-active nuxt-link-active data-v-5cbcef37>Home/a> a href/about classext-url ext-url--orange text-base noto-sans-regular data-v-5cbcef37>About the Toolkit /a>/nav> div classmt-12 text-center data-v-27caccf1>div classlg:w-3/4 mx-auto mb-4 data-v-27caccf1>p classtext-5xl noto-serif-jp-semi-bold data-v-27caccf1>Mother & Baby Substance Exposure Toolkit/p>/div> div classlg:w-2/3 mx-auto mb-12 data-v-27caccf1>p classmb-6 noto-sans-regular data-v-27caccf1>This toolkit introduces best practices to support and improve the quality of care for substance exposed mothers and newborns./p> p classmb-6 noto-sans-regular data-v-27caccf1>Throughout the toolkit, the terms mother or maternal or she or her are used in reference to the birthing person. We recognize not all birthing people identify as mothers or women. We believe all birthing people are equally deserving of patient-centered care that helps them attain their full potential and live authentic, healthy lives./p>/div> a href/explore-the-toolkit classstart-your-journey mb-8 noto-sans-regular data-v-27caccf1>Explore the Toolkit/a>/div> div classpush data-v-27caccf1>div classmb-8 text-center data-v-27caccf1>p classtext-4xl noto-serif-jp-semi-bold data-v-27caccf1>Lets learn about our Archetypes/p>/div> div classflex flex-wrap data-v-27caccf1>div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/archetypes/kayla data-v-27caccf1>div classarchetype jump data-v-27caccf1>div classflex items-center mb-6 data-v-27caccf1>img src/_nuxt/img/kayla.015fc62.svg altKayla classmr-4 data-v-27caccf1> p classtext-2xl noto-serif-jp-semi-bold data-v-27caccf1>Kayla/p>/div> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Kaylas prescription drug dependency and marijuana use are complicated by trauma, pregnancy, depression, and anxiety. How can we help Kayla?/p>/div>/a>/div> div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/archetypes/baby-m data-v-27caccf1>div classarchetype jump data-v-27caccf1>div classflex items-center mb-6 data-v-27caccf1>img src/_nuxt/img/baby_m.285df93.svg altBaby M classmr-4 data-v-27caccf1> p classtext-2xl noto-serif-jp-semi-bold data-v-27caccf1>Baby M/p>/div> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Baby M has had a difficult journey through gestation and will be born with an increased risk of Neonatal Abstinence Syndrome. Baby M will need focused care and evaluation from a number of team members whose main goal will be to create an environment of safety and maintain the mother-baby dyad./p>/div>/a>/div>/div>/div>/div>/div>/header> main data-v-27caccf1>div classaccent-bg data-v-27caccf1>div classcontainer mx-auto px-4 mb-8 data-v-27caccf1>section data-v-27caccf1>h2 classmb-6 mt-40 text-center text-4xl noto-serif-jp-semi-bold data-v-27caccf1>Where do you work?/h2> div classflex flex-wrap data-v-27caccf1>div classw-full p-3 mb-4 lg:w-2/6 data-v-27caccf1>a href/audience/outpatient data-v-27caccf1>div classaudience jump data-v-27caccf1>div classicon-wrapper icon-wrapper--outpatient data-v-27caccf1>img src/_nuxt/img/medical_box.1a09f50.svg altmedical box data-v-27caccf1>/div> div classflex items-center mb-6 data-v-27caccf1>p classtext-2xl noto-serif-jp-semi-bold data-v-27caccf1>Outpatient/p>/div> p classnoto-sans-regular color-secondary-black data-v-27caccf1>The Best Practices in this section apply to staff, administration, and providers who care for expecting and/or postpartum mothers, and newborns, in the outpatient setting./p>/div>/a>/div> div classw-full p-3 mb-4 lg:w-2/6 data-v-27caccf1>a href/audience/labor-delivery data-v-27caccf1>div classaudience jump data-v-27caccf1>div classicon-wrapper icon-wrapper--labor-delivery data-v-27caccf1>img src/_nuxt/img/large_hospital.8f02e68.svg althospital data-v-27caccf1>/div> div classflex items-center mb-6 data-v-27caccf1>p classtext-2xl noto-serif-jp-semi-bold data-v-27caccf1>Labor and Delivery/p>/div> p classnoto-sans-regular color-secondary-black data-v-27caccf1>The Best Practices in this section apply to staff, administration, and providers who provide inpatient care to women who are pregnant, in labor, or immediately postpartum./p>/div>/a>/div> div classw-full p-3 mb-4 lg:w-2/6 data-v-27caccf1>a href/audience/nursery-nicu data-v-27caccf1>div classaudience jump data-v-27caccf1>div classicon-wrapper icon-wrapper--nursery-nicu 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altsearch classicon cursor-pointer data-v-27caccf1>/div> h2 classmt-16 mb-8 text-center text-4xl noto-serif-jp-semi-bold data-v-27caccf1>Click below to see the Best Practices for each topic area/h2> div classflex flex-wrap data-v-27caccf1>div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/category/screening-assessment-level-of-care-determination data-v-27caccf1>div classcategory jump data-v-27caccf1>div classicon-wrapper icon-wrapper--screening-assessment data-v-27caccf1>img src/_nuxt/img/stethoscope.2748558.svg altstethoscope data-v-27caccf1>/div> p classw-3/4 mb-6 text-lg noto-serif-jp-bold data-v-27caccf1>Screening Assessment and Level of Care Determination/p> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Topic areas include: universal screening with a validated verbal screening tool, maternal urine toxicology and the role of explicit/implicit bias, selective newborn biological toxicology testing, and more./p>/div>/a>/div> div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/category/treatment data-v-27caccf1>div classcategory jump data-v-27caccf1>div classicon-wrapper icon-wrapper--treatment data-v-27caccf1>img src/_nuxt/img/syringe.cfd7e91.svg altsyringe data-v-27caccf1>/div> p classw-3/4 mb-6 text-lg noto-serif-jp-bold data-v-27caccf1>Treatment/p> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Topic areas include: inpatient treatment protocols, pain management and anesthesia, minimizing opioid use, breastfeeding, pharmacologic and nonpharmacologic treatment of newborns with NAS, and more./p>/div>/a>/div>/div> div classflex flex-wrap data-v-27caccf1>div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/category/transition-of-care data-v-27caccf1>div classcategory jump data-v-27caccf1>div classicon-wrapper icon-wrapper--transition-of-care data-v-27caccf1>img src/_nuxt/img/hospital.0859b73.svg althospital data-v-27caccf1>/div> p classw-3/4 mb-6 text-lg noto-serif-jp-bold data-v-27caccf1>Transition of Care/p> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Topic areas include: creating a dyad-centered Plan of Safe Care, implementing a discharge checklist, linking to home visitation programs and other resources, communication with the follow-up newborn provider, and more./p>/div>/a>/div> div classw-full p-3 mb-2 lg:w-1/2 data-v-27caccf1>a href/category/education data-v-27caccf1>div classcategory jump data-v-27caccf1>div classicon-wrapper icon-wrapper--education data-v-27caccf1>img src/_nuxt/img/patient.86f74a6.svg altpatient data-v-27caccf1>/div> p classw-3/4 mb-6 text-lg noto-serif-jp-bold data-v-27caccf1>Education/p> p classnoto-sans-regular color-secondary-black data-v-27caccf1>Topic areas include: educating staff about opioid use disorder, Neonatal Abstinence Syndrome, stigma, Trauma-Informed Care, and more./p>/div>/a>/div>/div>/section>/div>/div>/main> footer classmt-16 data-v-27caccf1>div classcontainer px-4 mx-auto data-v-27caccf1>div classcontent noto-sans-regular 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{layout:default,data:{},fetch:,error:b,state:{best-practice:{bestPractices:{id:j,title:Use validated verbal screening and assessment tools to evaluate all pregnant women for substance use disorders ,description:a,position:j,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement universal screening for substance use disorder (SUD) with a standardized, evidence-based screening tool at all locations that provide medical care to pregnant women. A universal screening tool for self-reporting of opioid use and identification of risk for opioid use disorder (OUD) should not be confused with toxicology testing (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Faudience\u002Foutpatient\u002Fcategory\u002Fscreening-assessment-level-of-care-determination\u002Fbest-practice\u002F3\\u003E\u003Cstrong\u003EBest Practice #3\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more on toxicology testing).\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIdentification of women with SUD as early as possible in pregnancy is critical in connecting them to treatment. Treatment for SUD, particularly OUD, during pregnancy results in better outcomes for mom and for her newborn.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EDrug addiction affects all racial, ethnic, and social groups. Universally screening all women minimizes the potential for implicit bias that can occur when providers use subjective risk factors to determine who should be screened and may also decrease the stigma associated with SUD and screening. Universal screening at the time of entry into prenatal care allows more time to intervene and mitigate the harms associated with SUD in pregnancy and to stabilize the home environment for newborns. If an individual screen is positive for risk of OUD or other SUD, a validated assessment tool (a deeper evaluation intended to solidify a diagnosis and severity of a condition) should be administered to determine the presence and severity of the SUD. It is important to remember that substance use is not synonymous with addiction.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EEducate staff on how to administer a validated screening tool and the importance of universal screening in order to reduce implicit bias.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInitial screening for risk takes little time and can be done at many points within care. Validated screening tools include the NIDA quick screen, 4Ps Plus, and the CRAFFT (for women and adolescents 12-26 years old). Refer to a full list of validated screening tools in the Resources section of this Best Practice.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EScreening should be performed at intake of prenatal care to identify needs as early as possible and at regular intervals thereafter.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIf screening is positive, use a validated verbal assessment tool to establish the diagnosis and severity of an actual SUD. Ideally, this assessment should immediately follow a positive screen. Examples include, but are not limited to, AUDIT-C (alcohol specific), ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test), and DAST-10 (drug use). For descriptions of these and other validated assessment tools, refer to the AIM Opioid Screening Tools in the Resources section of this Best Practice. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EA positive screening should stimulate a brief intervention and referral to appropriate treatment using resources within your setting and community\u003Cem\u003E. Determining severity of disease is critical in referring to the correct level of care\u003C\u002Fem\u003E (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Faudience\u002Foutpatient\u002Fcategory\u002Fscreening-assessment-level-of-care-determination\u002Fbest-practice\u002F2\\u003E\u003Cstrong\u003EBest Practice #2\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EScreen all women for coerced sex and the possibility of human trafficking. An Adult Human Trafficking Screening Tool has been created by the US Department of Health and Human Services. Please also see a commentary from \u003Cem\u003EThe Journal of Ethics\u003C\u002Fem\u003E in the References section of this Best Practice. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInquire about polysubstance use. If smoking tobacco or drinking alcohol, provide brief intervention and referral to services. Encourage cessation and refer to cessation services to decrease risk for a variety of adverse pregnancy outcomes and to decrease severity of neonatal abstinence syndrome (NAS). If drinking alcohol, counsel the patient that there is no known safe amount of alcohol during pregnancy. Inform patient\u002Ffamily that alcohol is the leading known cause of birth defects. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T16:23:47.017Z,updatedAt:2023-08-18T15:16:42.795Z,publishedAt:August 18th, 2023,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443383729,powerpointUrl:b,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla comes to her local community health clinic and asks to be seen for her ongoing problems with back pain and anxiety. Her history elicited the need for a routine pregnancy test. Kayla starts crying when she finds out she is pregnant and it is unclear at first what this means, but through continued discussion the physician realizes that although Kayla didn’t plan on getting pregnant now, she definitely wants to continue the pregnancy and is excited about this new possibility. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe physician asks Kayla if it would be ok to ask some questions about Kayla’s personal and family history. She explains that they ask these questions of all women who are pregnant to make sure they get the best possible care during pregnancy. With Kayla’s permission, the physician reviews Kayla’s medical, social, and family histories; she includes an evidence-based screening tool for substance use disorder that takes only a few minutes to administer. It was only through this interview that the physician identified Kayla as a person with possible SUD and was subsequently able to start her on the best possible care pathway to meet her unique needs. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:as,name:ax,description:ay},authors:{id:W,fullName:bw,professionalDesignation:bx,biography:by,disclosure:b},{id:ab,fullName:bz,professionalDesignation:bA,biography:bB,disclosure:b},resources:{id:j,title:bY,description:a,fileUrl:https:\u002F\u002Fsafehealthcareforeverywoman.org\u002Fwp-content\u002Fuploads\u002F2018\u002F08\u002FAIM-Opioid-Screening-Tools.pdf},{id:C,title:SAMHSA-HRSA Center for Integrated Health Solutions.,description:a,fileUrl:https:\u002F\u002Fwww.integration.samhsa.gov\u002Fclinical-practice\u002Fsbirt\u002Fscreening},{id:E,title:Council on Patient Safety Women’s Health Care Safety Bundle for Obstetric Care for Women with Opioid Use Disorder. ,description:a,fileUrl:https:\u002F\u002Fsafehealthcareforeverywoman.org\u002Fpatient-safety-bundles\u002Fobstetric-care-for-women-with-opioid-use-disorder\u002F#link_acc-1-3-d},{id:al,title:Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. SAMHSA.,description:a,fileUrl:bZ},{id:X,title:Adult Human Trafficking Screening Tool and Guide.,description:a,fileUrl:https:\u002F\u002Fwww.acf.hhs.gov\u002Fsites\u002Fdefault\u002Ffiles\u002Fotip\u002Fadult_human_trafficking_screening_tool_and_guide.pdf},{id:184,title:Accuracy of Three Screening Tools for Prenatal Substance Use.,description:a,fileUrl:https:\u002F\u002Fjournals.lww.com\u002Fgreenjournal\u002FFulltext\u002F2019\u002F05000\u002FAccuracy_of_Three_Screening_Tools_for_Prenatal.15.aspx#JCL-P-9},{id:185,title:ACOG Postpartum Toolkit (see screening tools in Table 1 of the Substance Use Disorder section of this toolkit).,description:a,fileUrl:https:\u002F\u002Fwww.acog.org\u002F-\u002Fmedia\u002Fproject\u002Facog\u002Facogorg\u002Ffiles\u002Fpdfs\u002Fpublications\u002F2018-postpartum-toolkit.pdf},references:{id:j,title:b_,body:a},{id:C,title:Chasnoff IJ, Mcgourty RF, Bailey GW, et al. The 4P’s Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol. 2005; 25(6): 368-374. doi:10.1038\u002Fsj.jp.7211266.,body:a},{id:E,title:Yonkers KA, Gotman N, Kershaw T, Forray A, Howell HB, Rounsaville BJ. Screening for prenatal substance use. Obstet Gynecol. 2010; 116(4): 827-833. doi:10.1097\u002Faog.0b013e3181ed8290.,body:a},{id:al,title:Wood SP. Trafficked. AMA J Ethics. 2018; 20(12): E1212-1216. doi:10.1001\u002Famajethics.2018.1212.,body:a}},{id:C,title:Once substance use is identified, perform a brief intervention and referral to appropriate treatment (SBIRT),description:a,position:C,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EScreening, Brief Intervention, and Referral to Treatment (SBIRT) is a comprehensive, evidence-based approach to the identification and delivery of services for a variety of conditions including substance use disorder (SUD). Once substance use is identified, perform a brief intervention and refer to the treatment most appropriate for a patient’s needs. A brief intervention is a patient-centered, structured conversation that utilizes the principles of Motivational Interviewing (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Faudience\u002Foutpatient\u002Fcategory\u002Ftreatment\u002Fbest-practice\u002F8\\u003E\u003Cstrong\u003EBest Practice #8\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E), in order to motivate the person to progress through the stages of readiness toward concrete changes that address their SUD. Brief interventions have been shown to improve outcomes for patients with substance use, and formal treatment is required for those with a diagnosable SUD.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESBIRT is a validated process for addressing SUD. Each facility should identify resources in their community to assist women who screen positive and include a warm hand-off to a care navigator to help connect them with appropriate resources. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EIdentify and train the appropriate staff in the use of screening and brief intervention techniques. This can include sample scripting for staff around screening itself and how to respond to positive screens – this is important for any type of screening completed. Refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F7\\u003E\u003Cstrong\u003EBest Practice 7\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more information on Trauma-Informed Care and how to avoid re-traumatization. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EHave a list of resources or informational packets available for each American Society of Addiction Medicine (ASAM) level of care to support women at all levels of risk. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEstablish a clear system and workflow for positive, validated screening and\u002For assessment tools. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPlease see the Resources section of this Best Practice for information on risk (“AIM Opioid Screening Tools”). \u003Cul\u003E\u003Cli\u003ELow risk patients can receive brief advice related to their identified substance. \u003C\u002Fli\u003E\u003Cli\u003EModerate risk patients should have a brief intervention\u003C\u002Fli\u003E\u003Cli\u003EAs described in \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F1\\u003EBest Practice # 1\u003C\u002Fa\u003E, after a positive screen for SUD, use a validated assessment tool to determine the presence and severity of the SUD followed by the identification of and referral to the appropriate level of care that matches the severity of the patient’s needs. The state of California mandates that all counties with Drug Medi-Cal Organized Delivery System (DMC-ODS) contracts use the ASAM criteria to determine the appropriate level of care for an individual with SUD. The ASAM Co-triage or the ASAM Continuum clinical decision supports are ideal assessment tools to meet that requirement.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EOther than the Co-triage, which is designed as a ten-minute provisional evaluation tool, each assessment typically takes an hour to complete. Identifying clinic personnel who can be trained to effectively administer the chosen screen, assessment, and level of care evaluation prior to SBIRT implementation will streamline workflow.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIdentify local options for each level of care, including the full spectrum of office-based treatment (level 1), methadone clinic management (level 1 OTP), intensive outpatient centers (levels 2.1 and 2.5), residential treatment centers (levels 3.1, 3.3, 3.5, and 3.7) and medically managed inpatient treatment (level 4). Please see the Resources section of this Best Practice for the SAMHSA treatment locator tool. For more on levels of care, please refer to the ASAM CONTINUUM in the Resources section of this Best Practice.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReferral sites may be any of the above depending on the level of care determined to be most appropriate.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T16:37:30.734Z,updatedAt:2020-10-07T14:21:11.832Z,publishedAt:ac,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443383912,powerpointUrl:b,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla’s screen is positive for risk of substance use disorder, and she has shared that she is using opioid pain medications for her back pain, marijuana for her anxiety, and smoking cigarettes. While you are talking, she takes a pack of cigarettes out of her purse and throws it in the trash. She tells you that she knows smoking isn’t good for her baby, and she is going to quit right now. She explains that she knows she should stop everything, but she needs the pain medication and marijuana to manage her back pain and anxiety, especially since pregnancy will probably make her back pain worse. \u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003EThe physician applauds Kayla’s desire to make healthy choices for herself and her baby. She explains that all medications women take during pregnancy may have some effects on the baby and that there are treatments available for women who have become dependent on opioids; these treatments not only help mom feel better but are safer for developing babies. She explains that abruptly stopping opioids suddenly can be dangerous for her baby. She asks if Kayla would like to meet with Hannah (a social worker), who can help her set up an appointment to talk about treatment, as well as assist with any other needs Kayla may have during her pregnancy.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:as,name:ax,description:ay},authors:{id:W,fullName:bw,professionalDesignation:bx,biography:by,disclosure:b},{id:ab,fullName:bz,professionalDesignation:bA,biography:bB,disclosure:b},resources:{id:az,title:SAMSHA’S guide to SBIRT.,description:a,fileUrl: https:\u002F\u002Fwww.samhsa.gov\u002Fsbirt},{id:W,title:ASI (Addiction Severity Index) Sample.,description:a,fileUrl:https:\u002F\u002Fpubs.niaaa.nih.gov\u002Fpublications\u002Fassessingalcohol\u002FInstrumentPDFs\u002F04_ASI.pdf},{id:am,title:ASAM Continuum - Guide to Levels of Care for Substance Use Treatment.,description:a,fileUrl:https:\u002F\u002Fwww.asamcontinuum.org\u002Fknowledgebase\u002Fwhat-are-the-asam-levels-of-care\u002F},{id:b$,title:NNEPQIN Toolkit for Perinatal Care of Women with Substance Use Disorders. Chapter 3 on SBIRT.,description:a,fileUrl:ca},{id:cb,title:SBIRT Oregon’s online curriculum guide to teaching and using SBIRT. ,description:a,fileUrl:http:\u002F\u002Fwww.sbirtoregon.org\u002Fsbirt-workflow\u002F},{id:cc,title:bY,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBKZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--7be77d92c3fd28f41452f8e1b83995ee6af3a95b\u002FAIM-Opioid-Screening-Tools.pdf},{id:167,title:Behavioral Health Treatment Services Locator. ,description:a,fileUrl:https:\u002F\u002Ffindtreatment.samhsa.gov },references:{id:193,title:Wright TE, Terplan M, Ondersma SJ, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol. 2016; 215(5):539-547. doi:10.1016\u002Fj.ajog.2016.06.038.,body:a}},{id:aK,title:Maternal urine toxicology and the role of explicit\u002Fimplicit bias in decision-making ,description:a,position:E,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EUnderstanding toxicology testing and its limitations is important for providing optimal care to women who use substances during pregnancy. Universal screening via a validated verbal screening tool (see \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Faudience\u002Foutpatient\u002Fcategory\u002Fscreening-assessment-level-of-care-determination\u002Fbest-practice\u002F1\\u003E\u003Cstrong\u003EBest Practice #1\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003Cstrong\u003E) \u003C\u002Fstrong\u003Eshould not be confused with urine or blood toxicology, which historically has been applied inconsistently and has often resulted in a system of race and class-based testing.\u003Csup\u003E \u003C\u002Fsup\u003EThus, toxicology testing should be carefully applied with the intention of improving clinical decision-making, such as informing the pain management approach during the intrapartum period and improving efforts to link the mother with appropriate services and treatment. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EProviders and staff should be educated on how explicit or implicit bias may impact their decision to perform biological toxicology testing on a pregnant or laboring woman. Standardization of criteria for toxicology testing may help curb the impact of these biases.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EToxicology testing has a necessary role in the care of women who use substances during pregnancy. The results are useful to encourage dialogue with the patient and can be necessary for clinical decision making. However, the results can also have devastating consequences for the mother and baby when used inappropriately by other agencies and can result in punitive consequences. Furthermore, toxicology results are easily misinterpreted by those who are unfamiliar with the nature and limitations of testing. Limitations of testing include, but are not limited to, the following:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMany substances may not be detected (false negatives), including synthetic opioids and designer drugs\u003C\u002Fli\u003E\u003Cli\u003ERisk of false positives \u003C\u002Fli\u003E\u003Cli\u003ENeed for confirmatory testing for any positive toxicology result\u003C\u002Fli\u003E\u003Cli\u003ETesting does not provide information on severity or duration of use\u003C\u002Fli\u003E\u003Cli\u003ETesting can only assess for current or recent use\u003C\u002Fli\u003E\u003Cli\u003EEven if results are negative, sporadic use is not ruled out\u003C\u002Fli\u003E\u003Cli\u003EA positive urine toxicology does not confirm a substance use disorder (SUD) any more than a negative result rules it out\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EThe evidence suggests that hospital staff are more likely to perceive Black women as being at higher risk of using drugs, even though white women have similar rates of illicit drug use. Black women are therefore more likely to be tested, and more likely than white women to face punitive consequences such as having their children placed in protective care.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EEven objective medical criteria for determining who should have toxicology testing may be subject to inadvertent bias. For example, “inadequate prenatal care” is a common, and often necessary, criterion for toxicology testing. If this criterion is used as a prompt for toxicology, providers and nurses must understand that a variety of factors other than substance use may influence whether a woman can remain in care, including lack of insurance, inability to take time off of work, and lack of culturally appropriate care. All these factors are more likely to impact poor women and women of color. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EEnsure policies that delineate criteria for toxicology testing do not directly or indirectly target low income women and women of color.\u003C\u002Fli\u003E\u003Cli\u003EBehaviors\u003Cem\u003E (\u003C\u002Fem\u003Ee.g signs of acute intoxication) are more important as prompts for toxicology screening than selective indicators of risk. \u003C\u002Fli\u003E\u003Cli\u003EEach institution should be aware of the sensitivity and specificity of the tests used at their facility. \u003C\u002Fli\u003E\u003Cli\u003EEveryone should be familiar with the current laws and regulations for their county and state. Each institution should have the following: \u003Cul\u003E\u003Cli\u003EA clear policy, consistent with state and federal law, regarding what constitutes grounds for reporting to child protective services (CPS)\u003C\u002Fli\u003E\u003Cli\u003EEducation for all staff members who work with pregnant women about this policy\u003C\u002Fli\u003E\u003Cli\u003ERoutine reviews to ensure that the policy is being applied consistently and appropriately\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEvery patient must be able to give informed consent. Informed consent requires a clear explanation of why testing is necessary, the benefits of testing, and risks of testing including the potential legal, criminal, or child welfare consequences. If the provider or nurse is unable or unwilling to thoroughly explain the typical course of events after a positive drug test at their facility, a reasonably prudent patient would not have sufficient information to make an informed decision. Additional talking points are included in the Resources section of this Best Practice.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEvery patient has a right to withhold consent and coercive language should not be used. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMultiple biological substances can be used for toxicology testing, including urine, saliva, blood, hair, and meconium. Urine is often used to test pregnant women as the filtering action of the kidneys allows detection of smaller quantities for a longer period than blood.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EToxicology tests generally fall into two types: screening tests and confirmatory tests.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIt is essential to confirm unexpected results from toxicology screening tests. If the result of the screening test matches an expected result, it is usually not necessary to obtain confirmatory testing. Examples of unexpected results might include:\u003Cul\u003E\u003Cli\u003EA patient tests positive for a substance that she denies taking\u003C\u002Fli\u003E\u003Cli\u003EA patient tests negative for a substance that is prescribed, and she indicates she is taking regularly\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EToxicology testing does not provide information on how recently someone used a substance or the quantity they used. Toxicology screening tests are qualitative and only indicate the presence\u002Fabsence of a substance. Confirmatory testing often does report a quantitative level, but this should not be used to infer how much a woman is using a substance. Many factors are involved, and any value over the cutoff level should be a qualitative positive unless evaluated by a medical review officer.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUrine drug toxicology on admission to the hospital need to be monitored for timing of the sample related to administration of intrapartum pain medications. Fentanyl can lead to false positive opioid results. Ephedrine and vasopressin can lead to false positive amphetamine.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EFor an excellent review of drug screening immunoassays for clinicians to become proficient in understanding and interpretation of results, please see Nelson ZJ et al. They also provide a full description of false positives and false negatives.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Caction-text-attachment sgid\BAh7CEkiCGdpZAY6BkVUSSI8Z2lkOi8vbmFzLXRvb2xraXQtYXBpL0FjdGl2ZVN0b3JhZ2U6OkJsb2IvOTk_ZXhwaXJlc19pbgY7AFRJIgxwdXJwb3NlBjsAVEkiD2F0dGFjaGFibGUGOwBUSSIPZXhwaXJlc19hdAY7AFQw--c249f76ec27829228926f9e82b5a50775dc1d9ae\ content-type\image\u002Fpng\ url\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--cb53665b6b7c8b4aa36c26c3e18376276349cb33\u002FToxicology%20Screening%20vs.%20Confirmatory%20Testing.png\ filename\Toxicology Screening vs. Confirmatory Testing.png\ filesize\74512\ width\494\ height\229\ previewable\true\ presentation\gallery\ caption\Toxicology Screening vs. Confirmatory Testing\\u003E\u003Cfigure class\attachment attachment--preview attachment--png\\u003E \u003Cimg src\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Frepresentations\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--cb53665b6b7c8b4aa36c26c3e18376276349cb33\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaDdCam9VY21WemFYcGxYM1J2WDJ4cGJXbDBXd2RwQWdBRWFRSUFBdz09IiwiZXhwIjpudWxsLCJwdXIiOiJ2YXJpYXRpb24ifX0--4fdbde571b604cff2c50a989f27a6f2e0a6ba082\u002FToxicology%20Screening%20vs.%20Confirmatory%20Testing.png\\u003E \u003Cfigcaption class\attachment__caption\\u003E Toxicology Screening vs. Confirmatory Testing \u003C\u002Ffigcaption\u003E\u003C\u002Ffigure\u003E\u003C\u002Faction-text-attachment\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-27T04:39:47.340Z,updatedAt:2020-09-03T21:10:16.279Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443384075,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBkdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--8d0e45b24287765c4d40ab2f04b7e7cea988040c\u002FBP_3.pptx,deepDive:b,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:as,name:ax,description:ay},authors:{id:X,fullName:ba,professionalDesignation:aL,biography:bb,disclosure:b},{id:ad,fullName:bc,professionalDesignation:bd,biography:be,disclosure:b},{id:at,fullName:cd,professionalDesignation:ce,biography:cf,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:cg,title:Maternity Drug Policies by State. ,description:a,fileUrl:https:\u002F\u002Fprojects.propublica.org\u002Fgraphics\u002Fmaternity-drug-policies-by-state},{id:ch,title:Toxicology FAQs.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBNdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--184d1ad5e538c66f2b7e6ab13fc520178b796088\u002FToxicology%20FAQs.pdf},references:{id:194,title:Kunins HV, Bellin E, Chazotte C, Du E, Arnsten JH. The effect of race on provider decisions to test for illicit drug use in the peripartum setting. J Womens Health. 2007; 16(2): 245-255. doi:10.1089\u002Fjwh.2006.0070.,body:a},{id:195,title:b_,body:a},{id:196,title:Hospital Staff More Likely to Screen Minority Mothers. Los Angeles Daily News. https:\u002F\u002Fwww.dailynews.com\u002F2008\u002F06\u002F30\u002Fhospital-staff- more-likely-to-screen-minority-mothers\u002F. Published June 30, 2008. Accessed June 14, 2019.,body:a},{id:197,title:Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med. 1990; 322(17): 1202-1206. doi:10.1056\u002Fnejm199004263221706.,body:a},{id:198,title:Gonzalez, S. Ye, J. Black Mothers Judged Unfit at Higher Rate than White Mothers in NJ. WNYC News. https:\u002F\u002Fwww.wnyc.org\u002Fstory\u002Fblack-parents-nj-lose-custody-their-kids-more- anyone-else\u002F. Published May 26, 2015. Accessed June 14, 2019.,body:a},{id:199,title:National Advocates for Pregnant Women. Memo: Standards for Drug Testing Pregnant Women, New Mothers & Newborns. March 2014.,body:a},{id:200,title:Jarvis M, Williams J, Hurford M, et al. Appropriate use of drug testing in clinical addiction medicine. J Addict Med. 2017; 11: 163-173. doi:10.1097\u002Fadm.0000000000000323.,body:a},{id:201,title:Barthwell AG, Allgaier J, Egli K. Definitive urine drug testing in office-based opioid treatment: a literature review. Crit Rev Toxicol. 2018; 48(10): 815-838. doi:10.1080\u002F10408444.2018.1553935.,body:a},{id:202,title:Nelson ZJ, Stellpflug SJ, Engebretsen KM. What can a urine drug screening immunoassay really tell us? J Pharm Pract. 2016; 29(5): 516-526. doi: 10.1177\u002F0897190015579611.,body:a},{id:259,title:Designer Drugs. DEA.gov. https:\u002F\u002Fwww.dea.gov\u002Ftaxonomy\u002Fterm\u002F341.,body:a}},{id:E,title:Create a prenatal checklist for care of women with opioid use disorder,description:a,position:al,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ECreate a flow chart and\u002For checklist of care steps for antenatal care of women with opioid use disorder (OUD). Refer to the example below and an additional example in the Resources section of this Best Practice.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA checklist will help providers remember the many steps involved in the antenatal care of women and families with OUD. While these services and activities would normally be addressed over the course of prenatal care, they may need to be compressed depending on when the woman presents for care. Referenced are examples from the Illinois Perinatal Quality Care Collaborative and the Northern New England Perinatal Quality Improvement Network.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ECollaborate with health care team members to adapt a written checklist that is specific for your site of care.\u003Cbr\u003E\u003Caction-text-attachment sgid\BAh7CEkiCGdpZAY6BkVUSSI9Z2lkOi8vbmFzLXRvb2xraXQtYXBpL0FjdGl2ZVN0b3JhZ2U6OkJsb2IvMTAwP2V4cGlyZXNfaW4GOwBUSSIMcHVycG9zZQY7AFRJIg9hdHRhY2hhYmxlBjsAVEkiD2V4cGlyZXNfYXQGOwBUMA--7dcb9fc38ee2aaf2696223bce9a1c42a1f5c1b12\ content-type\image\u002Fpng\ url\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--e8a9df81aa3ef6db4925a1f75e25820bc4be0106\u002FILPQC%20OUD%20Clinical%20Care%20Checklist%20(adapted%20for%20CA).png\ filename\ILPQC OUD Clinical Care Checklist (adapted for CA).png\ filesize\234827\ width\3196\ height\4356\ previewable\true\ presentation\gallery\ caption\ILPQC OUD Clinical Care Checklist (adapted for CA)\\u003E\u003Cfigure class\attachment attachment--preview attachment--png\\u003E \u003Cimg src\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Frepresentations\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--e8a9df81aa3ef6db4925a1f75e25820bc4be0106\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaDdCam9VY21WemFYcGxYM1J2WDJ4cGJXbDBXd2RwQWdBRWFRSUFBdz09IiwiZXhwIjpudWxsLCJwdXIiOiJ2YXJpYXRpb24ifX0--4fdbde571b604cff2c50a989f27a6f2e0a6ba082\u002FILPQC%20OUD%20Clinical%20Care%20Checklist%20(adapted%20for%20CA).png\\u003E \u003Cfigcaption class\attachment__caption\\u003E ILPQC OUD Clinical Care Checklist (adapted for CA) \u003C\u002Ffigcaption\u003E\u003C\u002Ffigure\u003E\u003C\u002Faction-text-attachment\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:25:12.436Z,updatedAt:2020-09-03T21:10:41.566Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443384203,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBkZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--fbb365f49812e40ec4a646876cbd2c8c85f5d8e0\u002FBP_4.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EChecklists come in many forms: some for use in emergencies, some for use prior to surgery, and some simply as reminders for the supermarket. A prenatal checklist serves both as an ongoing set of reminders and as documentation of important tasks completed. A checklist, such as the one above, is central to the care of a complex patient with many external consultations over a long period of time, and a pregnant woman with substance use disorder is one of the most challenging to care for. A provider must navigate special laws and unfamiliar regulations, co-manage with other key providers, order different panels of blood tests, approach building communication and developing trust differently, and provide education on topics not usually covered in prenatal care. Examples of the latter include special plans for labor pain management, preparation for neonatal substance withdrawal, and most important of all, developing a Plan of Safe Care (POSC) for both the baby and mother.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe Prenatal Checklist provides the central direction for the team’s actions in antenatal care. It belongs front and center in the prenatal record and should be reviewed at every visit by providers, staff, and the patient. This toolkit provides several examples. Through small tests of change, modifications can be made to the example checklists until it meets the needs of patients at the care site. Follow up at the postpartum visit should include questions about what the patient thinks could be improved—no checklist is ever a final product! \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},category:{friendlyId:as,name:ax,description:ay},authors:{id:X,fullName:ba,professionalDesignation:aL,biography:bb,disclosure:b},resources:{id:ci,title:ILPQC MNO-OB OUD Protocol.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBMUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--4322380ed9ba96301e0478d354581031378eb064\u002FILPQC%20MNO-OB%20OUD%20Protocol.pdf},{id:cj,title:ILPQC OUD Clinical Care Checklist.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBVQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--556e7794a35ab2379037ec0f1a1c802b2cba825e\u002FILPQC%20OUD%20Clinical%20Care%20Checklist.pdf},{id:162,title:ck,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBVZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--fc8fde3713a530dc87f8f5d8eacbdbb17203a06b\u002FNNEPQIN%20Opioid%20Use%20Disorder%20Clinical%20Pathway.pdf},references:},{id:al,title:Identify substance-exposed newborns,description:a,position:X,overview:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ESubstance use disorder (SUD) during pregnancy—whether involving illicit, legal, or prescription drugs—is an issue critical to the health of mothers and newborns, and the incidence is increasing in all socioeconomic groups. The examples included below demonstrate the multitude of exposures for mothers, fetuses, and newborns for which appropriate screening (verbal, written), or biologic testing exist. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe following are some of the substances and syndromes associated with maternal use and\u002For in utero exposure: opioids (neonatal abstinence syndrome), nicotine, alcohol (fetal alcohol spectrum disorder), methamphetamine, cocaine, serotonin-synaptic reuptake inhibitor (SSRI), serotonin-norepinephrine reuptake inhibitor (SNRI), and marijuana.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EIdentifying substance exposure during pregnancy requires effective communication within the multidisciplinary team caring for the mother\u002Fbaby dyad, the best screening methods and assessments to convey information on possible effects, and mobilization of available inpatient, outpatient and community resources to promote good health and bonding.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ENewborn selective (i.e., risk-based) screening policies, including toxicology testing, should be developed in conjunction with the policies of the maternal care team to support a family-centered approach to identification and treatment. These policies should be consistently applied to limit potential bias. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe results of maternal substance use screening and biological toxicology testing with confirmation provide important information to guide newborn health care providers on appropriate management, specifically if the newborn is demonstrating symptoms consistent with NAS.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EWe recommend that all hospitals with maternity services maintain updated policies and procedures for newborn selective (risk-based) screening policies, based on a family-centered approach which includes the results of maternal screening for substance use (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Faudience\u002Foutpatient\u002Fcategory\u002Fscreening-assessment-level-of-care-determination\u002Fbest-practice\u002F1\\u003E\u003Cstrong\u003EBest Practice #1\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more information on maternal screening). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ERisk-based screening may consist of items from a detailed prenatal history (including inquiries into prescription and nonprescription drug use), validated maternal SUD screening questionnaires, maternal symptoms, and newborn signs of withdrawal (refer to the References and Resources in this Best Practice for more details).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMaternal risk is based on the care team’s interpretation of verbal screening and, when appropriate, toxicology testing for each patient. If maternal toxicology testing or treatment history has been confirmed, testing of the newborn may not be clinically necessary; however, it is often requested by external agencies such as child protective services (CPS). Education of CPS about the validity of other information can avoid unnecessary and in appropriate use of screening resources.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EA consensus definition of Neonatal Opioid Withdrawal Syndrome has been developed (NOWS is considered a subset of Neonatal Abstinence Syndrome). To meet criteria, two elements must be met.\u003Csup\u003E 2 \u003C\u002Fsup\u003E(NB. Multiple gastrointestinal symptoms count as a single clinical criteria under element 2).\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E 1. In utero exposure to opioids, with or without other psychoactive substances\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E 2. At least two of the following five clinical signs:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E a. Excessive crying (easy irritability)\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E b. Fragmented sleep (less than 2-3 hours after feeding)\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E c. Tremors\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E d. Increased muscle tone\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E e. GI dysfunction, including \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E i. Hyperphagia\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E ii. Poor feeding\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E iii. Feeding intolerance\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E iv. Loose or watery stools\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUniversal biological toxicology testing for the newborn is not recommended, as the specific maternal situation will guide the approach to the newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe policies for newborn biological toxicology testing (e.g., of urine, meconium, or umbilical cord samples) should reflect a common understanding or written collaborative agreement from each of the following groups: obstetric and newborn medical and nursing staff, hospital-based social work and risk management, and the local\u002Fcounty CPS office.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENewborn biological toxicology testing may be warranted in certain instances including but not limited to:\u003Cul\u003E\u003Cli\u003EMother with limited or no prenatal care\u003C\u002Fli\u003E\u003Cli\u003EMaternal symptoms of drug intoxication or withdrawal that are otherwise unexplained\u003C\u002Fli\u003E\u003Cli\u003ENewborn signs and symptoms of potential substance exposure (i.e., withdrawal) that are otherwise unexplained\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsent for inpatient neonatal drug testing, may not be required for the purposes of guiding healthcare interventions and follow-up after discharge, and may depend on state specific regulations. However, each healthcare facility should develop its own policy given that most state regulations leave the decision about who should be tested to the health-care provider. Local CPS can neither require testing nor dictate the method of testing in the absence of specific state or federal regulatory requirements (i.e., it may be covered under the facility’s general consent).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:30:31.229Z,updatedAt:2024-05-29T17:03:23.391Z,publishedAt:an,videoUrl:cl,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBlQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--a6a00aa0bf6a0de78ba858490c5c2e8650f3684c\u002FBP%205_6.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla’s opioid use was identified during prenatal care and confirmed in Labor and Delivery through urine testing. This information was communicated to Baby M’s providers and prompted them to communicate early with Kayla and to provide her with information on his risk of developing NAS and the potential complications that could arise with a small for gestational age newborn. Baby M’s providers knew the importance of establishing a non-judgmental relationship with Kayla and by doing so were able to discuss her prenatal screening results with her, precluding the need to conduct further biological testing to screen Baby M for substance exposure. However, in some medical systems, testing may still be required. If biological testing is performed, urine will give the fastest result but reflects exposure in the prior few days. Meconium and umbilical cord testing will reflect exposure up to several months prior.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:as,name:ax,description:ay},authors:{id:ao,fullName:cm,professionalDesignation:bf,biography:cn,disclosure:b},{id:ae,fullName:co,professionalDesignation:c,biography:cp,disclosure:b},{id:E,fullName:bg,professionalDesignation:aM,biography:bh,disclosure:b},{id:Y,fullName:aN,professionalDesignation:c,biography:aO,disclosure:b},{id:ap,fullName:cq,professionalDesignation:bf,biography:cr,disclosure:b},{id:af,fullName:cs,professionalDesignation:c,biography:ct,disclosure:b},resources:{id:au,title:cu,description:a,fileUrl:cv},{id:cw,title:cx,description:a,fileUrl:a},{id:cy,title:Jilani, S. M., Jones, H. E., Grossman, M., Jansson, L. M., Terplan, M., Faherty, L. J., . . . Davis, J. M. (2022). Standardizing the Clinical Definition of Opioid Withdrawal in the Neonate. J Pediatr, 243, 33-39 e31. doi:10.1016\u002Fj.jpeds.2021.12.021.,description:a,fileUrl:a},references:{id:aE,title:cz,body:a},{id:az,title:cA,body:a},{id:ab,title:cB,body:a},{id:W,title:Stabler M, Giacobbi P, Jr., Chertok I, Long L, Cottrell L, Yossuck P. Comparison of biological screening and diagnostic indicators to detect in utero opiate and cocaine exposure among mother-infant dyads. Ther Drug Monit. 2017; 39(6): 640-647. doi: 10.1097\u002FFTD.0000000000000447.,body:a},{id:250,title:Farst KJ, Valentine JL, Hall RW. Drug testing for newborn exposure to illicit substances in pregnancy: pitfalls and pearls. Int J Pediatr. 2011;2011:951616. doi:10.1155\u002F2011\u002F951616.,body:a},{id:251,title:Price HR, Collier AC, Wright TE. Screening pregnant women and their neonate for illicit drug use: consideration of the integrated technical, medical, ethical, legal and social issues. Front Pharmacol. 2018; 9:961. doi: 10.3389\u002Ffphar.2018.00961.,body:a},{id:252,title:Screening for Substance Abuse During Pregnancy: Guidelines for Screening. Vermont Department of Health. http:\u002F\u002Fcontentmanager.med.uvm.edu\u002Fdocs\u002Fdefault-source\u002Fvchip-documents\u002Fvchip_screening_for_preg_subabuse.pdf?sfvrsn2. Published 2009. ,body:a},{id:253,title:Terplan M, Minkoff H. Neonatal abstinence syndrome and ethical approaches to the identification of pregnant women who use drugs. Obstet Gynecol. 2017; 129(1): 164-167.,body:a},{id:254,title:Understanding CAPTA and State Obligations. National Advocates for Pregnant Women. http:\u002F\u002Fadvocatesforpregnantwomen.org\u002FCAPTA%20requirements%20for%20states_NAPW.pdf. Published September 2018. ,body:a}},{id:aP,title:Implement selective newborn biological toxicology testing ,description:a,position:bC,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ENewborn toxicology testing is an important identification tool. However, it is limited by testing sensitivity and timing requirements.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EThe incidence of substance use in pregnancy is difficult to quantify. Maternal screening using validated surveys, and when necessary, toxicology testing in pregnancy may still underrepresent the true incidence.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIf in utero substance exposure has been identified from either prenatal history (including inquiries into prescription and nonprescription drug use) or maternal toxicology testing, this information is vital for guiding assessment and treatment options and may lead to improved outcomes for mothers and newborns.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIf maternal toxicology testing or treatment history has been confirmed, testing of the newborn may not be clinically necessary; however, it is often requested by external agencies such as child protective services (CPS). Education of CPS about the validity of other information can avoid unnecessary and in appropriate use of screening resources.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENewborn health care providers should be provided with information on the usefulness and limitation of the birth center’s biological toxicology testing and the availability\u002Fappropriateness of confirmatory testing.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EWhen the information would influence healthcare treatment, Selective biological toxicology testing should be considered for newborns when diagnostic information about the mother is limited or not available, or when the clinical picture indicates risk for in utero exposure, including but not limited to: \u003Cul\u003E\u003Cli\u003EMother with limited or no prenatal care\u003C\u002Fli\u003E\u003Cli\u003EMaternal symptoms of drug intoxication or withdrawal that are otherwise unexplained\u003C\u002Fli\u003E\u003Cli\u003ENewborn signs and symptoms of potential substance exposure (i.e., withdrawal) that are otherwise unexplained\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E Hospital policies and procedures should include protocols that would trigger newborn biological toxicology testing.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EToxicology testing is limited by substance levels (concentrations) and timing. Therefore, samples should be collected and sent for analysis as soon as possible after delivery.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReview available biological toxicology testing methods at each birth center. Traditionally, urine immunoassay has been used as the initial screen, and multiple commercial antibodies are validated.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EFor certain substances, immunoassay-based urine toxicology testing is a reliable method with rapid turnaround time. For opioid exposure, routine opioid testing panels usually only detects morphine, codeine, and heroin metabolites. Synthetic opioids such as methadone, oxycodone, fentanyl, buprenorphine, etc. may require more specific testing.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EA newborn who has a biological toxicology test with unexpected positive results should have confirmatory testing (gas chromatography-mass spectrometry) and\u002For confirmation of drug presence by a more time specific test sample (i.e., meconium, umbilical cord).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProviders should be aware of false-positive drug testing from common maternal medications including antihistamines, antidepressants, antibiotics, decongestants, analgesics, antipsychotics, and over-the-counter products (See table below).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDue to assay limitations, a negative biological toxicology result does not represent an absence of in utero substance exposure, specifically if the newborn exhibits clinical signs consistent with neonatal abstinences syndrome (NAS) and all other diagnoses have been appropriately ruled out.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EA positive biological toxicology result, in and of itself, does not represent child abuse or neglect. Hospitals must ensure that the multidisciplinary team caring for mothers and newborns includes social workers trained in care and treatment resources for affected families. Care should be taken to ensure that policies which delineate criteria for toxicology testing do not directly or indirectly target low income women and women of color (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F3\\u003E\u003Cstrong\u003EBest Practice #3\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more information on this).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Caction-text-attachment sgid\BAh7CEkiCGdpZAY6BkVUSSI9Z2lkOi8vbmFzLXRvb2xraXQtYXBpL0FjdGl2ZVN0b3JhZ2U6OkJsb2IvMTAxP2V4cGlyZXNfaW4GOwBUSSIMcHVycG9zZQY7AFRJIg9hdHRhY2hhYmxlBjsAVEkiD2V4cGlyZXNfYXQGOwBUMA--bc125efdf4d9341311b1c4a11ac6c0e9c9e40879\ content-type\image\u002Fpng\ url\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--18014c18aa4115e11109d73e435bd9daba11df0f\u002FCommonly%20prescribed%20medications%20in%20obstetrics%20that%20may%20result%20in%20false%20positives.png\ filename\Commonly prescribed medications in obstetrics that may result in false positives.png\ filesize\13947\ width\564\ height\338\ previewable\true\ presentation\gallery\ caption\Commonly prescribed medications in obstetrics that may result in false positives\\u003E\u003Cfigure class\attachment attachment--preview attachment--png\\u003E \u003Cimg src\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Frepresentations\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--18014c18aa4115e11109d73e435bd9daba11df0f\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaDdCam9VY21WemFYcGxYM1J2WDJ4cGJXbDBXd2RwQWdBRWFRSUFBdz09IiwiZXhwIjpudWxsLCJwdXIiOiJ2YXJpYXRpb24ifX0--4fdbde571b604cff2c50a989f27a6f2e0a6ba082\u002FCommonly%20prescribed%20medications%20in%20obstetrics%20that%20may%20result%20in%20false%20positives.png\\u003E \u003Cfigcaption class\attachment__caption\\u003E Commonly prescribed medications in obstetrics that may result in false positives \u003C\u002Ffigcaption\u003E\u003C\u002Ffigure\u003E\u003C\u002Faction-text-attachment\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-27T05:07:11.021Z,updatedAt:2020-10-07T14:22:08.458Z,publishedAt:ac,videoUrl:cl,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBlUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--7022a18071fb07657d5165dcb9cea61f0f847c4b\u002FBP%205_6.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:as,name:ax,description:ay},authors:{id:ao,fullName:cm,professionalDesignation:bf,biography:cn,disclosure:b},{id:ae,fullName:co,professionalDesignation:c,biography:cp,disclosure:b},{id:E,fullName:bg,professionalDesignation:aM,biography:bh,disclosure:b},{id:Y,fullName:aN,professionalDesignation:c,biography:aO,disclosure:b},{id:ap,fullName:cq,professionalDesignation:bf,biography:cr,disclosure:b},{id:af,fullName:cs,professionalDesignation:c,biography:ct,disclosure:b},resources:{id:cC,title:cu,description:a,fileUrl:cv},{id:cD,title:IDPH Decision Tree for Identifying Newborns at Risk for Prenatal Substance Exposure Decision Tree (see page 22).,description:a,fileUrl:http:\u002F\u002Fwww.dph.illinois.gov\u002Fsites\u002Fdefault\u002Ffiles\u002Fpublications\u002Fnas-annual-report-march-2019.pdf},references:{id:203,title:cz,body:a},{id:204,title:cA,body:a},{id:205,title:cx,body:a},{id:206,title:cB,body:a},{id:207,title:Price HR, Collier AC, Wright TE. Screening pregnant women and their neonates for illicit drug use: consideration of the integrated technical, medical, ethical, legal, and social issues. Front Pharmacol. 2018; 9:961. doi: 10.3389\u002Ffphar.2018.00961.,body:a},{id:208,title:Yee LM, Wu D. False-positive amphetamine toxicology screen results in three pregnant women using labetalol. Obstet Gynecol. 2011; 117(2 Pt 2): 503-506.,body:a}},{id:X,title:Implement Trauma-Informed Care to optimize patient engagement,description:a,position:aQ,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement Trauma-Informed Care to optimize patient engagement in prenatal care.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMany pregnant women with opioid use disorder (OUD) have experienced significant traumatic events, adversity, and toxic stress in their lives, including sexual abuse and other Adverse Childhood Experiences (ACEs). Trauma refers to intense and overwhelming experiences that involve serious loss, threat, or harm to a person’s physical and\u002For emotional well-being. These experiences may occur at any time in a person’s life; they may involve a single traumatic event or may be repeated over many years. These traumatic experiences often overwhelm a person’s coping capacity. In many cases, prescription and\u002For illicit opioid use begins as a coping mechanism to manage the symptoms of post-traumatic stress disorder (PTSD). \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ETrauma-Informed Care is a strengths-based service delivery approach “that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper E, et al, 2009). Trauma-Informed Care acknowledges a patient’s life experiences as key to improving engagement and outcomes while lowering unnecessary utilization. It changes the paradigm from one that asks, “What’s wrong with you?” to one that asks, “What has happened to you?” Just as with “universal precautions” for infection control, Trauma-Informed Care necessarily assumes that every patient, and indeed every provider or staff person, has a history of traumatic stress. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EIn order to be successful, Trauma-Informed Care must be adopted at both the organizational and clinical levels and cannot be implemented as a singular, disconnected intervention that occurs between providers and a few patients who are seemingly appropriate for this kind of care based on their diagnosis and social history. Successful implementation requires a commitment from the agency, service line, or department for significant culture change at the organizational and clinical levels. Trauma-Informed Care is not a “one and done” training for staff and management. Rather, it is a comprehensive journey to implement systematic changes in how care is delivered for every person who enters care. It involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to retraumatize individuals, and it upholds the importance of consumer participation in the development, delivery, and evaluation of services. Furthermore, a trauma-informed organizational structure addresses the impact of trauma across the lifespan and the critical role of health care service delivery systems to interrupt the cycle of trauma by employing trauma-aware services, policies, and mindsets.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ESAMHSA recognizes six principles that are fundamental to a Trauma-Informed Approach: \u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESafety. Do we help promote a sense of safety for every person? \u003C\u002Fli\u003E\u003Cli\u003ETrustworthiness and Transparency. Do we conduct all patient care with complete transparency and with the goal of building and maintaining trust? \u003C\u002Fli\u003E\u003Cli\u003EPeer Support. Do we provide any peer support services or mutual help services that build upon the trauma-informed framework of safety, trust, and collaboration in care? \u003C\u002Fli\u003E\u003Cli\u003ECollaboration and Mutuality. Do we share power in decision making in a meaningful way and maximize the ability of patients to engage in care decisions? \u003C\u002Fli\u003E\u003Cli\u003EEmpowerment, Voice, and Choice. How are we providing the resources necessary to both staff and patients in order to ensure skill building, goal-setting, and non-coercive treatment for every patient\u003C\u002Fli\u003E\u003Cli\u003ERecognition of cultural, historical, and gender issues. Are we actively working to move beyond cultural stereotypes based on gender-identity, race, sexual orientation, socio-economic status, and more? Do we recognize historical trauma and impact on race-based disparities? \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EThe Trauma-Informed Care Implementation Resource Center, developed by the Center for Health Care Strategies with support from the Robert Wood Johnson Foundation, offers a one-stop information hub for health care providers interested in implementing Trauma-Informed Care. It houses the following: \u003Cul\u003E\u003Cli\u003Efoundational content regarding the impact of trauma on health\u003C\u002Fli\u003E\u003Cli\u003Etestimonials from providers who have adopted trauma-informed principles\u003C\u002Fli\u003E\u003Cli\u003Ein-the-field examples illustrating how to integrate Trauma-Informed Care into health care settings\u003C\u002Fli\u003E\u003Cli\u003Epractical strategies and tools for implementing trauma-informed approaches\u003C\u002Fli\u003E\u003Cli\u003Einformation for state and federal policymakers interested in supporting Trauma-Informed Care\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReview SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach (refer the Resources section of this Best Practice), which offers first steps to organizational assessment and development around the Trauma-Informed Care model of care. Identify how this model of care can be integrated into your current care model.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ECreate a comprehensive organizational structure, whereby the entire workforce operates under a Trauma-Informed Care model. The San Francisco Department of Public Health Workforce Training Model and The Sanctuary Model examples can be found in the Resources section of this Best Practice. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EStart to adopt new organizational and clinical practices that address the impact of trauma on patients and staff, including but not limited to: \u003Cul\u003E\u003Cli\u003ELead and communicate about being trauma-informed\u003C\u002Fli\u003E\u003Cli\u003EEngage patients in organizational planning and shared decision making about treatments\u003C\u002Fli\u003E\u003Cli\u003ETrain both clinical and non-clinical staff in trauma-specific approaches and build a trauma-informed workforce\u003C\u002Fli\u003E\u003Cli\u003ECreate a safe physical and emotional environment\u003C\u002Fli\u003E\u003Cli\u003EPrevent secondary traumatic stress in staff\u003C\u002Fli\u003E\u003Cli\u003EHold each other accountable\u003C\u002Fli\u003E\u003Cli\u003EScreen all patients for trauma\u003C\u002Fli\u003E\u003Cli\u003EEngage referral sources and partner organizations that are also trauma-informed\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:35:34.677Z,updatedAt:2020-09-03T21:11:54.010Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F448616476,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBlZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--17e6ab31c9c6905e8d6a734bdb367002ae611b0f\u002FBP_7.pptx,deepDive:b,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:ad,fullName:bc,professionalDesignation:bd,biography:be,disclosure:b},{id:am,fullName:Margaret Yonekura,professionalDesignation:aL,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMargaret Lynn Yonekura, M.D., F.A.C.O.G. is a board certified obstetrician-gynecologist with subspecialty certification in Maternal-Fetal Medicine. She is a recognized expert in the fields of infectious diseases in Ob-Gyn and perinatal substance abuse. Throughout her career Dr Yonekura has established comprehensive care programs to address her patients’ complex needs. She is currently a member of the Women’s Health Policy Council of L.A. County’s Office of Women’s Health, L.A. County Perinatal & Early Childhood Home Visiting Consortium, Reproductive Health and the Environment Advisory Committee, and L.A. County Diabetes Prevention Program Community Advisory Committee.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},resources:{id:cE,title:Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.,description:a,fileUrl:https:\u002F\u002Fwww.integration.samhsa.gov\u002Fclinical-practice\u002FSAMSA_TIP_Trauma.pdf},{id:cF,title:Institute of Trauma and Trauma-Informed Care. Trauma-Informed Organizational Change Manual. Buffalo Center for Social Research. University at Buffalo, 2019.,description:a,fileUrl:a},{id:cG,title:Trauma-Informed Care Implementation Resource Center. Center for Health Care Strategies, Inc. Funded by Robert Wood Johnson Foundation.,description:a,fileUrl:https:\u002F\u002Fwww.chcs.org\u002Fresource\u002Ftrauma-informed-care-implementation-resource-center\u002F},{id:cH,title:A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders. SAMHSA.,description:a,fileUrl:bD},{id:cI,title:SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. ,description:a,fileUrl:https:\u002F\u002Fstore.samhsa.gov\u002Fsystem\u002Ffiles\u002Fsma14-4884.pdf},{id:cJ,title:S.E.L.F.: A Trauma-Informed Psychoeducational Group Curriculum. The Sanctuary Model. ,description:a,fileUrl:http:\u002F\u002Fsanctuaryweb.com\u002FProducts\u002FSELFGroupCurriculum.aspx},{id:cK,title:Implementing Trauma-Informed Practices throughout the San Francisco Department of Public Health. Center for Health Care Strategies. ,description:a,fileUrl:https:\u002F\u002Fwww.chcs.org\u002Fmedia\u002FSFDPH-Profile.pdf},{id:187,title:Center for Health Care Strategies. Laying the Groundwork for Trauma-Informed Care. ,description:a,fileUrl:http:\u002F\u002Fwww.traumainformedcareproject.org\u002Fresources\u002FLaying-the-Groundwork-for-TIC_012418.pdf},references:{id:cL,title:Harris M, Fallot RD. New Directions for Mental Health Services: Using Trauma Theory to Design Service Systems. San Francisco, CA: Jossey-Bass\u002FWiley; 2001. ,body:a},{id:cM,title:Menschner C, Maul A. Key Ingredients for Trauma-Informed Care Implementation. Center for Health Care Strategies. https:\u002F\u002Fwww.chcs.org\u002Fresource\u002Fkey-ingredients-for-successful-trauma-informed-care-implementation\u002F. Published January 8, 2019. Accessed December 18, 2019.,body:a},{id:cN,title:Resources for Implementing Trauma Informed Care. Trauma Informed Oregon. https:\u002F\u002Ftraumainformedoregon.org\u002F. Accessed December 18, 2019.,body:a},{id:cO,title:Tkach MJ. Trauma-Informed Care for Substance Abuse Counseling: A Brief Summary. Butler Center for Research. https:\u002F\u002Fwww.hazeldenbettyford.org\u002Feducation\u002Fbcr\u002Faddiction-research\u002Ftrauma-informed-care-ru-118. Published January 2018. ,body:a},{id:cP,title:Finding Your ACE Score. National Council of Juvenile and Family Court Judges. https:\u002F\u002Fwww.ncjfcj.org\u002Fsites\u002Fdefault\u002Ffiles\u002FFinding Your ACE Score.pdf. Published October 24, 2006. Accessed December 18, 2019.,body:a},{id:cQ,title:SAMHSA’s Trauma-Informed Approach: Key Assumptions and Principles. National Association of State Mental Health Program Directors. https:\u002F\u002Fwww.nasmhpd.org\u002Fsites\u002Fdefault\u002Ffiles\u002FTraumaTIACurriculumTrainersManual_8_18_2015.pdf. Published August 18, 2015. Accessed December 18, 2019. ,body:a},{id:cj,title:SAMHSA-HRSA Center for Integrated Health Solutions. SAMHSA. https:\u002F\u002Fwww.samhsa.gov\u002Fintegrated-health-solutions. ,body:a},{id:cR,title:Greater Richmond Trauma-Informed Community Network. SCAN. http:\u002F\u002Fgrscan.com\u002Ftrauma- informed-community-network\u002F. Accessed December 18, 2019.,body:a},{id:cS,title:The Sanctuary Model . http:\u002F\u002Fsanctuaryweb.com\u002F. Accessed December 18, 2019.,body:a},{id:166,title:Sperlich M, Seng JS, Li Y, Taylor J, Bradbury-Jones C. Integrating trauma- informed care into maternity care practice: conceptual and practical issues. J Midwifery Womens Health. 2017; 62(6): 661-72. doi:10.1111\u002Fjmwh.12674.,body:a},{id:cI,title:Substance Use Disorder Services Treatment on Demand. San Francisco Department of Public Health. https:\u002F\u002Fwww.sfdph.org\u002Fdph\u002Fcomupg\u002Foservices\u002FmentalHlth\u002FSUDTrainingResources.asp. Accessed December 19, 2019.,body:a},{id:cJ,title:San Francisco Department of Public Health. https:\u002F\u002Fwww.sfdph.org\u002Fdph\u002Fhc\u002FHCAgen\u002FHCAgen2016\u002FApril19\u002FTISFirstYearDataReport.pdf. Accessed December 18, 2019.,body:a},{id:cK,title:Schulman M, Menschner C. Laying the Groundwork for Trauma Informed Care. Center for Health Care Strategies. https:\u002F\u002Fwww.chcs.org\u002F. Published November 6, 2019. Accessed December 19, 2019.,body:a},{id:cT,title:TIC IC Implementation Planning Guide. SAMHSA-HRSA Center for Integrated Health Solutions. https:\u002F\u002Fwww.integration.samhsa.gov\u002F\u002Fabout-us\u002FTIC_IC_Implementation_Planning_Guide.pdf. Accessed December 19, 2019.,body:a},{id:cU,title:SAMHSAs Concept of Trauma and Guidance for Trauma-Informed Approach. SAMHSA . https:\u002F\u002Fstore.samhsa.gov\u002Fsystem\u002Ffiles\u002Fsma14-4884.pdf. Accessed December 19, 2019.,body:a},{id:cV,title:Machtinger EL, Cuca YP, Khanna N, Rose CD, Kimberg LS. From treatment to healing: the promise of trauma-informed primary care. Womens Health Issues. 2015; 25(3): 193-197. doi:10.1016\u002Fj.whi.2015.03.008.,body:a},{id:cW,title:The Trauma Informed Care Project . http:\u002F\u002Fwww.traumainformedcareproject.org\u002F. Accessed December 19, 2019.,body:a},{id:cX,title:Beyond ACES: Building Hope and Resiliency in Iowa. Trauma Informed Care Project. http:\u002F\u002Fwww.traumainformedcareproject.org\u002Fresources\u002Faces_execsummary2016_snglpgs.pdf. Accessed December 19, 2019.,body:a},{id:cY,title:Publications. Sanctuary Institute. http:\u002F\u002Fwww.thesanctuaryinstitute.org\u002Fpublications\u002F. Accessed December 19, 2019.,body:a},{id:cZ,title:Bloom SL, Farragher BJ. Restoring Sanctuary a New Operating System for Trauma-Informed Systems of Care. New York, NY: Oxford University Press; 2013.,body:a},{id:c_,title:Torchalla I, Linden IA, Strehlau V, Neilson E, Krausz M. \Like a lot’s happened with my whole childhood\: violence, trauma, and addiction in pregnant and postpartum women from Vancouver’s downtown eastside. Harm Reduct J. 2014; 11(1):34. doi:10.1186\u002F1477-7517-11-34.,body:a},{id:c$,title:Implementing trauma-informed practices throughout the San Francisco Department of Public Health. Center for Health Care Strategies. https:\u002F\u002Fwww.chcs.org\u002Fmedia\u002FSFDPH-Profile.pdf. Accessed December 15, 2019.,body:a},{id:230,title:S.E.L.F.: A Trauma-Informed Psychoeducational Group Curriculum. The Sanctuary Model. http:\u002F\u002Fsanctuaryweb.com\u002FPortals\u002F0\u002FPDFs\u002FOther%20PDFs\u002FOutline%20of%20S.E.L.F.%20Psychoeducational%20Curriculum.pdf.,body:a},{id:231,title:Saia KA, Schiff D, Wachman EM, et al. Caring for pregnant women with opioid use disorder in the USA: expanding and improving treatment. Curr Obstet and Gynecol Rep. 2016; 5(3):257-263. doi:10.1007\u002Fs13669-016-0168-9.,body:a},{id:234,title:Esaki N, Hopson LM, Middleton JS. Sanctuary model implementation from the perspective of indirect care staff. Fam Soc. 2014; 95(4): 261-268. doi:10.1606\u002F1044- 3894.2014.95.31.,body:a},{id:247,title:Hopper, E., et. al. Shelter from the storm: trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal. 2009; 2: 131-151. http:\u002F\u002Fwww.traumacenter.org\u002Fproducts\u002Fpdf_files\u002Fshelter_from_storm.pdf.,body:a}},{id:aQ,title:Understand and implement the principles of Motivational Interviewing,description:a,position:aR,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMotivational Interviewing (MI) is a patient-centered counseling approach rooted in key theoretical principles—including decisional balance, self-perception theory, and the transtheoretical model of change—that uses directed techniques to enhance patients’ intrinsic motivations for and reduce their ambivalence toward behavior change. Introduced in the early 1980s as a counseling strategy for encouraging behavior change among people with alcohol dependence, the principles, methods, and specific techniques employed in MI have been researched and analyzed for a variety of health conditions for which behavior change is a critical part of health-promoting interventions. MI has now been firmly established as an effective, evidence-based practice in the treatment of substance use disorders (SUDs) and other health conditions including diabetes, obesity, and smoking cessation.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EMI uses principles of collaboration between the provider and client (rather than confrontation), the intent of which is to develop rapport and trust, along with evocation of the client’s own thoughts and ideas (rather than imposing the provider’s opinions), and autonomy\u003Cstrong\u003E \u003C\u002Fstrong\u003Eand self-efficacy (rather than authority). MI recognizes that true motivation for behavioral change rests within the client. While the provider may have different opinions about the timing or approach to a particular condition, an understanding of the client’s experience and beliefs and ultimately eliciting the client’s own motivations for changing unhealthful behaviors is more likely to result in lasting change.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe optimal implementation of this best practice would be for hospital and office-based providers to organize MI trainings and regular practice opportunities for all of their staff, especially clinical staff involved in gathering patient information who might have the opportunity to motivate behavior change. In the absence of resources for MI training, this best practice includes several techniques that can be employed without significant training. Additionally, the curriculum included in the Resources section of this Best Practice incorporates links to several web-based videos demonstrating some of these techniques that may be helpful adjuncts to staff interested in further MI exposure and practice.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EMotivation is a key to behavior change. It is multidimensional, dynamic, and fluctuating; influenced by social interactions; and can be modified and influenced by the provider’s style. The provider’s task is to elicit and enhance motivation.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMI is effective as an adjunct to enhancing entry into and engagement and retention in interventions that support various kinds of behavior change, including but not limited to substance abuse treatment. It has also been used to encourage rapid return to treatment following relapse.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMI is increasingly used as a stand-alone brief intervention during routine encounters with patients. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMI is an approach that has been empirically shown to be more effective than giving advice, which tends to occur frequently in health care delivery.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E“Readiness to change bad habits is generally a developmental process, and the precepts of MI, including patience, listening, empathy, and change talk, can be useful tools.” (Prochaska J, et al, 1995).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIdeally, providers can use MI curricula to become more proficient in these techniques, and all levels of staff can participate in these curricula and employ these techniques. One such curriculum is included in the Resources section for this Best Practice. In the absence of formal training, several specific MI strategies and techniques are described below.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EIncorporate the foundational principles of MI into communication with pregnant and parenting women with opioid use disorder (OUD). These foundational principles of MI should be employed continuously over time and include:\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExpress empathy through reflective listening\u003C\u002Fli\u003E\u003Cli\u003EDevelop discrepancy between patient’s goals or values and their current behavior\u003C\u002Fli\u003E\u003Cli\u003EAvoid argument and direct confrontation\u003C\u002Fli\u003E\u003Cli\u003EAdjust to patient resistance rather than opposing it directly\u003C\u002Fli\u003E\u003Cli\u003ESupport self-efficacy and optimism\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EEmploy the following general style of MI in all patient communication:\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EAsking Permission\u003C\u002Fstrong\u003E – Permission is a deeply respectful foundation of mutual dialogue \u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EEngaging\u003C\u002Fstrong\u003E – Engagement is the establishment of trust and a mutually respectful relationship \u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EFocusing\u003C\u002Fstrong\u003E – Focus is the ongoing process of seeking and maintaining a direction for the exploration conversation\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EEvoking\u003C\u002Fstrong\u003E – Evoking refers to eliciting the patient’s own motivation for change. \u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EPlanning\u003C\u002Fstrong\u003E – Planning is the process of deciding on a specific plan for change that the patient agrees is important and is willing to undertake. \u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003ELinear and Iterative Processes\u003C\u002Fstrong\u003E – Change talk within MI is both a linear and iterative process.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe following are specific motivational skills and strategies that can be practiced and incorporated into all patient engagements, especially those that involve behavior change and compliance with treatment plans. Each of these strategies is described in more detail in the MI Curriculum included in the Resources section of this Best Practice. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EEmploy the \u003Cstrong\u003EOARS+\u003C\u002Fstrong\u003E model as one set of specific MI skills.\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EO\u003C\u002Fstrong\u003Epen ended questions elicit crucial information that may not be gathered from close ended questions.\u003Cul\u003E\u003Cli\u003E\u003Cem\u003EInstead of asking “Have you used any drugs during your pregnancy?”, one might say “I treat a number of women who have used prescription medications and other drugs during their pregnancy. Please share with me which kinds of prescription meds or other drugs, if any, you have used during or before this pregnancy.” \u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cem\u003EInstead of asking “Have you ever been in treatment?”, one could request “Tell me about your recovery journey.”\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EA\u003C\u002Fstrong\u003Effirmations are statements of appreciation\u003Cul\u003E\u003Cli\u003E\u003Cem\u003E“I’m impressed that you followed up with the MAT referral”\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cem\u003E“You’ve stayed off drugs for 2 months. That’s great!”\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ER\u003C\u002Fstrong\u003Eeflections establish understanding of what the patient is thinking and feeling by saying it back to the patient as statements, not questions.\u003Cul\u003E\u003Cli\u003E\u003Cem\u003EPatient: “I’ve been this way for so long.”\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cem\u003EProvider reflection: “So this seems normal to you” or “So this seems like a hard cycle to break.”\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ES\u003C\u002Fstrong\u003Eummaries are highlights of the patient’s ambivalence that are slightly longer than brief reflections and serve to ensure understanding and transition from one topic to another.\u003Cul\u003E\u003Cli\u003E\u003Cem\u003EFor a patient wanting to stop using drugs during pregnancy: “You have several reasons for quitting drugs: You want to get your life back, you want to give your baby the best chance at a healthy life, and you want to be able to manage life’s issues without relying on drugs as a crutch. On the other hand, you’re worried about what kind of recovery path would work for you; you’re worried that you won’t have the motivation and strength to stick with a recovery path. Would that sum it up?” \u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003ERolling with resistance\u003C\u002Fstrong\u003E requires the listener\u002Fprovider to pause and shift conversations when signs of an argument or confrontation begin to appear. Resistance behavior occurs when points of view differ, generally when the provider is moving the patient ahead too quickly, or the provider fails to understand something of importance to the patient. When resistance appears, the listener\u002Fprovider should change strategies and utilize OARS techniques.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003Cstrong\u003EDeveloping discrepancy\u003C\u002Fstrong\u003E involves the listener\u002Fprovider guiding the conversation so the patient can articulate their personal beliefs and future goals (listen especially for statements about life, family, health, financial status, living situation, and other personal considerations). Developing discrepancy between the patient’s behaviors and their broader life goals is essential because patients are more often motivated to change when they arrive at that conclusion themselves rather than hearing it from someone else.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003Cstrong\u003EChange Talk\u003C\u002Fstrong\u003E is defined as statements made by the patient that indicate motivation for, consideration of, or commitment to change behavior. There are clear correlations between patients’ change talk and outcomes. Once the listener\u002Fprovider and patient have established a trusting relationship and have open communication about the patient’s substance use, the listener\u002Fprovider can guide the patient to expressions of change talk using some of the techniques listed below. Each of these strategies is described in more detail in the Motivational Interviewing Curriculum included in the Resources section of this Best Practice, along with additional strategies for eliciting change talk.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EPreparing change talk\u003C\u002Fstrong\u003E employs the \u003Cstrong\u003EDARN\u003C\u002Fstrong\u003E model as one set of specific MI skills\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ED\u003C\u002Fstrong\u003Eesire to change (\u003Cem\u003EAsk “Why do you want to make this change?”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EA\u003C\u002Fstrong\u003Ebility to change (\u003Cem\u003EAsk “How might you be able to do it?”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003ER\u003C\u002Fstrong\u003Eeasons to change (\u003Cem\u003ERequest “Share one good reason for making this change.”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EN\u003C\u002Fstrong\u003Eeed to change (\u003Cem\u003EAsk “On a scale of 0-10, with 10 being the highest, how important is it for you to make this change?”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EImplementing change talk\u003C\u002Fstrong\u003E employs the \u003Cstrong\u003ECAT\u003C\u002Fstrong\u003E model as one set of specific MI skills.\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EC\u003C\u002Fstrong\u003Eommitment (\u003Cem\u003EAsk “What do you intend to do?”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EA\u003C\u002Fstrong\u003Ectivation (\u003Cem\u003EAsk “What are you ready (or willing) to do”?)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003ET\u003C\u002Fstrong\u003Eaking steps (\u003Cem\u003EAsk “What steps have you already taken?”)\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003ECoding and Reimbursement \u003C\u002Fstrong\u003E– MI focused on increasing the patient’s understanding of the impact of their substance use and motivating behavior change can be coded for reimbursement whenever a positive screen (through interview, formal screening tool, or toxicology) is identified and documented in the medical records. Evaluation and Management (E\u002FM) service codes for both assessment and intervention are listed below (and can be coded with modifier 25 when they are performed during the same clinical visit as other E\u002FM services):\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E99408 – Alcohol and\u002For substance abuse (other than tobacco) structured assessment and brief intervention services 15-30 minutes (the comparable Medicare code is G0396)\u003C\u002Fli\u003E\u003Cli\u003E99409 – Alcohol and\u002For substance abuse (other than tobacco) structured assessment and brief intervention services greater than 30 minutes (the comparable Medicare code is G0397)\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:47:13.791Z,updatedAt:2020-09-03T21:12:17.697Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443385077,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBldz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--19a0a31cdc6c57d668f9af90d39204e420a4d2e0\u002FBP_8.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDecisional Balance is a Motivational Interviewing tool that encourages change talk by eliciting the client’s own ideas and motivations for change. The grid below is an easy way of remembering the questions asked in Decisional Balance, which are most effective when asked in sequence.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E1. \u003Cstrong\u003EWhat are some of the good things about using\u003C\u002Fstrong\u003E\u003Cstrong\u003E\u003Cem\u003E fill in the substance\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cstrong\u003E?\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThis will not elicit much change talk, but will get the client talking in a non-defensive way.\u003Cbr\u003E\u003Cbr\u003E2. \u003Cstrong\u003EWhat are some of the bad things about using \u003C\u002Fstrong\u003E\u003Cstrong\u003E\u003Cem\u003Efill in the substance\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cstrong\u003E?\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThis question begins to elicit a client’s ambivalence about their behavior and will start the change talk.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E3. \u003Cstrong\u003EWhat are some of the downsides of getting into a treatment\u002Frecovery program? \u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EClients will often start talking about their fears.\u003Cbr\u003E\u003Cbr\u003E4. \u003Cstrong\u003EWhat are some of the good things about getting into a treatment\u002Frecovery program?\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThis question will likely elicit the most change talk, as the client discusses their own ideas and motivations for change. When this comes from the client instead of the provider, it comes without resistance and may include some motivations that the provider would not have considered.\u003Cbr\u003E\u003Caction-text-attachment sgid\BAh7CEkiCGdpZAY6BkVUSSI9Z2lkOi8vbmFzLXRvb2xraXQtYXBpL0FjdGl2ZVN0b3JhZ2U6OkJsb2IvMTAyP2V4cGlyZXNfaW4GOwBUSSIMcHVycG9zZQY7AFRJIg9hdHRhY2hhYmxlBjsAVEkiD2V4cGlyZXNfYXQGOwBUMA--c120b9cd38655a5af75f4764dee6d1fa8c055ee7\ content-type\image\u002Fpng\ url\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--024cc8704960548bc216e25fb2e3ee73d831c499\u002FDecisional%20Balance%20Grid.png\ filename\Decisional Balance Grid.png\ filesize\6099\ width\459\ height\101\ previewable\true\ presentation\gallery\ caption\Decisional Balance Grid\\u003E\u003Cfigure class\attachment attachment--preview attachment--png\\u003E \u003Cimg src\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Frepresentations\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBhdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--024cc8704960548bc216e25fb2e3ee73d831c499\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaDdCam9VY21WemFYcGxYM1J2WDJ4cGJXbDBXd2RwQWdBRWFRSUFBdz09IiwiZXhwIjpudWxsLCJwdXIiOiJ2YXJpYXRpb24ifX0--4fdbde571b604cff2c50a989f27a6f2e0a6ba082\u002FDecisional%20Balance%20Grid.png\\u003E \u003Cfigcaption class\attachment__caption\\u003E Decisional Balance Grid \u003C\u002Ffigcaption\u003E\u003C\u002Ffigure\u003E\u003C\u002Faction-text-attachment\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:E,fullName:bg,professionalDesignation:aM,biography:bh,disclosure:b},resources:{id:da,title:American College of Obstetrics and Gynecology. Motivational interviewing: a tool for behavior change. ACOG Committee Opinion No. 423. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:243–6.,description:a,fileUrl:https:\u002F\u002Fwww.acog.org\u002F-\u002Fmedia\u002FCommittee-Opinions\u002FCommittee-on-Health-Care-for-Underserved-Women\u002Fco423.pdf?dmc1&ts20190427T2309372544.},{id:db,title:Motivational Interviewing Network of Trainers (MINT), an international organization committed to promoting high quality MI practice and training.,description:a,fileUrl:https:\u002F\u002Fmotivationalinterviewing.org\u002F},{id:186,title:Ring, Jeff. Motivational Interviewing Practice Coach Training Curriculum.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBjUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--3a3682fae9aad7a6772ff174dd728aed45ee376f\u002F_BP_8_Motivational%20Interviewing%20Practice%20Coach%20Training%20Curriculum_7.8.20.pdf},references:{id:dc,title:TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment. SAMHSA. https:\u002F\u002Fstore.samhsa.gov\u002Fproduct\u002FTIP-35-Enhancing-Motivation-for-Change-in-Substance-Use-Disorder-Treatment\u002FPEP19-02-01-003. Published October 2019. ,body:a},{id:dd,title:Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford Publications, Inc.; 2002.,body:a},{id:de,title:Prochaska J, Norcross J, DiClemente C. Change for Good: A Revolutionary Six Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York, NY: Avon Books; 1995.,body:a}},{id:Y,title:Encourage breastfeeding for women with opioid use disorder,description:a,position:Y,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWomen should feel empowered to make an informed decision about newborn feeding. Women should be given information about the benefits of breastfeeding, as well as information that addresses concerns specific to opioid use disorder (OUD) and breastfeeding. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe first few hours and days of a newborn’s life constitute a critical window for establishing lactation. Breastfeeding confers many advantages on both mother and infant. The United States Surgeon General, World Health Organization (WHO), and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for the first six months unless contraindicated. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ECalifornia State Bill (SB) 402, signed into law in 2013, states “This bill would require all general acute care hospitals and special hospitals that have a perinatal unit to adopt, by January 1, 2025, the ‘Ten Steps to Successful Breastfeeding,’ as adopted by Baby-Friendly USA, per the Baby-Friendly Hospital Initiative, or an alternate process adopted by a health care service plan that includes evidenced-based policies and practices and targeted outcomes, or the Model Hospital Policy Recommendations as defined.”\u003Cbr\u003E \u003Cbr\u003EMultiple studies have shown the benefits of breastfeeding for newborns of mothers on agonist-based MAT, including decreased length of stay and decreased need for initiation and duration of pharmacotherapy. Research has not found a consistent, significant effect of breastfeeding on the severity of NAS symptoms, although that may be a consequence of variability in documentation of NAS symptoms. Future research, with stronger study designs is likely to yield additional information on these outcomes. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EAlthough a stable mother being treated for OUD with pharmacotherapy is encouraged to breastfeed her infant, there are some situations where breastfeeding is not recommended, including if the mother is HIV-positive, has active tuberculosis, has active herpes simplex lesions, is Hepatitis B or C-positive and has cracked or bleeding nipple(s), or has returned to illicit or inappropriate drug use.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EHIV: \u003C\u002Fstrong\u003EIn January 2023, the United States Health and Human Services Panel on the Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission revised the recommendations for infant feeding of individuals with HIV infection as follows: \u003Cbr\u003E\u003Cbr\u003EPeople with HIV should receive evidence-based, patient-centered counseling to support shared decision-making about infant feeding. Counseling about infant feeding should begin prior to conception or as early as possible in pregnancy; information about and plans for infant feeding should be reviewed throughout pregnancy and again after delivery (expert opinion). During counseling, people should be informed that—\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReplacement feeding with properly prepared formula or pasteurized donor human milk from a milk bank eliminates the risk of postnatal HIV transmission to the infant (validated by one or more randomized clinical trials).\u003C\u002Fli\u003E\u003Cli\u003EAchieving and maintaining viral suppression through antiretroviral therapy (ART) during pregnancy and postpartum decreases breastfeeding transmission risk to less than 1%, but not zero (validated by one or more randomized clinical trials).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cstrong\u003E\u003Cbr\u003E\u003C\u002Fstrong\u003EClinicians who are caring for people with HIV and who have questions about infant feeding should consult with an expert and\u002For the national \u003Ca href\https:\u002F\u002Fnccc.ucsf.edu\u002Fclinician-consultation\u002Fperinatal-hiv-aids\u002F\\u003EPerinatal HIV\u002FAIDS\u003C\u002Fa\u003E hotline (1‑888‑448‑8765).\u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EHepatitis B, Hepatitis C, Herpes Simplex:\u003C\u002Fstrong\u003E The CDC recommends breastfeeding for women with Hepatitis B infection when infants have been appropriately immunized with Hepatitis B Immunoglobulin and vaccine; and for women with Hepatitis C infection, as long as nipples are not cracked or bleeding. If the mother with Herpes Simplex Virus has lesions on the breast, or who has Hepatitis B or C and has cracked or bleeding nipples, the CDC recommends to temporarily stop nursing and to express and discard the breastmilk. When the nipple(s) are well-healed and no longer bleeding, the mother may return to breastfeeding. If only one side is affected, the mother may continue to breastfeed on the unaffected side.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EActive (untreated) tuberculosis: \u003C\u002Fstrong\u003EThe AAP recommends against breastfeeding in the setting of active, infectious tuberculosis. In this situation, expressed milk can still be given to the newborn. Breastfeeding can resume after a minimum of 2 weeks of treatment for tuberculosis, and when the mother is documented to no longer be infectious. \u003Cbr\u003E\u003Cbr\u003E\u003Cstrong\u003EIllicit or Inappropriate Drug Use\u003C\u002Fstrong\u003E\u003Cem\u003E: \u003C\u002Fem\u003EAccording to the AAP “maternal substance abuse is not a categorical contraindication to breastfeeding” and therefore well-nourished narcotic dependent mothers being treated for OUD with pharmacotherapy are encouraged to breastfeed in the absence of illicit drug use. Breastfeeding is contraindicated if “relapse” occurs, or a return to any illicit drug use or frequent legal substance misuse, especially if relapse has occurred in the 30-day period prior to delivery. Infrequent substance use, especially if outside of the 30-day window before delivery, may not necessarily be a contraindication to breastfeeding, but each woman must be carefully and individually evaluated for type of substance used, length of time since last use, and other risk factors. Refer to ABM Clinical Protocol #21 in the References section of this Best Practice for more detailed guidelines. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EDevelop breastfeeding protocol for women with OUD. \u003C\u002Fstrong\u003ECreate a multidisciplinary team ideally including obstetricians, midwives, family physicians, pediatricians, nurses, lactation specialists, pain\u002Faddiction specialists, pharmacists, and social workers to create a facility-specific protocol addressing the following topic areas:\u003Cul\u003E\u003Cli\u003EInformation for women with OUD and clinicians caring for them: Create user-friendly resources on the benefits of breastfeeding for women with OUD and their newborns and include important contraindications.\u003C\u002Fli\u003E\u003Cli\u003EDevelop a protocol for identification of women with OUD and mobilization of required resources to support breastfeeding, emphasizing best practices such as early skin-to-skin care. \u003C\u002Fli\u003E\u003Cli\u003EDevelop a plan for outpatient breastfeeding and newborn nutritional support. Develop a workflow to ensure pregnant patients with OUD are discharged with a plan to support breastfeeding and the overall nutrition for their newborns; this plan should include appropriate short interval pediatric follow-up, access to advice on lactation continuation, and access to local or online breastfeeding support resources. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ETrain the workforce on breastfeeding for women with OUD.\u003C\u002Fstrong\u003E Educate physicians, nurses, and other care team members on the benefits of breastfeeding for women with OUD and institute multimodal strategies for implementation of developed protocols.\u003Cul\u003E\u003Cli\u003EEducate clinical staff on the strength of evidence and criteria for safety of breastfeeding for women with OUD. Determine appropriate avenues through which to educate hospital staff (e.g., emails, physical bulletin boards, staff meetings) and mitigate discrimination and bias toward patients with OUD.\u003C\u002Fli\u003E\u003Cli\u003ETrain providers on OUD treatment protocols. Create standards for providers caring for pregnant patients to provide information relevant to breastfeeding decisions and ask questions about the mother’s concerns and barriers surrounding breastfeeding. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EImplement quality improvement strategies to improve breastfeeding in women with OUD:\u003C\u002Fstrong\u003E Create process metrics that allow for regular evaluation of facility-based breastfeeding support protocols.\u003Cul\u003E\u003Cli\u003EDefine target metrics for breastfeeding in OUD. Develop facility-specific metrics for tracking implementation and effectiveness of the breastfeeding program for women with OUD, including measurement of initiation and continuation of breastfeeding.\u003C\u002Fli\u003E\u003Cli\u003EDelineate role(s) for OUD treatment assessment and improvement. Designate either an individual or a team to take accountability for ongoing facility-level assessment and improvement of metrics for breastfeeding in women with OUD. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:57:55.578Z,updatedAt:2024-05-29T17:04:59.226Z,publishedAt:an,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443385265,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBmQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--b0c696b9d43a3cce95f7652d1cfd33cc94509798\u002FBP_9.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EAs soon as Baby M is born, the maternity nurse asks if she can place him on Kayla skin-to-skin. Although Kayla had been unsure about breastfeeding, with encouragement from the nurse with whom she has begun to establish a trusting relationship, she decides to place Baby M on the breast. This makes Kayla feel happy and helps her bond with Baby M. She feels that she can soothe his cries by breastfeeding.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EBreastfeeding is beneficial for the health of both the mother and newborn. It reduces the risk of infection, immune mediated disorders, and obesity in the newborn; and it reduces the risk of postpartum hemorrhage, hypertension, diabetes, and breast and ovarian cancer in the mother. In newborns at risk for NAS, breastfeeding reduces the need for pharmacologic treatment. The process of breastfeeding stimulates the release of oxytocin. Oxytocin induces the dopaminergic pathway of the reward system, which mediates a mother’s behavioral response to her newborn’s cues, promoting bonding and attachment between mother and newborn. Supporting breastfeeding in a woman with OUD empowers her to provide the best care for her newborn. The reward and stress response pathways may be altered in women with OUD, making it especially important that providers promote breastfeeding in this vulnerable population to optimize emotional and behavioral outcomes for both mother and newborn. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EWhile promoting breastfeeding and skin-to-skin care, it is important to emphasize safe sleep methods. If a mother is fatigued or too sleepy to safely hold her newborn, she should lay the newborn on its back on a firm sleeping surface to decrease the risk of sudden infant death syndrome.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:Z,fullName:aS,professionalDesignation:aT,biography:aU,disclosure:b},{id:_,fullName:bi,professionalDesignation:c,biography:bj,disclosure:b},{id:$,fullName:aV,professionalDesignation:aW,biography:aX,disclosure:b},{id:ag,fullName:bk,professionalDesignation:bl,biography:bm,disclosure:b},resources:,references:{id:267,title:SB-402 Breastfeeding. California Legislative Information. https:\u002F\u002Fleginfo.legislature.ca.gov\u002Ffaces\u002FbillNavClient.xhtml? bill_id201320140SB402. Accessed December 19, 2019.,body:a},{id:268,title:Feldman-Winter L, Goldsmith JP; Committee on Fetus and Newborn, Task Force on Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016; 138(3), e20161889. doi: 10.1542\u002Fpeds.2016-1889.,body:a},{id:269,title:9 Steps to Breastfeeding Friendly: Guidelines for Community Health Centers and Outpatient Care Settings. California Department of Public Health . https:\u002F\u002Fwww.cdph.ca.gov\u002FPrograms\u002FCCDPHP\u002FDCDIC\u002FNEOPB\u002FCDPH Document Library\u002FPPPDS_9StepGuide_ADA.pdf. Published 2015. Accessed December 19, 2019.,body:a},{id:270,title:Protecting, Promoting, and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services: The Revised Baby-Friendly Hospital Initiative 2018. World Health Organization. https:\u002F\u002Fwww.who.int\u002Fnutrition\u002Fpublications\u002Finfantfeeding\u002Fbfhi- implementation\u002Fen\u002F. Published 2018. Accessed December 19, 2019.,body:a},{id:271,title:Chu L, McGrath JM, Qiao J, Brownell E, Recto P, Cleveland LM, Lopez E, Gelfond J, Crawford A, McGlothen-Bell K. A Meta-Analysis of Breastfeeding Effects for Infants With Neonatal Abstinence Syndrome. Nurs Res. 2022 Jan-Feb 01;71(1):54-65. doi: 10.1097\u002FNNR.0000000000000555. PMID: 34596065; PMCID: PMC8663542 ,body:a},{id:272,title:Patricelli CJ, Gouin IJ, Gordon S, Carter N, Albert A, Paquette V, Stewart K, George S, Urbanoski K. Breastfeeding on Injectable Opioid Agonist Therapy: A Case Report. J Addict Med. 2023 Mar-Apr 01;17(2):222-226. doi: 10.1097\u002FADM.0000000000001055. Epub 2022 Aug 24. PMID: 36001061; PMCID: PMC10022656. ,body:a},{id:273,title:ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018; 131(5): e140-e150. doi: 10.1097\u002FAOG.0000000000002633.,body:a},{id:274,title:A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorder. SAMHSA. https:\u002F\u002Fstore.samhsa.gov\u002F\u002Fsystem\u002Ffiles\u002Fsma16-4978.pdf. Accessed December 19, 2019.,body:a},{id:275,title:Breastfeeding and the use of human milk. Pediatrics. 2012; 129(3): e827-41. doi:10.1542\u002Fpeds.2011-3552.,body:a},{id:276,title:ACOG committee opinion no. 756 summary: optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2018;132(4):1086-1088. doi: 10.1097\u002FAOG.0000000000002891.,body:a},{id:277,title:Breastfeeding and Special Circumstances. Centers for Disease Control. https:\u002F\u002Fwww.cdc.gov\u002Fbreastfeeding\u002Fbreastfeeding-special-circumstances\u002Findex.html. Updated June 2, 2020.,body:a},{id:278,title:Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder. Breastfeed Med. 2015;10(3):135-141. doi: 10.1089\u002Fbfm.2015.9992.,body:a}},{id:aY,title:Initiate medication assisted treatment in the prenatal setting,description:a,position:aE,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement an outpatient protocol for evidence-based evaluation, treatment, and continuity of care for pregnant patients with opioid use disorder (OUD). Arranging for the provision of medication assisted treatment (MAT) on site is an optimal way to deliver the standard of care for pregnant women with OUD. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe pregnant woman with OUD who presents for prenatal care has a unique opportunity to initiate treatment for OUD. While the care team may initially find such a patient challenging, they have a chance to introduce life-changing therapy. Along with the screening and brief intervention portions of SBIRT, obstetric providers can offer MAT treatment. Many obstetric providers have not received training in OUD management and feel reluctant to begin this practice. Obstetric providers often feel more comfortable referring patients with OUD to a stand-alone outpatient opioid treatment clinic or other office-based outpatient treatment (OBOT) program for induction and management of OUD with MAT. However, the best practice OUD treatment is for patients with OUD to be able to begin treatment wherever they receive medical or prenatal care. Providers who can initiate treatment for OUD will have a significant impact on the unmet treatment gap in their county. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EEngage the whole team. Successful integration of a new service will require front office, back office, and providers all educated about the successful outcomes in pregnant women with OUD who are on MAT. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEffective January 2023 the special waiver to prescribe buprenorphine is no longer required. Any provider licensed to prescribe Schedule III controlled substances may initiate and continue treatment with buprenorphine. Moreover, that same legislation removed limitations on the number of patients with OUD, who may be treated with buprenorphine by a single provider. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EBuild policies\u002Fprocedures for MAT to allow for a uniform care delivery system.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUse a toolkit. Numerous toolkits exist that provide clinics with the education and resources needed to offer MAT. One such is example is the Providers Clinical Support System (PCSS). \u003Ca href\https:\u002F\u002Fpcssnow.org\u002Fresources\u002Fclinical-tools\u002F\\u003Ehttps:\u002F\u002Fpcssnow.org\u002Fresources\u002Fclinical-tools\u002F\u003C\u002Fa\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EMultiple studies have shown beneficial effects for treatment of OUD with either methadone or buprenorphine. Recent studies have shown infants exposed to buprenorphine compared to methadone have higher birthweights, longer lengths, and less risk of prematurity, as well as lower rates of NAS and a decreased risk of admission to a neonatal intensive care unit (NICU). Other considerations aside, these factors may favor the use of buprenorphine in pregnant individuals with OUD.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EMultiple forms of injectable, extended-release buprenorphine are now available and are being used more widely. These products have not been systematically studied in pregnant individuals, however, multiple case studies of extended-release buprenorphine use in this population have been published. If the safety of these medications can be demonstrated, they may play an important role in OUD treatment in pregnancy.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIdentify who to call for help. Know how to refer patients who fail buprenorphine to methadone treatment programs when necessary. Consider using a consultation service such as the FREE Clinician Consultation Center at UCSF which has a Substance Use Warmline at 855-300-9595 and is available Monday through Friday during daytime business hours, and a specific Consultation line for licensed practitioners in California that is available 24\u002F7. This line is staffed by physicians, pharmacists, and nurses with special expertise in pharmacotherapy options.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExplore emerging therapies. Aside from traditional in-office induction, consider other modalities that best suit your patients. These include home and hospital induction, micro-dosing transition, and Buprenorphine Quick Start. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-27T05:50:27.634Z,updatedAt:2024-05-29T17:05:51.649Z,publishedAt:an,videoUrl:bE,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBmUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--e3cbcafba9fdda634c6de71836008d628cb03119\u002FBP%2010_11_13.pptx,deepDive:b,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},category:{friendlyId:p,name:q,description:r},authors:{id:ad,fullName:bc,professionalDesignation:bd,biography:be,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:df,title:SAMHSA Waiver Application and Training.,description:a,fileUrl:a},{id:217,title:Providers Clinical Support System (PCSS). Clinical Tools.,description:a,fileUrl:a},{id:218,title:Guidelines for Physicians Working in California Opioid Treatment Programs. Chapter 4.,description:a,fileUrl:a},{id:219,title:dg,description:a,fileUrl:a},{id:220,title:California Health Care Foundation Webinar: “Expanding Access to Buprenorphine in Primary Care Settings”.,description:a,fileUrl:a},{id:221,title:California Health Care Foundation. Everything You Need to Know About Buprenorphine.,description:a,fileUrl:a},{id:222,title:Urban Institute: California County Fact Sheets: Treatment Gaps in Opioid-Agonist Medication Assisted Therapy (OA-MAT) and Estimates of How Many Additional Prescribers Are Needed.,description:a,fileUrl:a},{id:dh,title:UCSF Substance Use Warmline,description:a,fileUrl:a},references:{id:279,title:Waiver Elimination (MAT Act). Substance Abuse and Mental Health Services Administration. https:\u002F\u002Fwww.samhsa.gov\u002Fmedications-substance-use-disorders\u002Fwaiver-elimination-mat-act Updated June 7, 2023.,body:a},{id:280,title:Goshgarian, G., Jawad, R., OBrien, L., Muterspaugh, R., Zikos, D., Ezhuthachan, S., . . . Ragina, N. (2022). Prenatal Buprenorphine\u002FNaloxone or Methadone Use on Neonatal Outcomes in Michigan. Cureus, 14(8), e27790. doi:10.7759\u002Fcureus.27790,body:a},{id:281,title:Kinsella, M., Halliday, L. O. E., Shaw, M., Capel, Y., Nelson, S. M., & Kearns, R. J. (2022). Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. Subst Use Misuse, 1-17. doi:10.1080\u002F10826084.2022.2083174,body:a},{id:282,title:Minozzi, S., Amato, L., Jahanfar, S., Bellisario, C., Ferri, M., & Davoli, M. (2020). Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev, 11(11), CD006318. doi:10.1002\u002F14651858.CD006318.pub4,body:a},{id:283,title:Suarez, E. A., Huybrechts, K. F., Straub, L., Hernandez-Diaz, S., Jones, H. E., Connery, H. S., . . . Bateman, B. T. (2022). Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med, 387(22), 2033-2044. doi:10.1056\u002FNEJMoa2203318,body:a},{id:284,title:Towers, C. V., & Deisher, H. (2020). Subcutaneous Extended-Release Buprenorphine Use in Pregnancy. Case Rep Obstet Gynecol, 2020, 3127676. doi:10.1155\u002F2020\u002F3127676 ,body:a}},{id:ab,title:Implement an inpatient treatment protocol for pregnant women with opioid use disorder,description:a,position:az,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhile the ideal timing for initiation of medication assisted treatment (MAT) would be early in the pregnancy, implementation of an inpatient protocol for evidence-based evaluation, initiation of treatment, and discharge of peripartum patients with opioid use disorder (OUD) is the next best opportunity to address the chronic disease of OUD and improve long term outcomes for the pregnant woman and her affected infant. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe patient with OUD who presents to labor and delivery in labor also presents with a unique opportunity to initiate treatment for opioid use. While the provider and nursing staff may initially find such a patient challenging, they can introduce life-changing therapy at this distinct moment. Staff plays a critical role in dismantling health-related stigma that often prevents this population from accessing life-saving treatments through education, interprofessional collaboration and engaging the pregnant\u002Fparenting person. Additionally, providers often feel uncomfortable prescribing MAT for various reasons, many of which are common misperceptions, including:\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMyth: Inpatient providers believe they cannot treat OUD because they do not have a waiver to prescribe MAT (“X waiver”).\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EFact: Section 1262 of the Consolidated Appropriations Act of 2023 eliminates the requirement for a separate DEA certification (i.e., DATA 2000, X waiver) to prescribe “medications like buprenorphine for the treatment of OUD.” (N.B. The Act includes a separate provision related to training requirements, effective June 2023).\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EFact: Even before the elimination of the waiver, federal law allowed providers without an X waiver to administer or dispense (but not prescribe) buprenorphine on an inpatient basis for up to 72 hours. This law is known as the “three-day rule” and provides for effective treatment of acute withdrawal in the emergency department or inpatient setting. \u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMyth: There may be possible deleterious fetal effect. \u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EFact: MAT, particularly buprenorphine, is the gold standard for treatment of OUD and is safe during pregnancy. Higher overall dosing of both buprenorphine and methadone and split dosing regimens are often required during pregnancy. On the other hand, withdrawal is associated with high rates of relapse and poor outcomes for both mother and infant.\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMyth: Neonatal abstinence syndrome (NAS) will be more severe, especially with the higher doses of buprenorphine needed during pregnancy.\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EFact: Buprenorphine reduces NAS severity and the dose is not correlated with NAS severity.\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EA clear, informed protocol that providers can leverage for safe management of OUD in pregnant women will increase provider comfort in caring for these patients and optimize health outcomes for patients and their newborns.\u003Cem\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fem\u003EIt is important to recognize that not all areas of the country have access to the same resources for MAT, especially for women who are pregnant. In rural and\u002For underserved areas, there may be access to only one type of treatment and\u002For treatment setting, and each group implementing this toolkit should become familiar with the treatment options available in their community. These settings may be integrated into primary care or OB\u002FGYN offices (e.g., office-based outpatient treatment), stand-alone outpatient treatment programs, residential treatment programs, opioid treatment programs (e.g., “methadone clinics\), emergency departments (e.g., emergency departments may be participating in the CA Bridge Programs, and initiating MAT), hospital labor and delivery units, or within the general hospital setting. Each of these locations has its own unique strengths and challenges. Referral protocols should be built by individual locations to reflect assessment of the severity of OUD matched with the ASAM level of care resources that are available in the local community with the goal of providing access to treatment for women during their pregnancy and after delivery.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EOutpatient Services\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ENot all women may require or accept inpatient induction of MAT. If a woman presenting for care declines inpatient or emergency department induction, ensure that the institution has referral processes in place to directly connect the patient with outpatient services, such as office-based outpatient treatment or an opioid treatment program, and provide a warm handoff.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EUtilize a multidisciplinary team, ideally with obstetricians, midwives, psychiatrists, nurses, anesthesiologists, addiction and pain medicine specialists, pharmacists, and social workers to create a facility-specific protocol that addresses the following:\u003Cul\u003E\u003Cli\u003EEvaluation of patients for OUD with a non-judgmental, trauma-informed approach (please see the Resources section of this Best Practice: Sample Evaluation of Opioid Use Disorder in Pregnancy Checklist).\u003C\u002Fli\u003E\u003Cli\u003EShared decision making for OUD treatment, emphasizing the risks of OUD in pregnancy and options for MAT, as well as the risks of supervised withdrawal (Please see the Resources section of this Best Practice: Considerations for, Treatment of Opioid Use Disorder in Pregnancy).\u003C\u002Fli\u003E\u003Cli\u003EAdoption or development and utilization of a treatment algorithm for initiation of inpatient MAT for both buprenorphine and methadone, including adjunctive therapies to optimize MAT induction and relief from withdrawal symptoms (please see the Resources section of this Best Practice: Sample Inpatient Medication-Assisted Treatment Induction Algorithms and the Buprenorphine Quick Start in Pregnancy Algorithm).\u003C\u002Fli\u003E\u003Cli\u003EAdoption or development and utilization of a treatment algorithm for outpatient buprenorphine induction\u003Cem\u003E. \u003C\u002Fem\u003EIf capacity for close follow up with provider(s) comfortable with outpatient induction of buprenorphine in pregnancy is available, develop guidelines for which patients can consider outpatient induction of MAT and develop a protocol for outpatient buprenorphine induction in settings affiliated with the institution (please see the Resources section of this Best Practice: Sample Outpatient Buprenorphine Induction Algorithm). Consider partnering with local residential treatment facilities and withdrawal management (detoxification) centers.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDevelopment of a Plan of Safe Care to ensure pregnant patients with OUD are discharged with appropriate transition to outpatient care with a focus on coordination of MAT (e.g., handoffs to methadone treatment programs and buprenorphine prescribing providers) and harm reduction. The “Transitions” section of this toolkit includes multiple best practices that will support development efforts in these areas (\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F29\\u003E\u003Cstrong\u003ESee Best Practice #29\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEducate physicians, nurses, and other care team members on OUD in pregnancy, strategies for caring for patients with OUD, and implementation of developed trauma-informed, evidence-based protocols.\u003Cul\u003E\u003Cli\u003ECreate awareness of OUD in Pregnancy through various mediums to educate hospital staff about OUD in pregnancy (e.g., emails, physical bulletin boards, staff meetings) and mitigate stigma, bias and discrimination toward patients with OUD.\u003C\u002Fli\u003E\u003Cli\u003ECreate opportunities for the workforce to learn about trauma-informed care in the inpatient setting (\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F7\\u003E\u003Cstrong\u003ESee Best Practice #7\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003C\u002Fli\u003E\u003Cli\u003EImplement a standardized approach to educating staff, such as the Safety Bundle to Reduce Adverse Maternal and Neonatal Outcomes.\u003C\u002Fli\u003E\u003Cli\u003ETrain providers on OUD treatment protocols for pregnancy and encourage them to prescribe buprenorphine.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ETrain nurses on OUD treatment protocols and the use of the Clinical Opiate Withdrawal Scale and the Ramsay Sedation Scale (refer to the Resources section of this Best Practice) in the care of patients taking buprenorphine and methadone (refer to the Resources section of this Best Practice: Considerations for Administration of Buprenorphine and Methadone).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ECreate process metrics to regularly evaluate the implementation of the facility-based protocols.\u003Cul\u003E\u003Cli\u003EDefine target metrics for OUD treatment\u003Cem\u003E. \u003C\u002Fem\u003EDevelop facility-specific metrics to track implementation and effectiveness of OUD treatment and referral protocols (e.g., development of a dashboard if enough volume vs. audit of OUD cases if a few cases) and assess for disparities in treatment (e.g., examine outcomes by race, preferred language).\u003C\u002Fli\u003E\u003Cli\u003EDelineate role(s) for assessment and improvement of OUD treatment. Designate either an individual or a team to take accountability for ongoing facility-level assessment and improvement of OUD treatment in pregnancy to ensure access and health equity.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:36:54.680Z,updatedAt:2024-05-29T17:06:40.327Z,publishedAt:an,videoUrl:bE,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBmZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--34510acd71869f8ab2e313a040b114ec171a4054\u002FBP%2010_11_13.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EFor acute pain requiring bolus control, consider using a moderate affinity µ-opioid agonist such as morphine IV at 4-6 milligrams or a strong affinity µ-opioid agonist such as fentanyl IV 100 micrograms. Evidence shows that total opioid requirements is less when MAT is continued as a basal pain medication. \u003Cbr\u003E\u003Cbr\u003E\u003Cem\u003EReference: Macintyre PE, Russell RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesthesia and intensive care. 2013;41(2):222-230.\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhen building an inpatient treatment protocol, consider increasing the total daily dose as we well as dividing the patient’s MAT doses to help with acute pain control. For example, if Kayla is taking 24 mg of buprenorphine as an outpatient and has acute pain from her delivery, one may consider increasing her total daily dose to 32 mg but providing it in 8 mg doses every 6 hours. Build a basal\u002Fbolus pain control protocol into your admission order sets. Both buprenorphine and methadone can be divided into 6-8-hour dosing regimens to allow for better basal pain control. There is now sufficient evidence that maintenance therapy for both methadone and buprenorphine usually necessitates increases in the baseline daily dose during pregnancy, especially during the third trimester to account for changes in pharmacokinetics. These recommendations are useful for pain management during the intrapartum and immediate post-partum period, after which a return to pre-labor dosing is appropriate. \u003Cbr\u003E\u003Cbr\u003E\u003Cem\u003EReference: Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of internal medicine. 2006;144(2):127-134.\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:p,name:q,description:r},authors:{id:W,fullName:bw,professionalDesignation:bx,biography:by,disclosure:b},{id:ad,fullName:bc,professionalDesignation:bd,biography:be,disclosure:b},{id:_,fullName:bi,professionalDesignation:c,biography:bj,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:af,title:bF,description:a,fileUrl:bn},{id:di,title:bG,description:a,fileUrl:bH},{id:dj,title:bI,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBOUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--d7dbe508813db9fb1fb0dba734326c0216e3e4a3\u002FConsiderations%20for%20Administration%20of%20Buprenorphine%20and%20Methadone.pdf},{id:dk,title:bJ,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBOZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--876fddd97fec2309c3f01873950df321dcab5002\u002FConsiderations%20for%20Treatment%20of%20Opioid%20Use%20Disorder%20in%20Pregnancy.pdf},{id:dl,title:dm,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBOdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--10b950b178d5b7884fc85811c28aa1349211ae25\u002FSample%20Evaluation%20of%20Opioid%20Use%20Disorder%20(OUD)%20in%20Pregnancy%20Checklist.pdf},{id:cL,title:dn,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBPQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--83416393e9190ab2bb5cf2162b5eaa783ff50d48\u002FSample%20Inpatient%20Medication-Assisted%20Treatment%20Induction%20Algorithms.pdf},{id:154,title:do_,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBPUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--b3db85835c7ffc7c7e13ec8665db8f637399756d\u002FSample%20Outpatient%20Buprenorphine%20Induction%20Algorithm.pdf},{id:cM,title:ck,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBQdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--17822abefa63daca3ba608deabfad17816c50d6a\u002FNNEPQIN%20Opioid%20Use%20Disorder%20Clinical%20Pathway.pdf},{id:224,title:dg,description:a,fileUrl:a},{id:225,title:Substance Abuse and Mental Health Services Administration (SAMHSA) resources on the MAT Act (i.e., DEA X-Waiver elimination). ,description:a,fileUrl:https:\u002F\u002Fwww.samhsa.gov\u002Fmedications-substance-use-disorders\u002Fwaiver-elimination-mat-act},{id:dp,title:The National Partnership for Maternal Safety developed the Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder.,description:a,fileUrl:https:\u002F\u002Fjournals.lww.com\u002Fgreenjournal\u002FFulltext\u002F2019\u002F08000\u002FNational_Partnership_for_Maternal_Safety_.23.aspx},{id:c_,title:A Comprehensive Care Approach for Pregnant Persons with Substance Use Disorders. ,description:a,fileUrl:Mckinney, J.R., Russell, M., Avellaneda-Ojeda, A. et al. A Comprehensive Care Approach for Pregnant Persons with Substance Use Disorders. Int J Ment Health Addiction (2022). https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs11469-022-00760-x },references:{id:am,title:ACOG committee opinion no 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017; 130(2): e81-94. doi: 10.1097\u002FAOG.0000000000002235. ,body:a},{id:aF,title:Guidelines for Identification and Management of Substance Use and Substance Use Disorders in Pregnancy. World Health Organization. https:\u002F\u002Fwww.who.int\u002Fsubstance_abuse\u002Fpublications\u002Fpregnancy_guidelines\u002Fe Published March 21, 2014. Accessed December 19, 2019.,body:a},{id:aq,title:The ASAM National Practice Guideline . American Society of Addiction Medicine . https:\u002F\u002Fwww.asam.org\u002Fdocs\u002Fdefault-source\u002Fpractice-support\u002Fguidelines-and-consensus-docs\u002Fasam-national-practice-guideline-supplement.pdf. Accessed December 19, 2019.,body:a},{id:au,title:Jones HE, Martin PR, Heil SH, et al. Treatment of opioid-dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008; 35(3): 245-259. doi:10.1016\u002Fj.jsat.2007.10.007.,body:a},{id:_,title:Buprenorphine QuickStart in Pregnancy Algorithm. ED Bridge. https:\u002F\u002Fstatic1.squarespace.com\u002Fstatic\u002F5c412ab755b02cec3b4ed998\u002Ft\u002F5d6d85 +9-1-2019.pdf. Accessed December 19, 2019.,body:a},{id:211,title:Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann of Intern Med. 2006;144(2):127-134. doi: 10.7326\u002F0003-4819-144-2-200601170-00010. ,body:a},{id:212,title:Macintyre PE, Russell RA, Usher KA, Gaughwin M, Huxtable CA. Pain relief and opioid requirements in the first 24 hours after surgery in patients taking buprenorphine and methadone opioid substitution therapy. Anaesth Intensive Care. 2013; 41(2): 222-230. doi: 10.1177\u002F0310057X1304100212.,body:a},{id:263,title:Krans, E. E., Campopiano, M., et al. (2019). National Partnership for Maternal Safety: Consensus bundle on obstetric care for women with opioid use disorder. Obstetrics and Gynecology, 134(2), 365–375. https:\u002F\u002Fdoi.org\u002F10.1097\u002F AOG.0000000000003381,body:a},{id:264,title:Linn N, Stephens K, at el. Implementing Trauma-Informed Strategies for Mothers of Infants with Neonatal Abstinence Syndrome. MCN Am J Matern Child Nurs. 2021 Jul-Aug 01;46(4):211-216. doi: 10.1097\u002FNMC.0000000000000728. PMID: 33973889.,body:a}},{id:W,title:Implement evidence-based anesthesia practices in the peripartum period for opioid use disorder in pregnancy,description:a,position:ab,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement evidence-based best practices for anesthesia care and pain relief for pregnant women with opioid use disorder (OUD).\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPregnant women with OUD have pain relief and anesthetic needs that vary from women without OUD in the peripartum period. Early consultation and use of best practices for management of intrapartum and postpartum pain relief will optimize maternal and newborn outcomes. Individual hospitals\u002Fsettings will have different availability of anesthetic\u002Fanalgesic options.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003E\u003Cstrong\u003EPre-delivery \u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsult with an anesthesiologist at the delivering facility who will be able to review and develop an anesthetic plan that addresses the patient’s needs and accounts for the options available at the local institution.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUtilize shared decision making for the degree of pain relief desired during intrapartum and postpartum recovery.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProvide resources for anesthesia providers about OUD and anesthetic consideration\u002Fneeds. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003E\u003Cbr\u003EIntrapartum\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENeuraxial anesthesia provides the best quality of pain relief, especially in opioid tolerant individuals. Patients will need adjustment of medication types and concentrations for optimal pain relief that do not interfere with and will not be affected by OUD or OUD medications. Increased strength or concentration of a medication (e.g., local anesthetic or the total dose or frequency of a dose of a medication that has a uniform concentration) will likely be needed. Neuraxial adjuncts may be helpful. Patients with a prior history of OUD who fear relapse may desire a method of analgesia\u002Fanesthesia that omits opioids entirely. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDuring labor, patients on agonist-based MAT should continue their current dose of methadone or buprenorphine. This should not be considered adequate pain control for the intrapartum period. The dose may be increased and divided into multiple daily doses (TID) for better pain control.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPatients with a prior history of OUD who fear relapse may desire a method of analgesia\u002Fanesthesia that omits opioids entirely, The risks and benefits of this approach should be discussed with the patient.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENon-pharmacologic pain management strategies, such as water immersion, relaxation, and massage, should be offered where available.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EAvoid nitrous oxide in combination with high dose opioids. Nitrous oxide is not recommended in this setting as nitrous combined with opioids may produce excessive sedation or respiratory depression, causing the patient deep sedation or general anesthesia. When the preferred method, epidural analgesia, is contraindicated, nitrous oxide may be considered under close supervision as an adjunct with other systemic therapies. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003ECesarean Delivery\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EAdjust use of neuraxial anesthesia according to the individual patient’s OUD or OUD medications and tolerances. Adjunct neuraxial medications may be considered.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUse general anesthesia only as otherwise indicated. This is not the preferred method for routine cesarean in pregnant women with OUD.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003E\u003Cbr\u003EPost-delivery pain relief\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ECreate a multimodal analgesia and multidisciplinary care plan.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUnderstand that multiple non-narcotic adjuncts are available. Choices may be affected by local resources and availability.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEmphasize local anesthetics used in neuraxial infusion and\u002For peripheral nerve blocks (e.g, Transverse Abdominis Plan (TAP), Quadratus Lumborum Block (QL2), epidural infusion, and wound liposomal bupivacaine). Consider use of a catheter for continued infusion of local anesthetics and adjuvants, as well as scheduled acetaminophen and NSAIDs.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIV patient-controlled analgesia (PCA) opioids may be used as a supplement to other multimodal treatment, but the requirements may be higher.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPost-delivery monitoring requirements should be considered. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003E\u003Cbr\u003EAdditional Considerations \u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDevelop an informational packet for anesthesia providers.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIf the patient was previously on buprenorphine, continue buprenorphine, although the dose may need to be split (e.g.,TID), and total dose may need to be increased.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUse of multiple opioids, analgesics, adjuncts, and\u002For sedatives may result in pharmacologic\u002Fpharmacogenetic additive or synergistic effects and result in shifting from minimal sedation to moderate sedation\u002Fanalgesia to deep sedation\u002Fanalgesia or even general anesthesia. Caution is urged, and proper monitoring for respiratory depression and oxygenation may be warranted. Underlying medical conditions will amplify the effect of sedatives, analgesics and other medications (e.g., obstructive sleep apnea, chorioamnionitis with fever). Rescue capacity is required under the Patients’ Rights standard at §482.13(c)(2), guaranteeing patients care in a safe setting (CMS Interpretive guidelines).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:37:49.244Z,updatedAt:2024-05-29T17:07:11.528Z,publishedAt:an,videoUrl:dq,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBmdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--0dd8ad979eae1dc77fecafcec70283e5d57a8775\u002FBP%2012_15.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla’s physician referred her for a consultation at 36 weeks of pregnancy with the anesthesiologist at her delivering facility. They reviewed together her current medications, any non-prescription medication usage including herbals and marijuana derivatives, medical issues, as well as her personal concerns about pain, pain medications, and her overall pain tolerance. Kayla expressed great concern about getting her regular pain medications and additional oxycodone for pain. The anesthesiologist reassured her that epidural analgesia for labor or post-cesarean does not aggravate her increasing back pain with the pregnancy and provides the highest quality pain relief for labor and post-partum. The use of non-narcotic neuraxial adjuvants is very important, as Kayla’s current total opioid and non-opioid pharmaceutical consumption may produce opioid induced hyperalgesia—suggesting use of another type of medication could be very helpful. If Kayla undergoes a cesarean delivery, increased doses of neuraxial narcotic will be needed as well as additional non-narcotic analgesic regimens (e.g., TAP Quadratus Lumborum type 2 local anesthetic block, or wound infusion). Even a complicated vaginal delivery (for example, a third- or fourth-degree laceration) may benefit from neuraxial morphine and adjuvants for post-delivery analgesia. The anesthesiologist will need to notify the hospital pharmacy if adjuvants will be used, as they may not be standard stock (e.g., clonidine for epidural administration), and if the hospital can accommodate post-delivery epidural infusions for analgesia, particularly adjuvants like clonidine.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EFailure to secure a pre-delivery consultation may adversely affect intrapartum or postpartum care. Not all anesthesia providers are familiar with OUD in pregnancy, and a consultation allows discussion and implementation of a multimodal analgesia plan, combining patient preferences and shared decision making with what is available at her particular delivery location. Care coordination becomes even more important if a consultation is not an option. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:p,name:q,description:r},authors:{id:ah,fullName:bo,professionalDesignation:bp,biography:bq,disclosure:br},{id:ag,fullName:bk,professionalDesignation:bl,biography:bm,disclosure:b},resources:,references:{id:285,title:Pan A, Zakowski M. Peripartum anesthetic management of the opioid- tolerant or buprenorphine\u002Fsuboxone-dependent patient. Clin Obstet and Gynecol. 2017; 60(2): 447-458. doi:10.1097\u002Fgrf.0000000000000288.,body:a},{id:286,title:Soens MA, He J, Bateman BT. Anesthesia considerations and post-operative pain management in pregnant women with chronic opioid use. Semin Perinatol. 2019; 43(3): 149-161. doi:10.1053\u002Fj.semperi.2019.01.004.,body:a},{id:287,title:George RB, Carvalho B, Butwick A, Flood P. Postoperative analgesia, chapter 29. In: Chestnut DH, Nathan N, eds. Chestnuts Obstetric Anesthesia: Principles and Practice. Philadelphia, PA: Elsevier; 2020.,body:a},{id:288,title:Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology. 2016;124(3):535-552. doi:10.1097\u002Faln.0000000000000975.,body:a},{id:289,title:Hoyt MR, Shah U, Cooley J, Temple M. Use of epidural clonidine for the management of analgesia in the opioid addicted parturient on buprenorphine maintenance therapy: an observational study. Int J Obstet Anesth. 2018;34:67-72. doi: 10.1016\u002Fj.ijoa.2018.01.001.,body:a},{id:290,title:Kohan L, Potru S, Barreveld AM, Sprintz M, Lane O, Aryal A, Emerick T, Dopp A, Chhay S, Viscusi E. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021 Oct;46(10):840-859. doi: 10.1136\u002Frapm-2021-103007. Epub 2021 Aug 12. PMID: 34385292 ,body:a},{id:291,title:Association of Women’s Health, Obstetric and Neonatal Nurses. Intrapartum Pain Management for People on Medication-Assisted Therapy for Opioid Use Disorder: AWHONN Practice Brief Number 17. Nurs Womens Health. 2023 Apr;27(2):e5-e7. doi: 10.1016\u002Fj.nwh.2022.11.003. ,body:a},{id:292,title:Landau R. Post-cesarean delivery pain. Management of the opioid- dependent patient before, during and after cesarean delivery. Int J Obstet Anesth. 2019;39:105-116. https:\u002F\u002Fdoi.org\u002F10.1016\u002Fj.ijoa.2019.01.011.,body:a},{id:293,title:Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation\u002FAnalgesia. American Society of Anesthesiologists. https:\u002F\u002Fwww.asahq.org\u002Fstandards-and-guidelines\u002Fcontinuum-of-depth-of-sedation- definition-of-general-anesthesia-and-levels-of-sedationanalgesia#\u002F. Accessed December 19, 2019.,body:a},{id:294,title:Volpe DA, McMahon Tobin GA, Mellon RD, Katki AG, Parker RJ, Colatsky T, et al. Uniform assessment and ranking of opioid mu receptor binding constants for selected opioid drugs. Regul Toxicol Pharmacol. 2011; 59:385- 90. doi: 10.1016\u002Fj.yrtph.2010.12.007.,body:a},{id:295,title:Enhanced Recovery After Cesarean (ERAC) Full Consensus Statement 5\u002F23\u002F2019. Society for Obstetric Anesthesia and Perinatology. https:\u002F\u002Fsoap.org\u002Feducation\u002Fprovider-education\u002Fmember-erac-consensus- statement- 5-23-19-2\u002F. Published May 23, 2019.,body:a}},{id:am,title:Ensure methadone and buprenorphine doses are not tapered in the immediate postpartum period,description:a,position:W,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement an inpatient postpartum protocol to ensure that patients on medication assisted treatment (MAT) have a plan for continued treatment in the postpartum period. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWomen whose opioid maintenance therapy is interrupted are at high risk of relapse and overdose during the postpartum period.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ETrain providers on evaluation of opioid withdrawal and over-sedation in women on opioid maintenance therapy. Create opportunities for nurses responsible for caring for pregnant inpatients to learn and ask questions about facility-specific protocols as well as to learn how to use the Clinical Opiate Withdrawal Scale and the Ramsay Sedation Scale in the care of patients taking maintenance buprenorphine and methadone (Please see the Resources section of this Best Practice: Considerations for Administration of Buprenorphine and Methadone). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProvide information to providers on how to educate women with opioid use disorder (OUD) about MAT. Educate providers on the importance of continuation of maintenance medication in the postpartum period and reassure women on this treatment that it will not be interrupted. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDevelop a protocol for ensuring regular dosing of maintenance methadone and buprenorphine. Work with nursing, obstetrics, and pain\u002Faddiction medicine specialists to create a protocol to ensure regular dosing and to assess for the need for increased or split dosing during the postpartum period. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EMethadone:\u003C\u002Fstrong\u003E Providers should not decrease the methadone dose in the immediate postpartum period unless it is at the patient’s request and the provider and patient agree using shared decision making or unless over-sedation is observed. Providers can consider increasing or splitting the postpartum methadone dose for better pain control post-cesarean.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EBuprenorphine:\u003C\u002Fstrong\u003E Doses should not be decreased in the immediate postpartum period unless it is at the patient’s request and the provider and patient agree using shared decision-making or if over-sedation is observed. Providers can consider increasing or splitting the postpartum buprenorphine dose for better pain control post-cesarean. Consider transitioning buprenorphine-only patients to buprenorphine\u002Fnaloxone prior to discharge. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDevelop a plan for safe outpatient hand-off to a provider who can maintain the patient on MAT. Develop a workflow to ensure pregnant patients with OUD are discharged with a mechanism for uninterrupted continuation of their therapy. Best practice is to continue MAT in the immediate postpartum period. Tapering or stopping MAT in the acute pain or recovery period may increase maternal morbidity and complications. Warn women that relapse and therefore overdose is common in the postpartum period and close follow-up is necessary.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsure follow-up with a physician or midwife who is aware of the patient’s OUD and MAT therapy. Ideally the patient will already know this provider. This follow-up should be made within 1-2 weeks of discharge. Postpartum depression should be assessed at this appointment or prior to discharge. Encourage anti-depressant medication for patients with a positive screen to treat their mood and improve MAT retention.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESee Resources section below for tools for evaluating patients on chronic opioids for withdrawal.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:38:09.206Z,updatedAt:2020-09-03T21:13:48.842Z,publishedAt:o,videoUrl:bE,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWHM9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--e2367264b2614eb9b09a3cbc11bb2454d575939a\u002FBP%2010_11_13.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EHaving her baby was one of the most amazing things Kayla had ever experienced. When she held her new baby, she felt like everything was good in the world. Kayla was inspired to take control of her health and her social situation for Baby M. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe postpartum period is a critical time for the mother and baby. Sudden, disruptive changes in the care plan that do not account for the patient’s preferences and what is presently working may lead to unintended consequences. As a rule, MAT should not be tapered in the postpartum period. Additionally, switching from methadone to buprenorphine is more difficult than the switch from buprenorphine to methadone, and should be done with caution, with full disclosure, at an appropriate time, and with a careful plan in place. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:p,name:q,description:r},authors:{id:ah,fullName:bo,professionalDesignation:bp,biography:bq,disclosure:br},{id:at,fullName:cd,professionalDesignation:ce,biography:cf,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:s,title:bG,description:a,fileUrl:bH},{id:t,title:bF,description:a,fileUrl:bn},{id:cN,title:dn,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBSQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--2c6fe0e16053269592b0139f0d007b5b9b77e80d\u002FSample%20Inpatient%20Medication-Assisted%20Treatment%20Induction%20Algorithms.pdf},{id:cO,title:do_,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBSUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--7d0626e00a5b781568b2feb3733f753095e4c0a7\u002FSample%20Outpatient%20Buprenorphine%20Induction%20Algorithm.pdf},{id:158,title:bI,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBTZz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--bfd6f6775db36d0def738d59827f6e08c579bfcd\u002FConsiderations%20for%20Administration%20of%20Buprenorphine%20and%20Methadone.pdf},{id:cP,title:bJ,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBUQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--0bd614ca020fb470490a55d522ba8bf95aa0d8c9\u002FConsiderations%20for%20Treatment%20of%20Opioid%20Use%20Disorder%20in%20Pregnancy.pdf},{id:cQ,title:dm,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBUUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--74ca2eaf30ccb352ef8426b34766ba15e1283d8d\u002FSample%20Evaluation%20of%20Opioid%20Use%20Disorder%20(OUD)%20in%20Pregnancy%20Checklist.pdf},references:{id:av,title:ACOG committee opinion no 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017;130: e81-94. doi: 10.1097\u002FAOG.0000000000002235.,body:a},{id:ar,title:Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, et al. Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts. Obstet Gynecol. 2018;132(2): 466-474. doi: 10.1097\u002FAOG.0000000000002734.,body:a},{id:aG,title:Caritis SN, Bastian JR, Zhang H. et al. An evidence-based recommendation to increase the dosing frequency of buprenorphine during pregnancy. Am J Obstet Gynecol. 2017;217(4): 459.e1-459.e6. doi: 10.1016\u002Fj.ajog.2017.06.029.,body:a},{id:ai,title:Jones HE, Johnson RE, O’Grady KE, Jasinski DR, Tuten M, Milio L. Dosing adjustments in postpartum patients maintained on buprenorphine or methadone. J Addict Med. 2008;103-7. doi: 10.1097\u002FADM.0b013e31815ca2c6.,body:a},{id:af,title:Ellis JD, Cairncross M, Struble CA, Carr MM, Ledgerwood DM, Lundahl LH. Correlates of treatment retention and opioid misuse among postpartum women in methadone treatment. J Addict Med. 2019;13(2):153-158. doi: 10.1097\u002FADM.0000000000000467.,body:a},{id:ae,title:O’Connor AB, Uhler B, O’Brien LM, Knuppel K. Predictors of treatment retention in postpartum women prescribed buprenorphine during pregnancy. J Subst Abuse Treat. 2018;86:26-29. doi: 10.1016\u002Fj.jsat.2017.12.001.,body:a},{id:ao,title:Krans EE, Bogen D, Richardson G, Park SY, Dunn SL, Day N. Factors associated with buprenorphine versus methadone use in pregnancy. Subst Abus. 2016;37(4):550-557. doi: 10.1080\u002F08897077.2016.1146649.,body:a},{id:ap,title:Laslo J, Brunner JM, Burns D, Butler E, Cunningham A, Killpack R, et. al. An overview of available drugs for management of opioid abuse during pregnancy. Matern Health Neonatol Perinatol. 2017;3:4. doi: 10.1186\u002Fs40748-017-0044-2.,body:a},{id:s,title:Raymond BL, Kook BT, Richardson MG. The opioid epidemic and pregnancy: implications for anesthetic care. Curr Opin Anaesthesiol. 2018;31(3):243-250. doi: 10.1097\u002FACO.0000000000000590.,body:a},{id:t,title:Safley RR, Swietlikowski J. Pain management in the opioid-dependent pregnant woman. J Perinat Neonatal Nurs. 2017;31(2):118-125. doi: 10.1097\u002FJPN.0000000000000261. ,body:a},{id:u,title:Wilder CM, Winhusen T. Pharmacological management of opioid use disorder in pregnant women. CNS Drugs. 2015;29(8):625-36. doi: 10.1007\u002Fs40263-015-0273-8.,body:a}},{id:aF,title:Implement care pathways for peripartum and postpartum pain management for pregnant patients without opioid use disorder to minimize opioid use,description:a,position:am,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPostpartum pain is common. All women experience uterine cramping in the early postpartum period that is necessary to prevent excess bleeding, and women with lacerations from vaginal birth experience perineal pain. After cesarean birth, women experience pain from the laparotomy. It is necessary to treat pain adequately to support maternal comfort and to reduce the stress response of the mother and newborn. It is also critically important to limit the amount of opioids prescribed on discharge that may lead to prolonged use and possibly misuse. Leftover medication is a common source of opioids that are diverted for misuse. The potential for diversion and misuse of opioids make it a public health priority to prescribe only the minimum amount required by the patient. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ECesarean birth is the most commonly performed surgery in the United States, yet little is known about appropriate pain management at discharge. In general, women consume half the amount of opioids prescribed to them on discharge. For example, a recent study found that the median number of opioid tablets prescribed was 40 and the median consumed was 20 (Bateman BT, et al, 2017). The amount of opioid consumed was directly proportional to the amount prescribed. However, the amount of opioids dispensed did not correlate with patient satisfaction, pain control, or the need to refill the opioid prescription. The majority of women do not require an opioid prescription after vaginal delivery. Despite the well-known risks, 29% of women were prescribed an opioid at the time of discharge after vaginal delivery. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EEnhanced Recovery:\u003C\u002Fstrong\u003E There is a national effort for all surgeries to redesign care for the peri-operative period to enhance recovery. In May 2019, the Society for Obstetric Anesthesia and Perinatology (SOAP) released a comprehensive set of guidelines (see Resources) for each phase of care for women undergoing a cesarean birth known as Enhanced Recovery After Cesarean (ERAC). Every obstetric unit should strongly consider these recommended approaches. A part of enhanced recovery is optimizing care so that the need for opioid pain medications is markedly lowered and\u002For replaced by non-opioid approaches. A Call to Action for ERAC with a comprehensive discussion was published in the August 2019 issue of \u003Cem\u003EThe American Journal of Obstetrics and Gynecology\u003C\u002Fem\u003E. One of the goals is to ensure that all women have access to adequate pain control while reducing the harms of opioid exposure.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThere is considerable evidence that new mothers are consistently over-prescribed opioids after delivery. Better pain control is achievable with less opioids using a multimodal approach. There is evidence that most women require fewer than 20 opioid tablets following uncomplicated cesareans and that scheduled non-opioid analgesics provide superior pain relief and facilitate reduced opioid consumption compared to PRN dosing. A similar protocol did not result in an increase in outpatient opioid refill rate. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EEstablish a multidisciplinary team to implement a unit-wide ERAC protocol.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EScheduled NSAIDs and acetaminophen are the first line agents for postpartum pain control. Ibuprofen 600 mg and Acetaminophen 650 mg PO Q 6 hours can be concurrent or staggered dosing. The oral route is preferred unless inappropriate.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EOffer oxycodone 5 mg PO Q6 hours PRN pain instead of the combination of APAP\u002Foxycodone. Avoid codeine and tramadol in breastfeeding women. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider a lidocaine patch for post-cesarean laparotomy pain. Consider transverse abdominus plane block immediately post-cesarean for post-incisional pain. See \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F15\\u003E\u003Cstrong\u003EBest Practice #15\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEvaluate the amount of opioids used by the patient in the 24 hours prior to discharge and use shared decision making to decide how many oxycodone tablets to give the patient, but limit the amount to a three-day supply or on average 15-20 tablets. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPerineal pain requiring opioids should prompt a careful evaluation for hematoma, wound breakdown, or infection. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Caction-text-attachment sgid\BAh7CEkiCGdpZAY6BkVUSSI9Z2lkOi8vbmFzLXRvb2xraXQtYXBpL0FjdGl2ZVN0b3JhZ2U6OkJsb2IvMTAzP2V4cGlyZXNfaW4GOwBUSSIMcHVycG9zZQY7AFRJIg9hdHRhY2hhYmxlBjsAVEkiD2V4cGlyZXNfYXQGOwBUMA--eb86d745fabbf3038118178826ee00e14602f158\ content-type\image\u002Fpng\ url\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBiQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--040695741de7f09c9322c40f210dd36decf4ef5f\u002FSample%20guideline%20for%20oral%20analgesic%20prescribed%20at%20discharge.png\ filename\Sample guideline for oral analgesic prescribed at discharge.png\ filesize\15383\ width\525\ height\206\ previewable\true\ presentation\gallery\ caption\Sample guideline for oral analgesic prescribed at discharge\\u003E\u003Cfigure class\attachment attachment--preview attachment--png\\u003E \u003Cimg src\https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Frepresentations\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBiQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--040695741de7f09c9322c40f210dd36decf4ef5f\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaDdCam9VY21WemFYcGxYM1J2WDJ4cGJXbDBXd2RwQWdBRWFRSUFBdz09IiwiZXhwIjpudWxsLCJwdXIiOiJ2YXJpYXRpb24ifX0--4fdbde571b604cff2c50a989f27a6f2e0a6ba082\u002FSample%20guideline%20for%20oral%20analgesic%20prescribed%20at%20discharge.png\\u003E \u003Cfigcaption class\attachment__caption\\u003E Sample guideline for oral analgesic prescribed at discharge \u003C\u002Ffigcaption\u003E\u003C\u002Ffigure\u003E\u003C\u002Faction-text-attachment\u003E\u003Cbr\u003E\u003Cbr\u003E\u003Cstrong\u003EProposed guidelines for uncomplicated normal spontaneous vaginal birth (Mills JR, et al, 2019)\u003Cbr\u003E\u003C\u002Fstrong\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EGuideline 1:\u003C\u002Fstrong\u003E Long-term opioid use often begins with the treatment of acute pain. When opioids are started, providers should order the lowest effective dosage and prescribe no greater quantity of opioids than needed for the expected duration of pain severe enough to require opioids. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EGuideline 2:\u003C\u002Fstrong\u003E When starting opioid therapy, providers should prescribe immediate-release opioids instead of extended-release or long-acting opioids. This is especially important on the day of discharge. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EGuideline 3:\u003C\u002Fstrong\u003E Providers should avoid prescribing opioid pain medications and benzodiazepines concurrently whenever possible. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EGuideline 4:\u003C\u002Fstrong\u003E Nonpharmacologic therapy and non-opioid pharmacologic therapy are preferred for patients who had a normal, spontaneous vaginal delivery with no complications. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EGuideline 5:\u003C\u002Fstrong\u003E When providers identify a patient with opioid use disorder (OUD), treatment discussions should be prioritized during hospitalization, on discharge, and at the postpartum appointment. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:38:42.797Z,updatedAt:2020-10-07T14:24:05.225Z,publishedAt:ac,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446555292,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWHc9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--0d0a5caf8bbc07a3b2daba68a5b71c2903624414\u002FBP_14.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThere are many elements of ERAC that can help limit opioids while providing adequate pain control.\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENeuraxial long-acting opioids.\u003C\u002Fli\u003E\u003Cli\u003ENon-opioid analgesia started in the operating room unless contraindicated. These are ideally started prior to onset of pain (ketorolac 15-30 mg IV after peritoneum closed and\u002For acetaminophen IV after delivery or PO before\u002Fafter delivery).\u003C\u002Fli\u003E\u003Cli\u003EConsider local wound pain control such as TAP block or lidocaine patch at incision site.\u003C\u002Fli\u003E\u003Cli\u003EPromote return of bowel function. Constipation can lead to increased unnecessary post-operative gas pain; limiting opioids, scheduled bowel regimen, and mobilization can mitigate this.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003EFor all patients, remember immediate skin-to-skin, early promotion of breastfeeding, early ambulation and promotion of rest periods all improve the maternal psyche and can improve overall perception and coping with pain.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cem\u003EReference: Society of Obstetric Anesthesia and Perinatology (SOAP) Enhanced Recovery After Cesarean (ERAC) Consensus Statement, \u003C\u002Fem\u003E\u003Ca href\https:\u002F\u002Fsoap.org\u002FSOAP-Enhanced-Recovery-After-Cesarean-Consensus-Statement.pdf\\u003E\u003Cem\u003Ehttps:\u002F\u002Fsoap.org\u002FSOAP-Enhanced-Recovery-After-Cesarean-Consensus-Statement.pdf\u003C\u002Fem\u003E\u003C\u002Fa\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:p,name:q,description:r},authors:{id:aZ,fullName:Dorothy DeGuzman,professionalDesignation:aM,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Dorothy DeGuzman, Family Medicine Faculty and Addiction and High Risk OB Faculty, Ventura County Medical Center.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},{id:X,fullName:ba,professionalDesignation:aL,biography:bb,disclosure:b},{id:ah,fullName:bo,professionalDesignation:bp,biography:bq,disclosure:br},{id:ag,fullName:bk,professionalDesignation:bl,biography:bm,disclosure:b},resources:{id:u,title:Sample patient-oriented teaching regarding multimodal pain management after cesarean delivery: UNC School of Medicine, Center for Maternal and Infant Health.,description:a,fileUrl: https:\u002F\u002Fwww.mombaby.org\u002Fwp-content\u002Fuploads\u002F2018\u002F03\u002FPain-management-after-c-section-3.5.18.pdf},{id:v,title:Sample discharge instructions regarding pain medication after delivery: UNC School of Medicine, Center for Maternal and Infant Health.,description:a,fileUrl:https:\u002F\u002Fwww.mombaby.org\u002Fwp-content\u002Fuploads\u002F2018\u002F03\u002FUNC-Post-Discharge-Pain-Manaagment-Revised-3-16-18.pdf},{id:A,title:Society of Obstetric Anesthesia and Perinatology (SOAP) Enhanced Recovery After Cesarean (ERAC) Consensus Statement.,description:a,fileUrl:https:\u002F\u002Fsoap.org\u002FSOAP-Enhanced-Recovery-After-Cesarean-Consensus-Statement.pdf},references:{id:v,title:Bateman BT, Cole NM, Maeda A, et al. Patterns of opioid prescription and use after cesarean delivery. Obstet Gynecol. 2017;130(1):29-35. doi: 10.1097\u002FAOG.0000000000002093. ,body:a},{id:A,title:Fahey JO. Best practices in management of postpartum pain. J Perinat Neonatal Nurs. 2017;31:126-136. doi: 10.1097\u002FJPN.0000000000000241.,body:a},{id:D,title:Inciardi JA, Surratt HL, Cicero TJ, Beard RA. Prescription opioid abuse and diversion in an urban community: the results of an ultrarapid assessment. Pain Med. 2009;10(3):537-548. doi:10.1111\u002Fj.1526- 4637.2009.00603.,body:a},{id:bK,title:Smith AM, Young P, Blosser CC, Poole AT. Multimodal stepwise approach to reducing in-hospital opioid use after cesarean delivery: a quality improvement initiative. Obstet Gynecol. 2019;133(4):700-706. doi: 10.1097\u002FAOG.0000000000003156.,body:a},{id:aK,title:Prabhu M, Dubois H, James K, et al. Implementation of a quality improvement initiative to decrease opioid prescribing after cesarean delivery. Obstet Gynecol. 2018;132(3):631-636. doi:10.1097\u002Faog.0000000000002789.,body:a},{id:aP,title:Prabhu M, Garry EM, Hernandez-Diaz S, MacDonald SC, Huybrechts KF, Bateman BT. Frequency of opioid dispensing after vaginal delivery. Obstet Gynecol. 2018;132(2):459-465. doi: 10.1097\u002FAOG.0000000000002741.,body:a},{id:aY,title:Osmundson SS, Schornack LA, Grasch JL, Zuckerwise LC, Young JL, Richardson MG. Postdischarge opioid use after cesarean delivery. Obstet Gynecol. 2017;130(1):36-41. doi: 10.1097\u002FAOG.000000000000209.,body:a},{id:a_,title:Prabhu M, McQuaid-Hanson E, Hopp S, et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol. 2017;130:42-46. doi: 10.1097\u002FAOG.00000000000020n4.,body:a},{id:bL,title:Komatsu R, Carvalho B, Flood PD. Recovery after nulliparous birth: a detailed analysis of pain analgesia and recovery of function. Anesthesiology. 2017;127(4):684-694. doi: 10.1097\u002FALN.0000000000001789. ,body:a},{id:bM,title:Mundkur ML, Franklin JM, Abdia Y, et al. Days supply of initial opioid analgesic prescriptions and additional fills for acute pain conditions treated in the primary care setting - United States, 2014. MMWR Morb Mortal Wkly Rep. 2019;68(6):140-143. doi: 10.15585\u002Fmmwr.mm6806a3.,body:a},{id:dr,title:Mills JR, Huizinga MM, Robinson SB, et al. Draft opioid-prescribing guidelines for uncomplicated normal spontaneous vaginal birth. Obstet Gynecol. 2019;133(1):81-90. doi: 10.1097\u002FAOG.0000000000002996.,body:a},{id:bN,title:Scully RE, Schoenfeld AJ, Jiang W, et al. Defining optimal length of opioid pain medication prescription after common surgical procedures. JAMA Surg. 2018;153(1):37-43. doi: 10.1001\u002Fjamasurg.2017.3132.,body:a},{id:bO,title:Peahl AF, Smith R, Johnson TRB, Morgan DM, Pearlman MD. Better late than never: why obstetricians must implement enhanced recovery after cesarean. Am J Obstet Gynecol. 2019;221(2):117.e1-117.e7. doi: 10.1016\u002Fj.ajog.2019.,body:a}},{id:aR,title:Utilize shared decision making to tailor post-procedure pain control,description:a,position:aF,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIndividual patients often fear the loss of autonomy in a hospital setting and, knowing their increased tolerance for medication, fear for their ability to relieve their pain. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThere is extensive variability in the needs of women with opioid use disorder (OUD) for pain control over and above their maintenance therapy.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EShared decision making is a dynamic process during which the provider and patient engage in an informed discussion to make health related choices that are best for the patient and in alignment with the patient’s personal values (refer the Resources section of this Best Practice for more information), Shared decision making has been shown to reduce overall opioid use.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EFor each patient with OUD, engage in an open and honest discussion about pain control and encourage shared decisions about pain management.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider Transverse Abdominis Plane (TAP) block, Quadratus Lumborum Block (QL2), or paravertebral blocks\u002Fcatheters with the consultation of an anesthesiologist. Create facilities, training, and procedures for providers to maintain these catheters and advise patients on their benefits and use. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESchedule adjuvant medications including non-steroidal anti-inflammatory medications and acetaminophen to reduce the need for opioid dose escalation. Develop procedures and training for the administration of other adjuvant medications including gabapentin or pregabalin, or short-term ketamine in consultation with and under the supervision of an anesthesiologist. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider local analgesic and other analgesic patches for postsurgical pain. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDo not routinely give opioids above maintenance doses for vaginal births. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T18:53:23.820Z,updatedAt:2020-09-03T21:14:55.764Z,publishedAt:o,videoUrl:dq,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWDA9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--3e48887727675fbe291a1f0d4a75f7f70f9b59f3\u002FBP%2012_15.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhat is shared decision making and why does it matter? Shared decision making occurs when the patient is considered a critical part of the team. Two axioms are important to shared decision making: “No decision about me without me” and “this patient is the only patient.” Together, this means each patient is an individual and should be treated as such, and their own individual values and preferences should be the starting point for all conversations. When done right, shared decision making leads to improved quality of care, improved outcomes, and better patient experience. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe basic components of shared decision making are:\u003C\u002Fdiv\u003E\u003Col\u003E\u003Cli\u003E\u003Cstrong\u003ES\u003C\u002Fstrong\u003Eeek your patient’s participation\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EH\u003C\u002Fstrong\u003Eelp your patient explore and compare treatment options\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EA\u003C\u002Fstrong\u003Essess your patient’s values and preferences\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003ER\u003C\u002Fstrong\u003Eeach a decision with your patient\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003EE\u003C\u002Fstrong\u003Evaluate the decision \u003C\u002Fli\u003E\u003C\u002Fol\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EMore information and an entire toolkit on the “SHARE Approach” can be found on the ARHQ website at: \u003Ca href\https:\u002F\u002Fwww.ahrq.gov\u002Fhealth-literacy\u002Fcurriculum-tools\u002Fshareddecisionmaking\u002Findex.html\\u003Ehttps:\u002F\u002Fwww.ahrq.gov\u002Fhealth-literacy\u002Fcurriculum-tools\u002Fshareddecisionmaking\u002Findex.html\u003C\u002Fa\u003E. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EShared decision making will shift Kayla’s focus away from the disease and towards creating a partnership with greater participation and compliance. Individual preference of and tolerance to advanced pain strategies may affect which ones are chosen together. Choices for Kayla include:\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EScheduled (not PRN) non-narcotic pain medications including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs).\u003C\u002Fli\u003E\u003Cli\u003ELocal anesthetic to prevent and treat pain. A local anesthetic wound infusion or injection of long acting local anesthetic such as a Transverse Abdominus Plane (TAP) block or Quadratus Lumborum (QL) type2 block single dose or catheter-based infusion.\u003C\u002Fli\u003E\u003Cli\u003EEpidural infusion of low dose local anesthetic, preferably with non-narcotic adjuvants (e.g., alpha\u003Csub\u003E2\u003C\u002Fsub\u003E adrenergic agonists clonidine, epinephrine).\u003C\u002Fli\u003E\u003Cli\u003EAdministration or infusion of other non-narcotic adjuvants (e.g., gabapentin\u002Fpregabalin, infusion of low dose ketamine).\u003C\u002Fli\u003E\u003Cli\u003EAvoidance\u002Fminimizing regular opioids (e.g., oxycodone) at high doses for post-delivery pain.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},category:{friendlyId:p,name:q,description:r},authors:{id:ah,fullName:bo,professionalDesignation:bp,biography:bq,disclosure:br},{id:ag,fullName:bk,professionalDesignation:bl,biography:bm,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:ds,title:bG,description:a,fileUrl:https:\u002F\u002Fpalliative.stanford.edu\u002Fpalliative-sedation\u002Fappendices\u002Framsay-sedation-scale\u002F },{id:dt,title:bF,description:a,fileUrl:bn},{id:cR,title:bI,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBWQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--71f2fcb3c06e3b42c6fe0e3b492ed0c65b899aca\u002FConsiderations%20for%20Administration%20of%20Buprenorphine%20and%20Methadone.pdf},{id:cS,title:bJ,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBWUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--d3dfc2243a77008b13d535b607716d0297826ff2\u002FConsiderations%20for%20Treatment%20of%20Opioid%20Use%20Disorder%20in%20Pregnancy.pdf},{id:cT,title:“SHARE Approach” AHRQ. Shared Decision Making.,description:a,fileUrl:https:\u002F\u002Fwww.ahrq.gov\u002Fhealth-literacy\u002Fcurriculum-tools\u002Fshareddecisionmaking\u002Findex.html.},references:{id:du,title:Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and pharmacodynamics of drugs commonly used in pregnancy and parturition. Anesth Analg. 2016;122(3):786-804. doi: 10.1213\u002FANE.0000000000001143.,body:a}},{id:aq,title:Implement a non-pharmacologic bundle of care for neonatal abstinence syndrome for medical staff and parents to follow,description:a,position:aq,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplement a non-pharmacologic bundle of care for neonatal abstinence syndrome (NAS) for medical staff and parents to follow.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA non-pharmacologic bundle of care for NAS will help to prioritize non-pharmacologic interventions over medication, may reduce the length of stay, and will keep staff and parents aligned on the care being provided to the newborn. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ECollaborate with nursing and health care teams to develop a written guideline with a bundle of care that is specific for your unit. An example of a non-pharmacologic bundle of care for NAS\u003Cstrong\u003E \u003C\u002Fstrong\u003Ewould include:\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EParent\u002Fcaregiver contact:\u003C\u002Fstrong\u003E Emphasize parental presence at the bedside (rooming in, where available), the importance of skin-to-skin\u002Fholding the newborn, swaddling with the newborn’s hands near the mouth, and non-nutritive sucking\u002Fpacifier use. Consider a volunteer cuddler when a parent or caregiver is unavailable. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EEnvironment:\u003C\u002Fstrong\u003E Establish an environment that is quiet with low lighting, limit the number of visitors, avoid excessive handling, encourage only one stimulus at a time (e.g., do not walk or sway while feeding). Swinging is okay but should be stopped if the newborn is overstimulated. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ENursing care:\u003C\u002Fstrong\u003E Cluster nursing assessments and interventions at times when the newborn is awake. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EFeeding:\u003C\u002Fstrong\u003E Feed on-demand; encourage breastfeeding and lactation consultation if eligible (in the absence of any contraindications, breastfeeding should be encouraged while the mother is on methadone or buprenorphine treatment as part of a program); prioritize feeding consult if bottle feeding; and if formula feeding, consider reduced lactose or partially hydrolyzed lactose (not evidence-based) and consider 22 kcal\u002Foz after day 2-3 if there is poor weight gain (loss of >10% of birthweight or not back to birthweight by 7 days of life).\u003Cul\u003E\u003Cli\u003EDetermine contraindications for maternal breastfeeding by unit for consistency. There are no medical contraindications to breastfeeding based on maternal methadone (prescribed as part of a treatment program), buprenorphine, or short-term low-dose prescription opioid use alone. The concentrations of methadone that can be found in human milk are low, and women on stable doses of methadone maintenance should be encouraged to breastfeed regardless of maternal methadone dose if they are in a treatment program. Buprenorphine has low levels in breastmilk and poor oral bioavailability in newborns.\u003C\u002Fli\u003E\u003Cli\u003EUse breastmilk when not contraindicated to reduce the severity of NAS and to minimize the need for pharmacologic exposure. Ensure a mother eligible for breastmilk use has a lactation consultation, access to a breast pump, and adequate instructions for its use. \u003C\u002Fli\u003E\u003Cli\u003EFeed based on hunger cues\u002Fad lib (usually q2-3 hours), if medically appropriate.\u003C\u002Fli\u003E\u003Cli\u003EAnticipate possible increased caloric needs.\u003C\u002Fli\u003E\u003Cli\u003ERule out non-NAS causes of poor feeding including transitional sleepiness or frequent spit-ups in the first\u003Csup\u003E \u003C\u002Fsup\u003E24 hours of life, poor latch due to newborn\u002Fmaternal anatomic factors or immature gestational age, and physiologic cluster feeding.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ESkin:\u003C\u002Fstrong\u003E Practice proactive prevention of diaper dermatitis and skin breakdown. Start diaper\u002Fbarrier creams on day one and treat other areas of skin excoriation due to newborn tremors promptly.\u003Cul\u003E\u003Cli\u003EFrequent stools increase the risk of perianal breakdown. This can be prevented by:\u003Cul\u003E\u003Cli\u003EStarting diaper creams\u002Fbarrier creams on day one\u003C\u002Fli\u003E\u003Cli\u003EFrequent diaper changes\u003C\u002Fli\u003E\u003Cli\u003ELiberal application of emollients and\u002For moisturizers\u003C\u002Fli\u003E\u003Cli\u003ECareful assessment with each diaper change\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003Cli\u003EExcoriation from tremors is most common on the extremities, face, chin, knees, and gluteal folds. \u003Cul\u003E\u003Cli\u003EApplying a medical dressing over the knees and other body surfaces that are being rubbed can be protective.\u003C\u002Fli\u003E\u003Cli\u003EUsing mittens to decrease scratching can also be helpful.\u003C\u002Fli\u003E\u003Cli\u003EAvoid friction with cleansing. Do not use harsh wipes. \u003C\u002Fli\u003E\u003Cli\u003EUse only water for cleansing; a sitz bottle works well. \u003C\u002Fli\u003E\u003Cli\u003EUse gentle patting to dry.\u003C\u002Fli\u003E\u003Cli\u003EApply a no-sting barrier to areas of skin breakdown.\u003C\u002Fli\u003E\u003Cli\u003EApply a skin protectant to areas of skin breakdown.\u003C\u002Fli\u003E\u003Cli\u003ELeave areas of skin breakdown open to air as much as possible.\u003C\u002Fli\u003E\u003Cli\u003ETreat areas of breakdown for at least 24 hours.\u003C\u002Fli\u003E\u003Cli\u003ETeach parents proper skin care techniques.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:39:02.188Z,updatedAt:2020-09-03T21:15:21.875Z,publishedAt:o,videoUrl:bs,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWDQ9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--14f7852e128519b0071e0a0294548decfaacc0e4\u002FBP%2016_17_18_19.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EBaby M is now 24 hours old and is being assessed for withdrawal based on functional impairment (his ability to eat, sleep, and be consoled within set periods of time). The hospital has recently implemented this system in place of the traditional Finnegan score assessment, and the staff has found that fewer newborns need medication and many are able to go home sooner. A nurse performs the assessment after Baby M awakens and is concerned because he slept less than an hour and has high-pitched cries. However, Kayla is able to breastfeed, and Baby M is calmer after feeding. The nurse is pleased that Baby M was adequately consoled. She talks to Kayla about keeping Baby M calm by decreasing environmental stimulation with low light, fewer visitors, and low sound. She also shows Kayla various techniques of how to console Baby M such as speaking to him softly, bringing his hands to his mouth, bringing his flexed arms and legs to the center of his body, placing him skin-to-skin or swaddling him, gently rocking him, giving him a pacifier, or feeding him if he shows hunger cues. The nurse talks to the charge nurse and moves Kayla and Baby M to a single room in the postpartum unit to minimize environmental stimulation. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:{id:D,title:PQCNC and MAiN resources under pharmacological section.,description:a,fileUrl:http:\u002F\u002Fwww.mainbabies.org\u002F},{id:aK,title:ILPQC Newborn Care Diary.,description:a,fileUrl:dv},{id:cU,title:Ohio Perinatal Quality Collaborative Provider Resources.,description:a,fileUrl:https:\u002F\u002Fopqc.net\u002Fpatients-providers\u002F%20NAS},{id:cV,title:Ohio Collaborative Crib Card.,description:a,fileUrl:https:\u002F\u002Fopqc.net\u002Fsites\u002Fbmidrupalpopqc.chmcres.cchmc.org\u002Ffiles\u002FResources\u002FNeonatal%20Abstinence%20Syndrome\u002Fopqc_nas_bassinet_card_090814.pdf},{id:cW,title:NeoQIC Resources for Hospitals.,description:a,fileUrl:dw},references:{id:bP,title:Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarko L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid- exposed infants. Acta Paediatr. 2013;102(11):1060- 1066. doi: 10.1111\u002Fapa.12378.,body:a},{id:53,title:Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6): e20163360. doi: 10.1542\u002Fpeds.2016-3360. ,body:a},{id:dx,title:Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatol. 2018;38(8):1114-1122. doi: 10.1038\u002Fs41372-018-0109-8.,body:a},{id:dy,title:Wiles JR, Isemann B, Ward LP, Vinks AA, Akinbi H. Current management of neonatal abstinence syndrome secondary to intrauterine opioid exposure. J Pediatr. 2014;165(3):440–446. doi:10.1016\u002Fj.jpeds.2014.05.010.,body:a},{id:dz,title:Abdel-Latif ME, Pinner J, Clews S, Cooke F, Lui K, Oei J. Effects of breast milk on the severity and outcome of neonatal abstinence syndrome among infants of drug-dependent mothers. Pediatrics. 2006;117(6):e1163-1169. doi: 10.1542\u002Fpeds.2005-1561.,body:a},{id:dA,title:Jansson, L, Choo R, Melez M, et al. Methadone maintenance and breast feeding in the neonatal period. Pediatrics. 2008;121:106-114. doi: 10.1542\u002Fpeds.2007-1182.,body:a},{id:dB,title:Reece-Stremtan S, Marinelli KA. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder. Breastfeed Med. 2015;10(3):135-41. doi: 10.1089\u002Fbfm.2015.9992.,body:a},{id:dh,title:Buprenorphine. Drugs and Lactation Database (LactMed). https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fbooks\u002FNBK501202\u002F. Accessed December 19, 2019.,body:a},{id:237,title:McQueen K, Taylor C, Murphy-Oikonen J. Systematic review of newborn feeding method and outcomes related to neonatal abstinence syndrome. J Obstet Gynecol Neonatal Nurs. 2019;48(4):398-407. doi: 10.1016\u002Fj.jogn.2019.03.004.,body:a},{id:238,title:Wu D, Carre C. The impact of breastfeeding on health outcomes for infants diagnosed with neonatal abstinence syndrome: a review. Cureus 2018;10(7):e3061. doi: 10.7759\u002Fcureus.3061.,body:a}},{id:au,title:Develop guidelines for inpatient monitoring of newborns managed with a non-pharmacologic bundle of care,description:a,position:au,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhen a newborn who is exposed to opioids in utero does not require pharmacotherapy and is managed solely with a non-pharmacologic bundle of care, we recommend a minimum of 72 hours of inpatient monitoring.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EOpioid clearance in newborns is variable due to patient clearance characteristics, type of opioid, and the presence of other drugs. Most newborns will present with withdrawal symptoms by 24–72 hours, depending on the half-life of the opioid used by the mother and the potential for exposure to multiple substances. Inpatient monitoring is important to allow for potential symptoms to present and for the newborn to receive the appropriate treatment.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EA recommended observation period should be included in each hospitals’ written guidelines.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDocumentation of potential opioid exposure should be included in the medical record to provide medical necessity justification when the observation period exceeds the otherwise expected length of stay.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:39:20.570Z,updatedAt:2024-05-29T17:07:22.721Z,publishedAt:an,videoUrl:bs,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWDg9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--7c3586153660e3a7b31f717ea673d065d53e476e\u002FBP%2016_17_18_19.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:dC,title:Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-561. doi: 10.1542\u002Fpeds.2013-3524.,body:a},{id:bQ,title:Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540- 560. doi: 10.1542\u002Fpeds.2011-3212.,body:a},{id:296,title:Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid withdrawal in newborns. Cochrane Database of Systematic Reviews 2020, Issue 12. Art. No.: CD013217. DOI: 10.1002\u002F14651858.CD013217.pub2.,body:a},{id:297,title:Seligman NS, Salva N, Hayes EJ, Dysart KC, Pequignot EC, Baxter JK. Predicting length of treatment for neonatal abstinence syndrome in methadone-exposed neonates. Am J Obstet Gynecol. 2008;199(4):396.e1-7. doi: 10.1016\u002Fj.ajog.2008.06.088.,body:a}},{id:_,title:Consider parental rooming-in with the newborn when safety of mother and newborn can be ensured,description:a,position:_,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EParental rooming-in with a newborn should be considered when a plan can be implemented to ensure safe care of the mother and newborn. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ERooming in and\u002For parental presence at the newborn’s bedside supports dyad care and bonding, and can reduce pharmacotherapy use and length of stay.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EIf rooming in is being considered, it is important to establish a patient care plan that includes assessment of the patient for appropriateness to room in and nursing vigilance to prevent and monitor for potential adverse events due to rooming in.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIt is also important to ensure that staff approach mothers with opioid use disorder (OUD) in a respectful and non-judgmental manner to optimize use of non-pharmacologic methods for managing neonatal abstinence syndrome (NAS).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESafe sleep habits should be taught and reinforced by staff throughout the hospital stay to prepare for discharge. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:39:35.858Z,updatedAt:2020-09-03T21:15:58.046Z,publishedAt:o,videoUrl:bs,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWUE9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--a102928490c1c02b1c8a4dc8e4be015012f475cc\u002FBP%2016_17_18_19.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:bR,title:Macmillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Holmes AV. Association of rooming-in with outcomes for Neonatal Abstinence Syndrome. JAMA Pediatr. 2018;172(4):345. doi: 10.1001\u002Fjamapediatrics.2017.5195.,body:a},{id:bS,title:Howard MB, Schiff DM, Penwill N, et al. Impact of parental presence at infants bedside on Neonatal Abstinence Syndrome. Hosp Pediatr. 2017;7(2):63-69. doi: 10.1542\u002Fhpeds.2016-0147.,body:a},{id:bT,title:Holmes AV, Atwood EC, Whalen B, et al. Rooming-in to treat Neonatal Abstinence Syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137(6): e20152929. doi: 10.1542\u002Fpeds.2015-2929.,body:a},{id:239,title:Kandall SR, Gaines J, Habel L, et al. Relationship of maternal substance abuse to subsequent sudden infant death syndrome in offspring. J Pediatr. 1993;123(1):120-126. doi: 10.1016\u002Fs0022-3476(05)81554-9.,body:a}},{id:F,title:Prioritize measurement of functional impairment as a basis for initiation and escalation of pharmacologic treatment,description:a,position:F,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EInstead of basing pharmacologic initiation and escalation of treatment solely on a total Finnegan score, consider prioritizing measures of functional impairment. A functional impairment-based strategy for managing neonatal abstinence syndrome (NAS) should employ staff who have been trained in engaging mothers with opioid use disorder (OUD) and in using non-pharmacologic interventions for the newborn. The use of a functional impairment-based treatment strategy should be designed and tailored to a specific unit within the context of a formal quality improvement initiative so that safety may be routinely monitored and reviewed. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESubacute symptoms of NAS can continue for weeks or months. Prolonged inpatient management and pharmacotherapy may lead to adverse infant neurodevelopment and poor parental engagement. Focusing on a newborn’s functional impairments to guide pharmacotherapy may reduce length of stay and pharmacotherapy exposure. Studies of this method indicate no increase in readmission rates; however, there are no long-term studies to evaluate benefit versus harm of this method. While there is work being done on pharmacokinetic and pharmacodynamic modeling for common pharmacologic agents used to treat NAS, the practical utility of those methods is still insufficient for use in optimizing treatment decisions.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ECreate a unit protocol for nurse scoring of functional measures, conduct nursing and staff education prior to implementation, and educate health care providers regarding guidelines for use of pharmacotherapy. Monitor acceptability and feasibility of this protocol within the hospital as well as readmission rates for infants.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExamples of published methods emphasizing functional impairment are: \u003Cul\u003E\u003Cli\u003EFinnegan Symptom Prioritization focuses on certain function-based items in the Finnegan score. Most recent reports include poor feeding, poor sleep, and continuous crying as prioritized functional measures. Other components of the Finnegan score that are sometimes included are emesis, diarrhea, tachypnea, or fever. \u003C\u002Fli\u003E\u003Cli\u003E“Eat, Sleep, Console” prioritizes a newborn’s inability to take an age-appropriate volume of food, sleep more than one hour after feeding, or be consoled within ten minutes. Studies in recent years, including cluster-randomized controls, increasingly demonstrate the effectiveness of this method compared to the Finnegan NAS assessment.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003Cli\u003EFunctional-based assessment and management of newborns with NAS should be designed for the specific hospital. The formal “Eat, Sleep, Console” (ESC) approach was initially developed by Dr. Matthew Grossman at Yale New Haven Children’s Hospital. Similar quality improvement efforts are being successfully implemented at both academic centers and community hospitals as part of a non-pharmacologic approach. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThese are emerging (best) practices with encouraging short-term outcomes, and about which further study is needed to confirm long term outcomes.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EAlternative strategies employ the use of a modified Finnegan checklist with the mother scoring subjective functional items (e.g., quality of cry, stool consistency, tremulousness, etc.). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:40:01.820Z,updatedAt:2024-05-29T17:07:57.809Z,publishedAt:an,videoUrl:bs,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWUU9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--a1625a16dbc89ac4c7340d52d3482364162e37b8\u002FBP%2016_17_18_19.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe total Finnegan score describes NAS symptoms, but it does not reflect how NAS severity affects the infant’s ability to function. Several of the symptoms included in the Finnegan scoring system can be attributed to cluster feeding or other normal newborn behaviors. This symptom-based score may lead to unnecessary opioid treatment of infants without functional impairment. Studies show that opioid pharmacotherapy and length of stay decrease significantly with use of a function-based assessment compared to use of the total Finnegan score alone. Use of a function-based assessment can avoid initiation of opioid treatment, separation of the dyad, and a newborn’s transfer to the high-stimulation NICU environment. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:{id:cX,title:Eat Sleep Console as part of neoQIC,description:a,fileUrl:https:\u002F\u002Fwww.neoqicma.org\u002Feat-sleep-console},{id:189,title:Eat Sleep Console Pathway, Yale New Haven Children’s Hospital ,description:a,fileUrl:https:\u002F\u002Fapp.lucidchart.com\u002Fdocuments\u002Fembeddedchart\u002F32c26d63-9662-4597-9b24-dc5b5797f2af},references:{id:299,title:Young LW, Ounpraseuth ST, Merhar SL, et al. Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal. N Engl J Med. 2023 Jun 22;388(25):2326-2337. doi: 10.1056\u002FNEJMoa2214470. Epub 2023 Apr 30. PMID: 37125831.,body:a},{id:300,title:Tang F, Ng CM, Bada HS, Leggas M. Clinical pharmacology and dosing regimen optimization of neonatal opioid withdrawal syndrome treatments. Clin Transl Sci. 2021 Jul;14(4):1231-1249. doi: 10.1111\u002Fcts.12994. Epub 2021 May 1. PMID: 33650314; PMCID: PMC8301571.,body:a},{id:301,title:Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for Neonatal Abstinence Syndrome. J Perinatol. 2018;38(8):1114-1122. doi: 10.1038\u002Fs41372-018-0109-8.,body:a},{id:302,title:Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with Neonatal Abstinence Syndrome. Pediatrics. 2017;139(6): e20163360. doi: 10.1542\u002Fpeds.2016-3360.,body:a},{id:303,title:Grossman MR, Lipshaw MJ, Osborn RR, Berkwitt AK. A novel approach to assessing infants with neonatal abstinence syndrome. Hosp Pediatr. 2018;8(1):1-6. doi: 10.1542\u002Fhpeds.2017-0128.,body:a},{id:304,title:Holmes AV, Atwood EC, Whalen B, et al. Rooming-in to treat neonatal abstinence syndrome: improved family-centered care at lower cost. Pediatrics. 2016;137(6): e20152929. doi: 10.1542\u002Fpeds.2015-2929.,body:a},{id:305,title:Blount T, Painter A, Freeman E, et al. Reduction in length of stay and morphine use for NAS with the “eat, sleep, console” method. Hosp Pediatr. 2019;9(8):615-623. doi:,body:a}},{id:ag,title:If pharmacotherapy is indicated, consider a trial of morphine every 3 hours PRN as an initial strategy for the treatment of neonatal abstinence syndrome instead of scheduled dosing or more long-acting pharmacotherapy options,description:a,position:ag,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIf criteria for pharmacotherapy are met per a hospital-specific written guideline, morphine every3 hours as needed (PRN) may be trialed as an initial strategy for the treatment of neonatal abstinence syndrome (NAS) instead of scheduled dosing or more long-acting pharmacotherapy options.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESigns of NAS are not consistent throughout the day, nor is parental presence. Pharmacologic treatment may not be necessary every 3 hours. PRN dosing of morphine may minimize pharmacotherapy exposure and therefore side effects from scheduled morphine doses (e.g., respiratory depression, bradycardia, hypotension, urinary retention, decreased intestinal motility) or long-acting pharmacotherapy such as methadone.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIncorporate guidelines for initiation of PRN morphine for the treatment of NAS into the hospital’s guideline when a newborn meets criteria to initiate pharmacotherapy. Consider including guidelines to describe a threshold for escalating to scheduled q3 hour dosing and when to escalate the dose of scheduled morphine. Consider cardiorespiratory monitoring continuously or intermittently when the newborn is receiving morphine.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:40:17.096Z,updatedAt:2020-09-03T21:16:50.594Z,publishedAt:o,videoUrl:a$,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWUk9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--77660d53924bf396384eeedc0504c1f00febfb6c\u002FBP%2020_21_22_23_24.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla continues to care for Baby M with breastfeeding, holding skin-to-skin, and minimizing overstimulation. A nurse assesses Baby M and notes at 2 days old that he is unable to sleep for at least one hour after feeding and has continuous crying. The nurse confirms that both she and Kayla have had difficulty consoling Baby M and that at the time of the last assessment he was still crying after 10 minutes of attempts at consolation. He also has moderate tremors when disturbed, a hyperactive Moro reflex, and nasal stuffiness. The nurse assists Kayla with trying to optimize non-pharmacologic interventions, but Baby M continues to have poor sleep and persistent crying. Kayla and the medical team discuss the situation and, given their concern for functional impairment, Baby M is moved to an inpatient room where he is given one dose of PRN morphine by mouth and placed on a cardiorespiratory monitor. Medical staff have recently worked with hospital administrators to ensure newborns with NAS can be placed in private rooms to preserve the mother\u002Fbaby dyad. After Kayla is discharged, she can stay with him and continue to provide his care. \u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003ENon-pharmacologic measures continue to be optimized. After feeds, Baby M is occasionally irritable, but with swaddling and holding he soothes quickly. Once soothed, he sleeps until the next feeding. He requires one additional dose of PRN morphine the following day for poor feeding and inconsolability, after which his symptoms do not recur. He completes a period of monitoring without medication for a day and a half, with Kayla providing all of his care. Baby M is discharged home to Kayla with close follow-up from the outpatient pediatrician. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:dD,title:Zimmermann-Baer U, Notzli U, Rentsch K, Bucher HU. Finnegan neonatal abstinence scoring system: normal values for first 3 days and weeks 5-6 in non-addicted infants. Addiction. 2010;105(3):524-528.,body:a},{id:dE,title:bU,body:a},{id:243,title:Blount T, Painter A, Freeman E, et al. Reduction in length of stay and morphine use for NAS with the “Eat, Sleep, Console” method. Hosp Pediatr. 2019;9(8):615-623.,body:a},{id:256,title:Achilles J, Castaneda-Lovato J. A quality improvement initiative to improve the care of infants born exposed to opioids by implementing the eat, sleep, console assessment tool. Hosp Pediatr. 2019;9(8):624-631.,body:a}},{id:$,title:Consider methadone as first-line pharmacotherapy for the treatment of neonatal abstinence syndrome following evaluation of its benefits\u002Frisks,description:a,position:$,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMethadone may be considered as first-line pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS) following evaluation of its benefits\u002Frisks.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EMultiple studies have shown decreased length of treatment with methadone compared to morphine for the treatment of NAS. The decreased length of treatment varies from 2–7 days. One single site randomized controlled trial (RCT) reported a shorter length of treatment on methadone versus morphine with a median of 14 vs. 21 days. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMultiple studies have also shown decreased length of stay with methadone compared to morphine treatment. The decreased length of stay varies from 2–5 days.\u003Cul\u003E\u003Cli\u003EOne multi-site RCT reported decreased mean length of stay by 2.7 days and decreased mean length of treatment by 2.3 days in NAS infants treated with methadone compared to morphine. \u003C\u002Fli\u003E\u003Cli\u003EA multicenter, non-randomized, retrospective study (Pediatrix dataset) showed a decreased median length of stay of 18 days with methadone vs. 23 days with morphine.\u003C\u002Fli\u003E\u003Cli\u003EAn analysis of 14 children’s hospitals showed NAS infants treated with methadone had shorter mean length of treatment (17.4 days with methadone vs. 22.2 days with morphine) and mean length of stay (21 days for methadone vs. 25 days for morphine) compared to those treated with morphine. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMethadone’s longer half-life allows for fewer swings in NAS symptoms and fewer drug administrations per day. The longer half-life, however, also makes it more complicated to titrate. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMethadone is associated with prolonged QTc in adults and in newborns exposed to maternal methadone in the first two days of life, but it is unclear if this is clinically significant or an issue with doses used to treat newborns. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInfants treated with morphine or methadone have similar short and long-term neurobehavioral outcomes.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThere are no studies to date comparing scheduled methadone to PRN morphine treatment strategies.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDevelop a unit-specific guideline for initiation, escalation, and weaning of methadone to promote consistency and safety of practice.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EBuprenorphine pharmacologic treatment in newborns is not yet recommended until additional studies regarding safety and efficacy are available. A small phase one clinical trial in newborns has been conducted. There is currently minimal safety data on use in newborns and the phase one trial formulation contained 30% ethanol. However, breastfeeding for mothers on buprenorphine is recommended (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F30\\u003E\u003Cstrong\u003EBest Practice #30\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003Cbr\u003E\u003Cem\u003E\u003Cbr\u003EReferences\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003Col\u003E\u003Cli\u003EGrim K, Harrison TE, Wilder RT. Management of neonatal abstinence syndrome from opioids. \u003Cem\u003EClin Perinatol\u003C\u002Fem\u003E. 2013 Sep;40(3):509-24.\u003C\u002Fli\u003E\u003Cli\u003EKraft et al. Buprenorphine for the treatment of neonatal abstinence syndrome. \u003Cem\u003EN Engl J Med\u003C\u002Fem\u003E. 2017 June 15; 376(24): 2341–2348.\u003C\u002Fli\u003E\u003C\u002Fol\u003E\u003C\u002Fdiv\u003E,createdAt:2020-02-14T20:40:37.653Z,updatedAt:2020-10-07T14:24:45.881Z,publishedAt:ac,videoUrl:a$,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWU09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--bf28db7a9d4a17e95b41c3f479ebd6e396fdb0f6\u002FBP%2020_21_22_23_24.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESome centers have studied and adopted a practice of using methadone as first-line pharmacotherapy for the treatment of NAS. Methadone has a longer half-life and provides a steadier exposure. However, the longer half-life may also make dose adjustment more complicated. Hospitals should develop a protocol that addresses all available options for pharmacotherapy for NAS within that institution, including information on initiation, monitoring with PRN dosing, when to escalate to scheduled dosing and strategies for using methadone. Developing such a protocol is likely to facilitate standardization of practice and reduce cumulative pharmacotherapy received.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EWhile most newborns that require pharmacotherapy for NAS will need only one medication, some newborns with NAS whose symptoms are not controlled with first-line agents such as morphine and methadone may benefit from a second-line medication\u002Fadjunctive therapy. While phenobarbital has been a traditional second-line treatment, it is not an ideal therapy for opioid withdrawal. Therefore, clonidine is recommended as the second-line treatment of choice. Because of the theoretical risk of an effect on autonomic function, newborns receiving clonidine should have their heart rate and blood pressure closely monitored during the first two days of administration and also for 48 hours after discontinuation. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ERegardless of which medication(s) are used, a pharmacotherapy weaning protocol should be established to guide practice. During the weaning process and for several days after completing pharmacotherapy, newborns should be monitored as an inpatient and assessed for rebound symptoms. Newborns that receive morphine or clonidine for NAS should receive inpatient monitoring for at least 48 hours and those receiving methadone for at least 72 hours after receiving the last dose of medication. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:dF,title:Brown MS, Hayes MJ, Thornton LM. Methadone versus morphine for treatment of neonatal abstinence syndrome: a prospective randomized clinical trial. J Perinatol. 2015;35:278-83.,body:a},{id:dG,title:dH,body:a},{id:dI,title:Tolia VN, Murthy K, Bennett MM, et al. Morphine vs methadone treatment for infants with neonatal abstinence syndrome. J Pediatr. 2018;203:185-189.,body:a},{id:73,title:Patrick SW, Kaplan HC, Passarella M, Davis MM, Lorch SA. Variation in treatment of neonatal abstinence syndrome in US Children’s Hospitals, 2004-2011. J Perinatol. 2014;34:867-872.,body:a},{id:dJ,title:Parikh R, Hussain T, Holder G, Bhoyar A, Ewer AK. Maternal methadone therapy increases QTc interval in newborn infants. Arch Dis Child Fetal Neonatal Ed. 2011;96(2):F141-F143.,body:a},{id:dK,title:Peltz G, Anand KJ. Long-Acting Opioids for Treating Neonatal Abstinence Syndrome: A High Price for a Short Stay? JAMA. 2015;314(19):2023-2024.,body:a},{id:dL,title:Burke S, Beckwith AM. Morphine versus methadone treatment for neonatal withdrawal and impact on early infant development. Glob Pediatr Health. 2017;4:2333794x17721128.,body:a},{id:dM,title:Kraft et al. Buprenorphine for the treatment of neonatal abstinence syndrome. N Engl J Med. 2017 June 15; 376(24): 2341–2348.,body:a},{id:dN,title:Grim K, Harrison TE, Wilder RT. Management of neonatal abstinence syndrome from opioids. Clin Perinatol. 2013 Sep;40(3):509-24.,body:a},{id:244,title:Czynski AJ, Davis JM, Dansereau LM et al. Neurodevelopmental outcomes of neonates randomized to morphine or methadone for treatment of neonatal abstinence syndrome. J Peds. 2020;19:31651-8.,body:a}},{id:Z,title:Consider clonidine instead of phenobarbital as a potential second line\u002Fadjunctive therapy for neonatal abstinence syndrome,description:a,position:Z,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EClonidine may be considered as a second\u003Csup\u003E \u003C\u002Fsup\u003Eline\u002Fadjunctive therapy for neonatal abstinence syndrome (NAS). Studies are ongoing on the use of clonidine as a first-line agent. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPhenobarbital is a nonselective central nervous system depressant that is sometimes used in combination therapy for NAS. It has been recommended mainly for non-opioid withdrawal in polysubstance exposure as an adjunct therapy. Its role is limited in opioid withdrawal given several disadvantages, such as lack of relief of gastrointestinal symptoms, impaired bonding and feeding in infants due to central nervous system depression, and potentially more long-term neurodevelopmental effects. Clonidine is an alpha-2 adrenergic receptor agonist that inhibits central nervous system sympathetic outflow and reduces norepinephrine levels. It reduces the autonomic symptoms (mediated in the locus coeruleus) of NAS. Clonidine has at least one high quality RCT supporting its use as an adjunctive agent to reduce length of pharmacotherapy treatment for NAS.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EDevelop unit-specific guidelines for initiation of clonidine as adjunct therapy if NAS is not adequately controlled with first-line therapy alone.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEstablish guidelines for escalation of clonidine.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EWhen weaning clonidine, consider a two-step reduction of the clonidine dose over 48 hours or weaning of opioids before stopping clonidine. This may reduce rebound NAS withdrawal symptoms.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EClonidine has the potential to cause heart rate or blood pressure changes and monitoring is recommended. Monitor heart rate and blood pressure more closely during the first two days of clonidine therapy and for 48 hours after discontinuation.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:41:10.491Z,updatedAt:2020-09-03T21:17:29.964Z,publishedAt:o,videoUrl:a$,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWVE9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--4550243de45c839ea01d1aee6689b6910b4a6060\u002FBP%2020_21_22_23_24.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:dO,title:Chen J, Cai F, Cao J, Zhang X, Li S. Long-term antiepileptic drug administration during early life inhibits hippocampal neurogenesis in the developing brain. J Neurosci Res. 2009;87:2898-2907.,body:a},{id:dP,title:Stefovska V, Uckermann O, Czuczwar M, Smitka M, Czuczwar P, Kis J et al. Sedative and anticonvulsant drugs suppress postnatal neurogenesis. Ann Neurol. 2008;64:434–445.,body:a},{id:dQ,title:Reinisch J, Sanders S, Mortensen E, Rubin D. In utero exposure to phenobarbital and intelligence deficits in adult men. JAMA. 1995;274:1518– 1525.,body:a},{id:dR,title:Bhardwaj S, Forcelli P, Palchik G, Gale K, Srivastava L, Kondratyev A. Neonatal exposure to phenobarbital potentiates schizophrenia-like behavioral outcomes in the rat. Neuropharmacology. 2012; 62(7):2337-45.,body:a},{id:dS,title:Hoder EL, Leckman JF, Poulsen J, Caruso KA, Ehrenkranz RA, Kleber HD, Cohen DJ. Clonidine treatment of neonatal narcotic abstinence syndrome. Psychiatry Res. 1984 Nov;13(3):243-51.,body:a},{id:dT,title:Agthe AG, Kim GR, Mathias KB, et al. Clonidine as an adjunct therapy to opioids for neonatal abstinence syndrome: a randomized, controlled trial. Pediatrics. 2009;123: e849-e856.,body:a},{id:dU,title:Bada HS, Sithisarn T, Gibson J, et al. Morphine versus clonidine for neonatal abstinence syndrome. Pediatrics. 2015;135(2):e383-391.,body:a},{id:dV,title:bt,body:a},{id:dW,title:Siu A, Robinson CA. Neonatal abstinence syndrome: essentials for the practitioner. JPPT. 2014;19(3):147-155.,body:a}},{id:ad,title:Develop guidelines for inpatient monitoring of newborns receiving morphine, clonidine, or methadone pharmacotherapy prior to discharge,description:a,position:ad,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhen morphine and\u002For clonidine are used for pharmacologic treatment in a newborn with neonatal abstinence syndrome (NAS), our consensus-based recommendation is that the newborn be monitored as an inpatient for a minimum of 48 hours after the last dose. A newborn treated with methadone, given the longer half-life, should be monitored as an inpatient for a minimum of 48–72 hours after the last dose of methadone is administered. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMedication clearance in newborns is variable. There are no well-established, evidence-based guidelines for duration of monitoring after pharmacotherapy cessation for NAS. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA recommended observation period after discontinuation of medication should be included in a hospital’s written guidelines. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:41:27.600Z,updatedAt:2020-09-03T21:17:54.363Z,publishedAt:o,videoUrl:a$,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWVU9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--350e71f994b8d025f3eaba540657b6319f327112\u002FBP%2020_21_22_23_24.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:cH,title:Pacifici GM. Metabolism and pharmacokinetics of morphine in neonates: a review. Clinics. 2016;71(8):474-480.,body:a},{id:108,title:Saarenmaa E, Neuvonen PJ, Rosenberg P, Fellman V. Morphine clearance and effects in newborn infants in relation to gestational age. Clin Pharmacol Ther. 2000;68(2):160-166.,body:a},{id:da,title:Lynn AM, Slattery JT. Morphine pharmacokinetics in early infancy. Anesthesiology. 1987;66(2):136-139.,body:a},{id:245,title:Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatol. 2018;38(8):1114-1122.,body:a},{id:246,title:dH,body:a}},{id:at,title:Establish a pharmacotherapy weaning protocol,description:a,position:at,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EHospitals should establish a clear weaning protocol for all potential pharmacotherapy treatments of neonatal abstinence syndrome (NAS) rather than relying on individual approaches that are likely to yield patient outcomes and experiences that are highly variable. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ERegardless of the treatment opioid chosen, newborns receiving protocol-based weans experience a significantly shorter duration of opioid treatment (17.7 vs. 32.1 days, \u003Cem\u003EP\u003C\u002Fem\u003E < .0001) and shorter hospital stay (22.7 vs. 32.1 days, \u003Cem\u003EP\u003C\u002Fem\u003E .004).\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ECollaborate with members of the care team to establish an acceptable weaning protocol for all pharmacologic therapies for NAS. Some hospitals may consider weaning opioid doses q24-48 hours if meeting criteria; others may wean as rapidly as 10% up to three times a day. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWe do not recommend routine discharge of newborns while still weaning pharmacotherapy due to the evidence for longer length of pharmacotherapy exposure associated with this practice. However, we recognize that this strategy may be utilized in specific situations in which a well-established structure between the discharging hospital and the community PCP exists for close monitoring, strict follow-up criteria and prescription tracking are used, and the family is deemed reliable to follow-up.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EWhile discharging home on outpatient pharmacotherapy decreases the initial hospital length of stay, outpatient NAS pharmacotherapy has been associated with longer length of treatment (60 vs. 19 days) and higher rates of emergency department utilization within 6 months of discharge compared to infants treated exclusively as inpatients.\u003Cbr\u003E\u003Cem\u003E\u003Cbr\u003EReferences\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003Col\u003E\u003Cli\u003E\u003Cem\u003EMaalouf FI, Cooper WO, Slaughter JC, Dudley J, Patrick SW. Outpatient pharmacotherapy for neonatal abstinence syndrome. J Pediatr 2018;199:151-157. https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F29754866.\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003Cli\u003E\u003Cem\u003ELai A, Philpot P, Boucher J, Meyer A. An outpatient methadone weaning program by a neonatal intensive care unit for neonatal abstinence syndrome. Popul Health Manag 2017 Oct;20(5):397-401. \u003C\u002Fem\u003E\u003Ca href\https:\u002F\u002Fwww-ncbi-nlm-nih-gov.laneproxy.stanford.edu\u002Fpubmed\u002F28430046\\u003E\u003Cem\u003Ehttps:\u002F\u002Fwww-ncbi-nlm-nih-gov.laneproxy.stanford.edu\u002Fpubmed\u002F28430046#\u003C\u002Fem\u003E\u003C\u002Fa\u003E\u003Cem\u003E.\u003C\u002Fem\u003E\u003C\u002Fli\u003E\u003C\u002Fol\u003E\u003C\u002Fdiv\u003E,createdAt:2020-02-14T20:42:06.490Z,updatedAt:2020-09-03T21:18:12.327Z,publishedAt:o,videoUrl:a$,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWVk9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--87d95251312876f6d739d8788ccaa3319836225b\u002FBP%2020_21_22_23_24.pptx,deepDive:b,archetypes:,audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:p,name:q,description:r},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:127,title:Hall ES, Wexelblatt SL, Crowley M, et al. A multicenter cohort study of treatments and hospital outcomes in neonatal abstinence syndrome. Pediatrics. 2014;134(2):e527-534.,body:a},{id:128,title:Hall ES, Wexelblatt SL, Crowley M, et al. Implementation of a neonatal abstinence syndrome weaning protocol: a multicenter cohort Study. Pediatrics. 2015;136(4):e803-810.,body:a},{id:129,title:bU,body:a},{id:cw,title:Maalouf FI, Cooper WO, Slaughter JC, Dudley J, Patrick SW. Outpatient pharmacotherapy for neonatal abstinence syndrome. J Pediatr 2018;199:151-157. https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F29754866.,body:a},{id:cy,title:Lai A, Philpot P, Boucher J, Meyer A. An outpatient methadone weaning program by a neonatal intensive care unit for neonatal abstinence syndrome. Popul Health Manag. 2017 Oct;20(5):397-401. https:\u002F\u002Fwww-ncbi- nlm-nih gov.laneproxy.stanford.edu\u002Fpubmed\u002F28430046#.,body:a}},{id:ah,title:Identify community care resources for the mother and newborn,description:a,position:ah,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIdentify community care resources for the mother and newborn and appropriate partner agencies and services in the community. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EProviding adequate transitions of care pre- and postnatally that include outpatient support structures with expertise in addressing the needs of both mothers with opioid use disorder (OUD) or substance use disorder (SUD) and their exposed newborns can improve outcomes and support the development of protective factors that reduce or mitigate the effects of adverse life experiences for children and their families. Early interventions like home visits are a prime example of this.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EInvolve the mother and newborn in outpatient support programs as early as possible, ideally prenatally for the mother. Descriptions of evidence-based programs can be found below. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEach unit should maintain an updated list of outpatient resources (federal, state, and local) that families can access. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EArrange a system to refer the mother and newborn to outpatient OUD\u002FSUD treatment and recovery programs. The system should clarify who refers (physician, social worker, etc.) and when to refer (upon admission or discharge). Consider a default referral on admit orders.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInform and educate mothers on these referrals and highlight the benefits of these programs.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPotential short-term and long-term neurodevelopmental delays exist for these infants. Early intervention programs, child protective services, and\u002For health care services are recommended to cover neurodevelopmental, psycho-behavioral, growth and nutrition, ophthalmologic, and family support assessments. Refer to \u003Cstrong\u003EBest Practices \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F31\\u003E\u003Cstrong\u003E#31 \u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003Cstrong\u003Eand \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F32\\u003E\u003Cstrong\u003E#32\u003C\u002Fstrong\u003E\u003Cstrong\u003E\u003Cem\u003E \u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003C\u002Fa\u003Efor additional information on these topics.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe identification of key community care resources and supports for mom and baby should be incorporated into the Plan of Safe Care as described in \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F29\\u003E\u003Cstrong\u003EBest Practice #29\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003Cstrong\u003E.\u003C\u002Fstrong\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EPre-, Peri-, and Postnatal Programs\u003C\u002Fstrong\u003E: The programs described below begin services during pregnancy and cover the mother\u002Fbaby dyad. Most pre-, peri-, and postnatal programs are federally funded. In California, many of these programs are also funded by local First 5 Commissions, which use money from a state excise tax on cigarettes and other tobacco products to fund programs from birth (i.e., during pregnancy) to five years of age. In addition to the ones listed in this toolkit, other evidence-based pre-, peri-, and postnatal programs can be found in the Resources section of this Best Practice. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Ca href\https:\u002F\u002Fwww.cdph.ca.gov\u002FPrograms\u002FCFH\u002FDMCAH\u002FCHVP\u002FPages\u002Fdefault.aspx\\u003ECalifornia Home Visiting Program (CHVP):\u003C\u002Fa\u003E CHVP oversees implementation of various evidence-based home visiting programs throughout California, including the Nurse-Family Partnership (NFP) and Healthy Families America (HFA), and currently 23 California counties have these evidence-based programs. State-level agency workgroups conduct needs assessments to determine the greatest need for and potential impact from these programs based on factors such as poverty rates, rates of child abuse and neglect, and the ability to find and enroll at-risk parents in particular areas.\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003ENFP:\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E Geared towards low income, first-time pregnant women. Care starts in pregnancy and follows the dyad until the child reaches two years of age. The mother must be referred before 28 weeks of pregnancy.\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EHFA\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cstrong\u003E:\u003C\u002Fstrong\u003E Geared towards low-income, at-risk families from birth to a minimum of three years.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Ca href\https:\u002F\u002Feclkc.ohs.acf.hhs.gov\u002Fprograms\u002Farticle\u002Fearly-head-start-programs\\u003EEarly Head Start\u003C\u002Fa\u003E\u003Cem\u003E:\u003C\u002Fem\u003E Early Head Start provides preschool and home visiting services geared towards low-income, at risk families. This is one of the few programs that can be started either during pregnancy or after delivery and follows the dyad until the child reaches three years of age. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Ca href\http:\u002F\u002Fwww.cdss.ca.gov\u002Finforesources\u002FCalWORKsHomeVisitingInitiative\\u003ECalWORKS:\u003C\u002Fa\u003E CalWORKS offers a new three-year home visiting pilot initiative that began in January 2019. It is supported by both state General Fund and federal Temporary Assistance for Needy Families dollars. The program provides up to 24 months of home visiting for pregnant and parenting people, families, and infants born into poverty. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Ca href\https:\u002F\u002Fmchb.hrsa.gov\u002Fmaternal-child-health-initiatives\u002Fhealthy-start\\u003EHealthy Start\u003C\u002Fa\u003E\u003Cem\u003E: \u003C\u002Fem\u003EHealthy start targets communities with infant mortality rates that are at least one and a half times the U.S. national average. Women and their families can be enrolled into Healthy Start at various stages of pregnancy, including pre- inter-, and post-conception. Each family that enrolls receives a standardized, comprehensive assessment. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EPostnatal Programs\u003C\u002Fstrong\u003E: These programs are primarily geared towards infants and can be implemented in the postnatal period.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Ca href\https:\u002F\u002Fwww.dds.ca.gov\u002Fservices\u002Fearly-start\u002F\\u003EEarly Start\u003C\u002Fa\u003E: Early Start is California’s early intervention program (i.e., Part C of the Individuals with Disability Education Act), providing early intervention services to at-risk infants and children less than three years of age who meet eligibility criteria based on the presence or risk of developmental disability. Services include infant education, occupational therapy, physical therapy, and speech therapy. Referrals can be made from the NICU or newborn nursery and are often coordinated by a social worker, although anyone can make a referral, including parents, medical providers, neighbors, family members, foster parents, and day care providers.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EHome Health Visits: A number of public and commercial insurance companies offer home health visits, usually in response to a medical need. If the patient does not have insurance, or if the patient’s insurance declines to cover the home health visit, the county often will provide a public health nurse. Some counties or local areas have established their own system (e.g,. \u003Ca href\https:\u002F\u002Fwww.palomarhealth.org\u002Fabout-us\u002Fpalomar-home-health-services\\u003EPalomar Home Health Services\u003C\u002Fa\u003E).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:42:21.423Z,updatedAt:2020-10-07T14:25:45.063Z,publishedAt:ac,videoUrl:bu,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWWM9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--4231ccb9658c9534b65bd2ff72d4b0d1c98f4b7f\u002FBP%2025_27_29_32.pptx,deepDive:b,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:Y,fullName:aN,professionalDesignation:c,biography:aO,disclosure:b},{id:ai,fullName:bV,professionalDesignation:c,biography:bW,disclosure:b},resources:{id:dX,title:dY,description:a,fileUrl: https:\u002F\u002Fcalbudgetcenter.org\u002Fresources\u002Fhome-visiting-is-a-valuable-investment-in-californias-families\u002F},{id:dZ,title:d_,description:a,fileUrl:d$},{id:dO,title:ea,description:a,fileUrl:eb},{id:dP,title:ec,description:a,fileUrl: https:\u002F\u002Fwww.healthyfamiliesamerica.org\u002Four-approach\u002F},{id:dQ,title:Local First 5 Commission websites and their local programs.,description:a,fileUrl:ed},{id:dR,title:ee,description:a,fileUrl:ef},{id:dS,title:eg,description:a,fileUrl:eh},{id:dT,title:ei,description:a,fileUrl:ej},{id:dU,title:ek,description:a,fileUrl:el},{id:dV,title:em,description:a,fileUrl:en},{id:dW,title:eo,description:a,fileUrl:ep},{id:eq,title:er,description:a,fileUrl:https:\u002F\u002Fwww3.dds.ca.gov\u002FEarlyStart\u002F},{id:es,title:et,description:a,fileUrl:eu},references:{id:138,title:bt,body:a},{id:139,title:McQueen K, Murphy-Oikonen J. Neonatal abstinence syndrome. N Eng J Med. 2016;375(25):2468-2479.,body:a}},{id:a_,title:Codevelop a multidisciplinary peripartum plan of care for pregnant women on medication assisted treatment and ensure a warm handoff to the hospital,description:a,position:aZ,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDevelop a patient-centered approach to developing a peripartum plan of care for pregnant patients with opioid use disorder (OUD) to facilitate continuation of appropriate medication assisted treatment (MAT) dosing, pain management and related needs.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA clear, informed plan developed with patients and relevant providers for the management of OUD in the peripartum period will avoid physiologic instability, facilitate patient buy-in, and optimize transitions of care. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EDevelop a peripartum checklist for patients with OUD, ideally with multidisciplinary input, highlighting key patient health information, current MAT therapeutic regimen, contact information for providers, and recommended activities to prepare patients for the peripartum period in the hospital (please see the Resources section of this Best Practice: Sample Peripartum Checklist for Patients with OUD).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDevelop a protocol to utilize the peripartum checklist. Plan strategically for how to incorporate the designed checklist into prenatal care (ideally at the beginning of the third trimester, or at any time for late entrants into prenatal care) and how to share the checklist with the hospital at which a patient intends to deliver (e.g., faxing when checklist is completed, and\u002For at 36 weeks).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EImplement peripartum checklist. Ideally patients and providers would have updated copies of the checklist and it could be customized (e.g., more elaborated paper checklist for patients, abbreviated electronic text checklist for providers). Consider incorporating it into the electronic medical record.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-27T07:06:09.742Z,updatedAt:2020-09-03T21:20:15.276Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386641,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWWc9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--f674913d3dc676f75d7be4248580036bfdf729b2\u002FBP_26.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla is now 38 weeks pregnant and doing well on buprenorphine. She calls your office complaining of leaking fluid. You advise her to go to obstetrical triage for evaluation. She is found to have ruptured membranes and is admitted by the laborist for induction. Kayla is quite uncomfortable and neglects to inform her care team that she is on buprenorphine. The staff is unable to retrieve her prenatal records. Twelve hours into her stay, she begins having significant pain, sweats, nausea, and chills. The nurse also notes some irregularities and changes in the fetal heart rate. Kayla finally states she is experiencing opiate withdrawal and requests buprenorphine. Unfortunately, the hospital does not have buprenorphine immediately available in the medication dispensing machine. Two extremely uncomfortable hours later, Kayla receives her buprenorphine and is finally comfortable again. By this point her records, including the consultation with the anesthesiologist, have been retrieved and her pain is managed with an epidural. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EFailed communication to inpatient providers leads to fragmented care once the patient is admitted for labor. There are various ways that a warm handoff can be undertaken at the time of labor to ensure that patient care is not compromised. These include, but are not limited to, a third trimester patient review with the hospital team and\u002For a pre-registration exchange of critical information (including buprenorphine duration and dosage) that allows confidential information sharing with the medical staff, a prenatal care summary or card \u003Cstrong\u003Especific to MAT\u003C\u002Fstrong\u003E that allows the patient to confidentially inform hospital staff of her medication and dosage upon admission, and having the prenatal care provider discuss with the patient the importance of disclosing her MAT needs with hospital staff at the time of admission. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},category:{friendlyId:aa,name:aj,description:ak},authors:{id:_,fullName:bi,professionalDesignation:c,biography:bj,disclosure:b},{id:F,fullName:aA,professionalDesignation:aB,biography:aC,disclosure:b},resources:{id:ev,title:Sample Peripartum Checklist for Patients with SUD.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBNUT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--5650fb2dbb98171bdde929a211d170be64de6f74\u002FSample%20Peripartum%20Checklist%20for%20Patients%20with%20SUD.pdf},references:},{id:aH,title:Implement opioid use disorder discharge checklists for all hospital-based points of entry,description:a,position:aH,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EAll collaborators for the Plan of Safe Care (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F29\\u003E\u003Cstrong\u003EBest Practice # 29\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E) should focus on interventions that take into consideration the safety and needs of both mother and newborn. While there has been extensive attention to a Plan of Safe Care for the newborn, a plan for the mother is equally important. The Plan of Safe Care should instill confidence in the mother in her ability to care for herself and her newborn; build trust and relationships with providers and other health and wellness partners; facilitate connections to resources; and ensure access to care that is inclusive of the mental, emotional, and physical aspects of opioid use disorder (OUD) postpartum and newborn health, and motherhood. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EThe following Plan of Safe Care discharge recommendations are best practice guidelines known to support the safety, recovery, and wellness of the mother\u002Fbaby dyad, yet they should not limit the provision of resources, support, and\u002For interventions that may be necessary to overcome unique situations and challenges of individual mothers and newborns. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EEvery episode of care is an important opportunity to implement a Plan of Safe Care regardless of the point of entry or disposition (e.g., delivered or undelivered). Some patients have not received prenatal care, been referred to and\u002For participated in available support services, and may initially present to an emergency department or an alternate point of entry for care. Pregnant women presenting to the emergency department prior to 20 weeks gestation are traditionally declined by L&D units for interdepartmental transfer and, therefore, only receive care in the emergency department. Finally, not all pregnant women who present to labor and delivery (L&D) units will progress to delivery. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EFor some pregnant women, L&D units and emergency departments are the first providers of pregnancy-related care; in fact, these environments may be their only source of care during pregnancy. Providers should understand that:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ERecognition and identification of mothers with OUD at the earliest point of care will support efforts to protect the fetus from continued opioid exposure and sequela and will support maternal recovery and wellness. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReinforcement and assessment of the Plan of Safe Care during each episode of care is an opportunity to prevent program fallouts through reinforcement of positive behaviors through praise and recognition of successes and the identification of challenges and barriers to participation, gaps of service\u002Fsupport, and new service\u002Fsupport needs. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ETransitions of care (e.g., hospital discharges) place the OUD screen positive mother\u002Fbaby dyad at risk due to potential gaps in service, communication, and understanding of the Plan of Safe Care. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EImplementation of a discharge checklist supports the team and individuals responsible for this complex discharge by aiding memory, team communication, and consistency of practice. All elements of the discharge checklist should be evidence-based, taking into consideration the unique characteristics of the mother\u002Fbaby dyad and the community into which they are being discharged. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPostpartum women with OUD are at very high risk for perinatal mood and anxiety disorders and should be screened using the Edinburgh Postnatal Depression Scale or the PHQ-9 plus GAD-7 prior to discharge.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EThe Discharge Checklist (please see example in the Resources section of this Best Practice):\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProvides an opportunity to identify and implement opportunities for reinforcement of the OUD plan of care. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsures consistency of best practices and equity of the services, referrals, and resources required to achieve and sustain recovery and wellness. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EShould support\u002Fencourage breastfeeding if not contraindicated.\u003Cul\u003E\u003Cli\u003EWomen should feel empowered to make an informed decision about infant feeding.\u003C\u002Fli\u003E\u003Cli\u003EWomen should be given complete information on the benefits of breastfeeding and the recommendations surrounding OUD and breastfeeding. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThis is a critical portion of the toolkit and we have therefore provided especially detailed implementation steps.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIdentify and assess all hospital-based points of entry (inpatient\u002Foutpatient) used by the pregnant OUD patient (e.g., L&D, antepartum, emergency department). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEngage hospital leadership and partner with department leaders to recruit at least one provider and staff champion from each identified point of entry for support and implementation of the standardized maternal OUD screen positive discharge checklist.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExplain the importance of a discharge checklist with identified care providers and teams. Get their buy-in. \u003Cul\u003E\u003Cli\u003EWhat is the goal? \u003C\u002Fli\u003E\u003Cli\u003EWhat is the benefit of implementation for the patient, provider, and community?\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EAssess culture and staff readiness for implementation of a checklist.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUnderstand the roles and responsibilities for the discharge planning project.\u003Cul\u003E\u003Cli\u003EWho comprises the care teams? \u003C\u002Fli\u003E\u003Cli\u003EWhere is discharge occurring? \u003C\u002Fli\u003E\u003Cli\u003EWho is creating the discharge plan?\u003C\u002Fli\u003E\u003Cli\u003EWho is facilitating the discharge?\u003C\u002Fli\u003E\u003Cli\u003EWho is providing\u002Fmanaging care for pregnant and\u002For delivered mothers in the inpatient and outpatient settings?\u003C\u002Fli\u003E\u003Cli\u003EWhere is the discharge occurring (e.g., L&D, postpartum, antepartum, emergency department, medical\u002Fsurgical unit)?\u003C\u002Fli\u003E\u003Cli\u003EWho are the receiving teams for discharge (e.g., community, provider resource, service representatives)? \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EAs a team, create and\u002For adopt an evidence-based OUD discharge checklist (please see the Resources section of this Best Practice for an example)\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ECirculate the OUD discharge checklist and provide education for all care providers responsible for discharge of the OUD mother and newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUse the teach-back method to ensure all staff understand:\u003Cul\u003E\u003Cli\u003ETool use\u003C\u002Fli\u003E\u003Cli\u003EGoals of a successful maternal OUD discharge \u003C\u002Fli\u003E\u003Cli\u003EShared accountability of the tool and use of standard work \u003C\u002Fli\u003E\u003Cli\u003EResources available for support\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMonitor use of the OUD discharge checklist:\u003Cul\u003E\u003Cli\u003ERegularly observe the process \u003C\u002Fli\u003E\u003Cli\u003EAudit patient charts for standard work compliance and completion\u002Fsupport of the elements of the Plan of Safe Care.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEncourage and sustain use of the OUD discharge checklist by providing feedback to staff about: \u003Cul\u003E\u003Cli\u003ESuccesses and opportunities of tool use\u003C\u002Fli\u003E\u003Cli\u003ECase outcomes\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMonitor outcomes:\u003Cul\u003E\u003Cli\u003EAssess the discharge checklist and process early and often after implementation.\u003C\u002Fli\u003E\u003Cli\u003EAsk for feedback related to successes, challenges, and barriers. Be open to feedback. \u003C\u002Fli\u003E\u003Cli\u003EUse feedback and outcomes data to guide quick tests of change that support quality improvement.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:42:54.358Z,updatedAt:2020-10-07T14:26:30.877Z,publishedAt:ac,videoUrl:bu,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWWs9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--877f7e288ffee29414c3b5554d66b9515dd94860\u002FBP%2025_27_29_32.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe checklist has quickly become the gold standard for high reliability health care organizations that want to provide exceptional, team-based care. For example, the Safe Surgery Checklist was adapted for use in U.S. hospitals in 2009 and quickly became the benchmark for improving quality and safety in the surgical suite. But are checklists enough to save lives? \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EIn 2017, the \u003Cem\u003ENew England Journal of Medicine\u003C\u002Fem\u003E published a report\u003Csup\u003E1 \u003C\u002Fsup\u003Eon the BetterBirth Study, one of the largest maternal-newborn studies with over 300,000 women and their babies, that looked at maternal and newborn outcomes after implementation of the WHO Safe Childbirth Checklist. The checklist improved adherence to best practices that are associated with better outcomes; but in this large-scale study in India, there was no difference in perinatal mortality, maternal mortality, or maternal morbidity between the control and intervention groups, even though the intervention groups showed high adherence to the checklist protocols. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EChecklists in and of themselves are not enough. A discharge checklist cannot simply be about “checking the box.” The postpartum period is the most complex for mother and newborn, with multiple opportunities for relapse and the resulting sequelae. Therefore, the discharge checklist must be about providing better communication between all care providers; inpatient providers must better engage with their outpatient counterparts and community-based organizations who will be responsible for helping the patient navigate a complex pathway to recovery. \u003Cstrong\u003E\u003Cem\u003EIt’s about changing the system, not just checking a box. \u003Cbr\u003E\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cem\u003EReference\u003C\u002Fem\u003E\u003Cstrong\u003E\u003Cem\u003E: \u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cem\u003ESemrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. The New England journal of medicine. 2017;377(24):2313-2324.\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:X,fullName:ba,professionalDesignation:aL,biography:bb,disclosure:b},{id:Z,fullName:aS,professionalDesignation:aT,biography:aU,disclosure:b},resources:{id:165,title:Maternal-Postpartum Opioid Use Disorder Discharge Checklist.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBXQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--6a6f5e6dbdbd9b018f020326849bd98176d57412\u002FMaternal-Postpartum%20Opioid%20Use%20Disorder%20Discharge%20Checklist.pdf},references:{id:ew,title:ex,body:a},{id:ey,title:ez,body:a},{id:dj,title:ACOG committee opinion no. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212.,body:a},{id:dp,title:Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a coaching-based WHO safe childbirth checklist program in India. N Eng J Med. 2017;377(24):2313-2324.,body:a}},{id:av,title:Continue to establish a therapeutic relationship with parents\u002Fcaregivers once the infant has been born and empower parents to be involved with the care of their newborn,description:a,position:av,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EAfter delivery continue to establish a therapeutic relationship with parents\u002Fcaregivers and engage and empower parents to be involved with the care of their newborn.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EInvolving parents in newborn care early will increase their confidence in and preparation for managing neonatal abstinence syndrome (NAS) symptoms, establish healthy attachment to their newborn, and allow both mother and baby to better succeed in the transition to home. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EIdeally, parents receive prenatal counseling and meet members of the newborn care team.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ETrain staff to maintain a non-judgmental and supportive attitude and treat the mother as a parent first, not someone with a substance use problem.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProvide consistency in care team members as much as possible. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsure confidentiality by not discussing NAS or other clinical matters in front of other family members or friends unless the parents have explicitly consented. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPromote positive maternal\u002Fpaternal attachment to the newborn:\u003Cul\u003E\u003Cli\u003EEngage the parents in the care of their newborn.\u003C\u002Fli\u003E\u003Cli\u003EEncourage the parents to visit and help them maintain a quiet environment for the newborn.\u003C\u002Fli\u003E\u003Cli\u003EEmphasize and reinforce positive attributes of the newborn and maternal\u002Fpaternal behavior.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider providing a parent\u002Fcaregiver diary so that the parents may record eating and sleeping information about their newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider posting a HIPAA-compliant sign at the bedside to remind parents and staff about general tips for calming their newborns, skin care, feeding, and other non-pharmacologic interventions. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider providing a brochure or written guide about NAS for parents and standardizing the hospital’s method of pre-natal and postnatal counseling. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:43:12.344Z,updatedAt:2020-09-03T21:20:46.004Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386701,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWW89IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--310a3d1a439253cba6b3033c4a4501bb3b1f7efa\u002FBP_28.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESince Kayla was identified as having been exposed to opioids during pregnancy, the pediatric team was notified prior to delivery. The pediatrician assigned to care for Baby M met with Kayla and started to build a relationship with her, describing Kayla’s important role as a mother and the importance of skin-to-skin care and breastfeeding. In addition, due to her exposure, the pediatrician explained the plan for assessing Baby M for symptoms of NAS after delivery. \u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003ETraining staff to maintain a non-judgmental and supportive attitude and treat the mother as a parent first is an important aspect of establishing a constructive therapeutic relationship with the family. This attitude should be present whether or not the baby develops NAS. Staff should not discuss confidential information in front of family and friends unless the mother has given explicit consent for that communication to occur.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:{id:cY,title:ILPQC Newborn Care Diary. ,description:a,fileUrl:dv},{id:177,title:NAS Symptom Diary.,description:a,fileUrl:dw},{id:cZ,title:NAS Parent Brochure used by NNEPQIN.,description:a,fileUrl:http:\u002F\u002Fwww.nnepqin.org\u002Fwp-content\u002Fuploads\u002F2019\u002F08\u002FNAS_NNEPQIN_brochure_press-8.19.pdf},{id:dc,title:NAS Parent Guide used by OPQC.,description:a,fileUrl:https:\u002F\u002Fopqc.net\u002Fsites\u002Fbmidrupalpopqc.chmcres.cchmc.org\u002Ffiles\u002FResources\u002FNeonatal%20Abstinence%20Syndrome\u002Fopqc_nas_parent_guide_092914.pdf},references:{id:dk,title:bU,body:a},{id:dl,title:Wachman EM, Grossman M, Schiff DM, et al. Quality improvement initiative to improve inpatient outcomes for neonatal abstinence syndrome. J Perinatol. 2018;38(8):1114-1122.,body:a}},{id:ar,title:Develop a dyad-centered Plan of Safe Care,description:a,position:ar,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ECalifornia Penal Code 11165.13 was amended in 1990 with language indicating that a “positive toxicology screen at the time of the delivery of an infant is not in and of itself a sufficient basis for reporting child abuse or neglect,” but would require “…any indication of maternal substance abuse to lead to an assessment of the needs of the mother and child.” According to California Penal Code 123605, the assessment must be established by protocol “…between county health departments, county welfare departments, and all public and private hospitals in the county…”\u003Csup\u003E \u003C\u002Fsup\u003EMore recently, in 2016, the federal Comprehensive Addiction and Recovery Act (CARA) amended the long-standing Child Abuse Prevention and Treatment Act (CAPTA) to require development of a Plan of Safe Care, a concept that encourages a comprehensive, multidisciplinary care plan that addresses the needs of both infant and mother\u002Fcaregiver. While there is still discussion about the interpretation of these state and federal regulations, it is clear that the Plan of Safe Care shifts the response to maternal and infant substance exposure from one centered predominantly on newborn safety to one that anticipates the needs of the mother\u002Fbaby dyad. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003EThis Best Practice addresses the Plan of Safe Care for the dyad, regardless of whether the mother and newborn are discharged together, or parental rights have been temporarily suspended. Because evidence demonstrates that retention of the mother\u002Fbaby dyad is preferable to separation, attention to her well-being is essential to the welfare of the dyad.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EKey elements of a dyad-centered Plan of Safe Care are the development of structured protocols at the county and hospital level, comprehensive assessment of needs and assets, collaborative wraparound care, transparency, and the identification and engagement of community partners.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA dyad-centered Plan of Safe Care will facilitate positive outcomes for the mother and baby. Having these services in place during the pregnancy and certainly prior to postpartum discharge support mothers to acquire or optimize the skills necessary to provide a safe and nurturing environment for the dyad and family. There is an opportunity and an obligation to ensure new families have the best opportunities afforded them.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003E\u003Cstrong\u003EStructured Protocols:\u003C\u002Fstrong\u003E Although protocols may have been developed years ago in response to CA Penal Code 11165.13 and Health and Safety Code 123605, new evidence supports best practices that address the effects of adverse childhood events (ACE) on long term health and wellbeing, attachment and bonding, early intervention, the treatment of substance use disorder (SUD), and the role of protective factors in eliminating or mitigating risk in families and communities. While no one template fits all situations, domains covered in the Plan of Safe Care might include: \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMaternal primary, obstetric, and gynecological care, including interconception care and family planning\u003C\u002Fli\u003E\u003Cli\u003EBehavioral health and substance use prevention, treatment, and recovery\u003C\u002Fli\u003E\u003Cli\u003EParenting and family support\u003C\u002Fli\u003E\u003Cli\u003EInfant and family safety, including intimate partner violence\u003C\u002Fli\u003E\u003Cli\u003EInfant health and child development, including primary care, early intervention, and infant and early childhood mental health (IECHM) services\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe adoption and implementation of standardized protocols to develop, execute, and monitor a Plan of Safe Care for all women and children in need is critical. Further, the Plan of Safe Care protocol should reflect the collaborative expertise of key agencies at the county level (e.g., behavioral health and substance use treatment departments, social service departments, Child Protective Services (CPS), etc.), and multiple disciplines in the hospital and other health care settings (e.g., pediatric and OB\u002FGYN health care providers, medical social work, etc.).\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003ECollaboration\u003C\u002Fstrong\u003E: To provide a Plan of Safe Care for the dyad, community-based organizations and agencies must collaborate to make wrap-around services covering the above domains easily accessible. To address the needs of the mother, communities must come together to support her with a network of programs and providers that transcend stigma and engage mothers with respect and trust, are trauma-informed, and have expertise in the care of women with substance use disorders (SUDs). Similarly, addressing the needs of the infant should include providers and agencies skilled in high risk infant follow-up, Early Head Start and other early intervention programs, and primary care pediatric providers with expertise in managing infants exposed to substances or at risk for neurodevelopmental challenges. The mother\u002Fcaregiver must be the core member of this partnership. The partnership should include:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPrimary care providers\u003C\u002Fli\u003E\u003Cli\u003EMedication assisted treatment (MAT) providers (office-based or narcotics treatment programs) or other treatment and recovery programs\u003C\u002Fli\u003E\u003Cli\u003EPublic health nursing, including home visitation programs\u003C\u002Fli\u003E\u003Cli\u003EBehavioral health providers\u003C\u002Fli\u003E\u003Cli\u003EPeer support\u003C\u002Fli\u003E\u003Cli\u003EBoard-certified lactation consultant if the mother desires to breastfeed or provide expressed breastmilk (and it’s not medically contraindicated)\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EProviding Transparency\u003C\u002Fstrong\u003E: From the initial meeting with the mother, clarity of purpose is fundamental, and expectations are based on how each individual program or service can meet the needs of the dyad. Assessment of the mother’s needs, with consideration for her self-efficacy, SUD treatment, and recovery, will support her goal attainment. Follow through with plans and interventions developed with her input will further a sense of security in the relationship. Communication between community supports should occur with full knowledge and consent from the mother and include her whenever possible. Community partners should maintain transparency with each other to avoid duplication of services and provision of conflicting information to the mother, which may confuse and overwhelm her. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EPresently, guidance regarding interpretation of the federal and state legislation in this area is not straightforward, and hopefully will be clarified soon. Counties vary in how they address the Plan of Safe Care requirement within their communities. In many instances, CPS will take the lead; however, if there is no CPS involvement, or CPS does not address the provision of services to the mother, the community should be ready to support mothers with trauma-informed programs and partners that employ the Five Protective Factors model (refer to the Resources Section of this Best Practice). If CPS engagement is anticipated, full understanding of the laws and resources will afford medical and other service providers the ability to have more transparent conversations with mothers.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003ECommunity Partners\u003C\u002Fstrong\u003E: The partners from the community may include: CPS, Cal-Works eligibility, behavioral health providers, peer support workers, hospital social workers, MAT providers, recovery programs specific to parenting women, First 5, mother-infant intervention programs (e.g., Minding the Baby or Parents as Teachers), Regional Center, Early Start, Medicaid, and Women, Infants and Children (WIC). Communities may identify and designate additional partners specific to their region.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EFederal and State Child Welfare Regulations: \u003C\u002Fstrong\u003EIn 2016, the Comprehensive Addiction and Recovery Act (CARA) amended the Child Abuse and Prevention Treatment Act (CAPTA) to require the development of a Plan of Safe Care for all children referred to their agency who are born affected by legal or illegal substance use, have withdrawal symptoms resulting from prenatal drug exposure, or have indications of Fetal Alcohol Spectrum Disorder.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EIn response to California Penal Code 11165.13, and the Federal CARA\u002FCAPTA amendments, the California Department of Social Services (CDSS) All County Letters (17-92 and 17-107) state, “when investigating a referral, the county child welfare agency must assess and identify any safety threats to the child, including any safety threat posed by the parent’s substance abuse. The caseworker must document such safety threats when completing statewide safety assessment tools. This also includes the completion of a risk assessment. If the caseworker determines the caregiver has the protective capacity to mitigate such safety threats and\u002For risks with appropriate services while keeping the child in the home or placement, the caseworker shall develop a safety plan as described in CDSS Manual of Policies and Procedures, section 31-002(s) (2)… to permit the child to remain in the home with specific, timely actions that mitigate the identified safety threats.”\u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EInitial Steps to Consider \u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EContact the county Public Health Department (Maternal Child and Adolescent Health), Child Protective Services, and\u002For Hospital Council to determine if a current protocol exists for the identification of perinatal substance exposure and the development of Plans of Safe Care that is consistent with state and federal law. \u003C\u002Fli\u003E\u003Cli\u003EIf a county-level protocol does not exist, or needs revisions, establish a county-level multidisciplinary Plan of Safe Care Committee. Stakeholders to engage might include champions from the aforementioned agencies, Pediatrics, Obstetrics, Midwifery, Family Medicine, Addiction Medicine, Psychiatry, Behavioral Health, Family Treatment Court, and community organizations that serve this population (essential for culturally appropriate and engaging care). Protocols should address at least the following:\u003Cul\u003E\u003Cli\u003EDefine which mothers and newborns will qualify for a Plan of Safe Care and whether it will be used only for substance exposed mothers and infants as mandated or for the many other families at risk (e.g., prematurity, intimate partner violence, mental health issues, etc.).\u003C\u002Fli\u003E\u003Cli\u003EIdentify who will oversee implementation of the Plan of Safe Care, and at which stage of the pregnancy the plan of safe care may be initiated. Current CDSS All County Letters assign that responsibility to the local CPS agency regardless of whether the newborn is discharged in the care of the mother.\u003C\u002Fli\u003E\u003Cli\u003EIdentify key community-based organizations and resources and establish relationships including with primary care providers, substance use treatment and recovery providers, community resources for collaborative support of vulnerable families, home visitation, parenting classes, lactation support, addiction support (if needed), and early intervention services.\u003C\u002Fli\u003E\u003Cli\u003EOutline ongoing care plans that identify family challenges and strengths (and tools to support those assessments, such as Protective Factors Survey 20 or 30), detail recommended\u002Frequired resources and supports to ensure ready access to those services, and include contact information and appointments for benefit of the family and support network.\u003C\u002Fli\u003E\u003Cli\u003EPrioritize continuity of care with maternal treatment and recovery providers and with infant care providers wherever possible and appropriate \u003C\u002Fli\u003E\u003Cli\u003EEnsure that the Plan of Safe Care covers a sufficient duration to ensure a foundation of stability.\u003C\u002Fli\u003E\u003Cli\u003EInclude a comprehensive release of information consent signature page (see Delaware’s Plan of Safe Care example) to facilitate timely information sharing and coordination between organizations to ensure shared understanding and accountability.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsure that hospital protocols are in place for the identification of substance exposed mothers and infants and the development and implementation of Plans of Safe Care for the dyad. These should be consistent with local, state, and federal policies and regulations.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsure families and providers are educated about the Plan of Safe Care, what to expect in the hospital and beyond, the focus on maintaining the mother\u002Fbaby dyad, and the potential for CPS involvement.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEngage the mother\u002Fcaregiver in collaborative decision making around what supports are most valuable for them and any anticipated challenges for program participation while maintaining sobriety, work obligations, or court hearings.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider using the Plan of Safe Care as a dynamic document that may evolve over time in response to regular assessments of the parent and infant health and well-being.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnsure sufficient monitoring of maternal depression and anxiety, continuing recovery, and parental capacity to meet her infant’s and her own needs. There are many conflicting demands placed on these mothers such as attachment, sustaining employment, recovery, and the voluntary programs we recommend.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EConsider using a consultant or the complete reference below to implement of a Plan of Safe Care.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003EThe relationships we build across departments and in the community will afford us a greater support network, and transparency and accountability in caring for our most vulnerable new families during a peak emotional time. The dyad-centered Plan of Safe Care is an opportunity for providers to leverage community resources and ensure optimal support of new families impacted by substance use or other risk factors. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:43:27.691Z,updatedAt:2020-09-03T21:19:21.670Z,publishedAt:o,videoUrl:bu,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWXM9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--d6c18f2021dd397ad0a3b026a5d4b14716f66c87\u002FBP%2025_27_29_32.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EIn the past year, the hospital Kayla delivered at held a monthly meeting to develop and refine a thorough county-wide Plan of Safe Care (POSC). These meetings consisted of interdisciplinary representatives from the inpatient hospitals, outpatient clinics, CPS, community organizations, and health care system clients. They have been developing, refining, and organizing roll out plans for policies and procedures that link the practices of the entire community through the processes of urine toxicology, outpatient and inpatient screening, support opportunities, inpatient management, and ultimately the coordination and documentation of a POSC. The team has effectively kept their focus on keeping families intact and supporting the family as a unit.\u003Cbr\u003E \u003Cbr\u003EAfter delivery, Kayla’s primary care provider and primary outpatient social worker (SW) called a team meeting to review and adjust (as needed) Kayla’s POSC. Kayla was involved in this meeting as it focused on her as the most important piece of Baby M’s health and well-being. She was given time to ask questions, discuss concerns and invite any further support. Prior to this meeting, Kayla’s traumatic life history was also briefly reviewed in the POSC as well as the services and safe guards that were already in place (MAT, GED attainment, and more).\u003Cbr\u003E \u003Cbr\u003EPrior to Kayla’s discharge, the outpatient SW, who is responsible for tracing the POSC and is the team member who best knows Kayla, provided further support. Kayla identified herself as early in sobriety and continuing to struggle with feelings of anxiety that were triggered in the role as a new parent. Kayla chose a supportive housing community resource that felt like the right fit for her family, and her primary SW assigned referrals to this program to be completed. The inpatient SW had met a representative from this community program at the monthly POSC meeting and felt comfortable describing their services and participation requirements. This added to Kayla’s comfort to explore this option of support.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:aH,fullName:Heather Briscoe,professionalDesignation:c,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Heather Briscoe is an Assistant Professor at University of California, San Francisco based at Zuckerberg San Francisco General Hospital in the Department of Pediatrics. She is a pediatric hospitalist and is engaged in a number of projects around the interface of pregnancy and social complexity including an active role in the Plan of Safe Care Community Collaborative of San Francisco. She is particularly interested in how substance use policy affects pregnant women both positively and negatively with regard to utilization of prenatal care, access to needed resources, family unity & safety, and trauma-informed patient-centered care. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},{id:E,fullName:bg,professionalDesignation:aM,biography:bh,disclosure:b},{id:Z,fullName:aS,professionalDesignation:aT,biography:aU,disclosure:b},{id:bK,fullName:Kelly Brandon,professionalDesignation:MSN, RNC, CNS, IBCLC,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKelly Brandon, MSN, RNC, CNS, IBCLC has been a nurse for over a decade. She currently works as a Perinatal Clinical Nurse Specialist at Zuckerberg San Francisco General Hospital and Trauma Center where she oversees the training, education, policy writing and implementation of nursing care in the Birth Center at ZSFGH. Prior to her nursing work she was a counselor and program manager for a street outreach program in downtown San Francisco. Kelly focuses her clinical work by involving compassion, kindness, and patient autonomy in every encounter. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},{id:$,fullName:aV,professionalDesignation:aW,biography:aX,disclosure:b},resources:{id:eA,title:National Center on Substance Abuse and Child Welfare. A Planning Guide: Steps to Support a Comprehensive Approach to Plans of Safe Care. March 2018 Draft. Retrieved 4\u002F10\u002F19.,description:a,fileUrl:https:\u002F\u002Fwww.cffutures.org\u002Ffiles\u002Ffdc\u002FA-Planning-Guide_-Steps-to-Support-a-Comprehensive-Approach-to-Plans-of-Safe-Care-3.21.18-final.pdf},{id:eB,title:eC,description:a,fileUrl:bD},{id:eD,title:Children and Family Futures presentation with national statistics, overall background, concept of family-centered treatment and suggestions for the implementation of Plans of Safe Care.,description:a,fileUrl:http:\u002F\u002Fnadcpconference.org\u002Fwp-content\u002Fuploads\u002F2018\u002F05\u002FCG-28.pdf},{id:eE,title:Delaware Plan of Safe Care Template Example.,description:a,fileUrl:http:\u002F\u002Fwww.cffutures.org\u002Fwp-content\u002Fuploads\u002F2018\u002F12\u002FDelaware-POSC-Template.pdf},{id:eF,title:Vermont Plan of Safe Care Template Example.,description:a,fileUrl:https:\u002F\u002Fdcf.vermont.gov\u002Fsites\u002Fdcf\u002Ffiles\u002FFSD\u002FDocs\u002FHospital-Plan-Safe-Care.pdf},{id:eG,title:National Center on Substance Abuse and Child Welfare. Child Abuse and Prevention Treatment Act (CAPTA) Substance Exposed Infants Statutory Summary.,description:a,fileUrl:https:\u002F\u002Fncsacw.samhsa.gov\u002Ffiles\u002FCAPTA_SEI_Statutory_Summary.pdf},{id:190,title:The Protective Factors Framework. ,description:a,fileUrl:https:\u002F\u002Fwww.flgov.com\u002Fwp-content\u002Fuploads\u002Fchildadvocacy\u002Fstrengthening_families_protective_factors.pdf},{id:dM,title:Protective Factors Survey ,description:a,fileUrl:https:\u002F\u002Fwww.cebc4cw.org\u002Fassessment-tool\u002Fprotective-factors-survey\u002F},{id:dN,title:Ac P Yurok Tribe Health and Human Services. Healthy Circles Intake Form.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBjdz09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--51d6302a3a7e727bffc91b331086d765cedca9e3\u002FPOSC%20Yurok.pdf},references:{id:141,title:The Child Abuse and Neglect Reporting Act . California Penal Code 11165.13. California Legislature. http:\u002F\u002Fleginfo.legislature.ca.gov\u002Ffaces\u002Fcodes_displaySection.xhtml? lawCodePEN§ionNum11165.7. Accessed December 19, 2019.,body:a},{id:cc,title:Perinatal Health Care. California Health and Safety Code, Section 123605. California Legislature. http:\u002F\u002Fleginfo.legislature.ca.gov\u002Ffaces\u002Fcodes_displaySection.xhtml? sectionNum123605&lawCodeHSC. Accessed December 19, 2019.,body:a},{id:eH,title:Substance Abuse and Mental Health Services Administration. Family-centered treatment for women with substance use disorders – history, key elements and challenges. https:\u002F\u002Fwww.samhsa.gov\u002Fsites\u002Fdefault\u002Ffiles\u002Ffamily_treatment_paper508v.pdf Accessed December 19, 2019.,body:a},{id:144,title:Browne CH. The strengthening families approach and protective factors framework: branching out and reaching deeper. The Center for the Study of Social Policy. https:\u002F\u002Fcssp.org\u002Fwp-content\u002Fuploads\u002F2018\u002F11\u002FBranching- Out-and-Reaching-Deeper.pdf. Accessed April 5, 2019.,body:a},{id:ci,title:California Health and Human Services Agency, Department of Social Services. All County Letter No. 17-92, pg.5 Development and Monitoring of Plans of Safe Care. http:\u002F\u002Fwww.cdss.ca.gov\u002FPortals\u002F9\u002FACL\u002F2017\u002F17-92.pdf?ver2017-09-15- 150104-073. Published in 2017. Accessed on April 9, 2019.,body:a},{id:ev,title:Slade A, Sadler L, De Dios-Kenn C, Webb D, Currier-Ezepchick J, Mayes L. Minding the baby a reflective parenting program. Psychoanal Study Child. 2005;60:74-100.,body:a},{id:ch,title:Bugental DB, Ellerson PC, Lin EK, Rainey B, Kokotovic A, OHara N. A cognitive approach to child abuse prevention. J Fam Psychol. 2002;16(3):243-258. ,body:a}},{id:aG,title:Implement a warm handoff strategy to follow at time of discharge,description:a,position:aG,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EImplementation of a warm handoff process at the time of discharge, when key information can be easily lost or forgotten, will reduce the risk of communication breakdowns that compromise patient safety and jeopardize a smooth and cohesive transition to care. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EUse of warm handoffs:\u003Cul\u003E\u003Cli\u003EIncreases patient safety through improved communications and provides an opportunity to question, clarify, and confirm information. \u003C\u002Fli\u003E\u003Cli\u003EBuilds partnerships for improved care, outcomes, and experiences.\u003C\u002Fli\u003E\u003Cli\u003EIncreases shared decision making and patient\u002Ffamily engagement.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUse of standardized workflows (the most efficient method or approach that all follow):\u003Cul\u003E\u003Cli\u003EProvides a structured communication tool and handoff process.\u003C\u002Fli\u003E\u003Cli\u003EDecreases variation in practice. \u003C\u002Fli\u003E\u003Cli\u003EPrevents omission of practice elements, ensuring every discharge\u002Ftransition of care will benefit from all aspects of the warm handoff.\u003C\u002Fli\u003E\u003Cli\u003EAllows for analysis of practice and process improvement when issues or gaps are identified.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ECollaborate with discharge caregivers, receivers, and patients to develop written standard work that supports next steps of the plan of care and meets the needs of all team members.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EWarm handoff standard work should:\u003Cul\u003E\u003Cli\u003EBe in person (whenever possible) and in front of the patient and\u002For family.\u003C\u002Fli\u003E\u003Cli\u003EInclude an introduction by the discharging team member to the next care provider.\u003C\u002Fli\u003E\u003Cli\u003EInclude pertinent details related to prenatal care and the acute care stay.\u003C\u002Fli\u003E\u003Cli\u003EInclude a review of the discharge goals and plan.\u003C\u002Fli\u003E\u003Cli\u003EInclude a review of next steps and who is responsible. \u003C\u002Fli\u003E\u003Cli\u003EInclude a review of what is important to the patient\u002Ffamily.\u003C\u002Fli\u003E\u003Cli\u003EProvide an opportunity for all participants, including patient and family, to question, clarify, and confirm information.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:43:46.964Z,updatedAt:2020-09-03T21:21:12.906Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386769,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWXc9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--d06f36806c08826a7e83e1dc69991bbd55160f4d\u002FBP_30.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe hospital caring for Kayla has both an inpatient and outpatient social worker who routinely meet to discuss cases and prepare for postpartum discharges. Both social workers rely on a newly developed, structured process for the warm handoff. The process was developed by a multidisciplinary group of stakeholders in the maternity and newborn departments, similar to the group that developed the Plan of Safe Care recommendations that are included in the discharge checklist. It was quickly realized that the discharge checklist was necessary but not sufficient to complete the warm hand off in the transition from inpatient to outpatient care. A standardized communication tool outlines the warm handoff process for each patient that: occurs in person with the patient, verbally reviews the discharge checklist and Plan of Safe Care, outlines who is responsible for specific next steps of the process, provides an introduction to the next care provider whenever possible, and provides an opportunity for the patient and family to ask questions and clarify any missing information.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EKayla agreed to meet with the outpatient social worker who will oversee her and Baby M’s Plan of Safe Care. Contact with Kayla’s post-discharge caregiver was completed, based on Kayla’s preferences, and a comprehensive transmission of medical records was underway. The nurse caring for Kayla was able to attend part of the warm handoff meeting to review the discharge checklist and complete all medication reconciliation oversight. Kayla was discharged feeling supported. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:av,fullName:Christina Oldini,professionalDesignation:MBA, RN, CPHQ,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EChristina is the Associate Director of Programs at CMQCC and a nurse leader dedicated to process improvement, high quality health care for all, technological innovation and staff growth & development. She has extensive experience in lean improvement, patient relations\u002Fexperience, Informatics, provider relations and change management. Christina’s clinical program background includes Maternal Fetal Medicine, Gynecological Surgery and Obstetrical & Gynecological Ultrasound.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},{id:$,fullName:aV,professionalDesignation:aW,biography:aX,disclosure:b},resources:,references:{id:260,title:Agency for Healthcare Research and Quality. Design Guide for Implementing Warm Handoffs. https:\u002F\u002Fwww.ahrq.gov\u002Fsites\u002Fdefault\u002Ffiles\u002Fwysiwyg\u002Fprofessionals\u002Fquality-patient-safety\u002Fpatient-family-engagement\u002Fpfeprimarycare\u002Fdesign-guide-warm-handoff.pdf. Accessed December 19, 2019. ,body:a},{id:261,title:Shaked, D. (2014). Strength-based lean six Sigma: building positive and engaging business improvement. New York: Kogan Page; 2013.,body:a}},{id:ai,title:Ensure linkage to home visitation programs or that other in-home supports are in place,description:a,position:ai,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPrior to discharge, appropriate referrals to home-based services should be made, or if the patient has previously been referred, services should be confirmed. This may include Public Health Nursing, Early Head Start Programs, or any other program that provides evidence-based in-home supports to the family. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EHome Visitation Programs have shown high rates of return on investment. By participating in prenatal and early childhood home visiting programs, families gain the necessary knowledge and resources to successfully parent. These programs not only provide one-on-one in-home support to the families, but also ensure that the family is linked to any additional resources and aid the family in ensuring that all medical care is followed. Especially within the first weeks of the newborn’s life, it may be difficult for the parent to leave the house; by receiving services in the home, there is better ability to ensure that the family does not fall out of care. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Ca href\https:\u002F\u002Fwww.cdph.ca.gov\u002FPrograms\u002FCFH\u002FDMCAH\u002FCHVP\u002FPages\u002Fdefault.aspx\\u003ECalifornia Home Visiting Program (CHVP):\u003C\u002Fa\u003E CHVP oversees implementation of various evidence-based home visiting programs throughout California, including the Nurse-Family Partnership (NFP) and Healthy Families America (HFA), and currently 23 California counties have these evidence-based programs. State-level agency workgroups conduct needs assessments to determine the greatest need for and potential impact from these programs based on factors such as poverty rates, rates of child abuse and neglect, and the ability to find and enroll at-risk parents in particular areas.\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003ENFP:\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E Geared towards low income, first-time pregnant women. Care starts in pregnancy and follows the dyad until the child reaches two years of age. The mother must be referred before 28 weeks of pregnancy.\u003C\u002Fli\u003E\u003Cli\u003E\u003Cstrong\u003E\u003Cem\u003EHFA\u003C\u002Fem\u003E\u003C\u002Fstrong\u003E\u003Cstrong\u003E:\u003C\u002Fstrong\u003E Geared towards low-income, at-risk families from birth to a minimum of three years.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Ca href\https:\u002F\u002Feclkc.ohs.acf.hhs.gov\u002Fprograms\u002Farticle\u002Fearly-head-start-programs\\u003EEarly Head Start\u003C\u002Fa\u003E\u003Cem\u003E:\u003C\u002Fem\u003E Early Head Start provides preschool and home visiting services geared towards low-income, at risk families. This is one of the few programs that can be started either during pregnancy or after delivery and follows the dyad until the child reaches three years of age.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Ca href\http:\u002F\u002Fwww.cdss.ca.gov\u002Finforesources\u002FCalWORKsHomeVisitingInitiative\\u003E\u003Cbr\u003ECalWORKS:\u003C\u002Fa\u003E CalWORKS offers a new three-year home visiting pilot initiative that began in January 2019. It is supported by both state General Fund and federal Temporary Assistance for Needy Families dollars. The program provides up to 24 months of home visiting for pregnant and parenting people, families, and infants born into poverty. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Ca href\https:\u002F\u002Fmchb.hrsa.gov\u002Fmaternal-child-health-initiatives\u002Fhealthy-start\\u003EHealthy Start\u003C\u002Fa\u003E\u003Cem\u003E: \u003C\u002Fem\u003EHealthy Start serves communities with infant mortality rates that are at least one and a half times the U.S. national average. Women and their families can be enrolled into Healthy Start at various stages of pregnancy, including pre- inter-, and post-conception. Each family that enrolls receives a standardized, comprehensive assessment. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Ca href\https:\u002F\u002Fwww.dds.ca.gov\u002FEarlyStart\u002FWhatsES.cfm\\u003EEarly Start\u003C\u002Fa\u003E: Early Start is California’s early intervention program (i.e., Part C of the Individuals with Disability Education Act), providing early intervention services to at-risk infants and children less than three years of age who meet eligibility criteria based on the presence or risk of developmental disability. Services include infant education, occupational therapy, physical therapy, speech therapy, and home visits. Referrals can be made by the NICU or newborn nursery and are often coordinated by a social worker, although anyone can make a referral, including parents, medical providers, neighbors, family members, foster parents, and day care providers. \u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cdiv\u003EHome Health Visits: A number of public and commercial insurance companies offer home health visits, usually in response to a medical need. If the patient does not have insurance, or if the patient’s insurance declines to cover the home health visit, the county often will provide a public health nurse. Some counties or local areas have established their own system (e.g., \u003Ca href\https:\u002F\u002Fwww.palomarhealth.org\u002Fabout-us\u002Fpalomar-home-health-services\\u003EPalomar Home Health Services\u003C\u002Fa\u003E).\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEnsure that staff is trained and has a full understanding of the availability of specific home visitation programs that are available to the population. It is optimal to refer the mother during prenatal care and to resume home visits following delivery. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EMaintain resource listings and referral forms for home visitation programs in your area. These can be kept in a binder that is easily accessed by providers and staff or can be kept digitally. It is important to regularly review and update agency referral forms to ensure the accuracy of referrals. \u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EReadily available referral forms will streamline the referral process. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDetermine if the patient has already been working with a home visiting program. \u003Cul\u003E\u003Cli\u003EIf she has, ensure care coordination happens with that program so the home visitor is aware of the delivery and that no gap in services occurs. \u003C\u002Fli\u003E\u003Cli\u003EIf she had not been referred, ensure a referral is made and inform the patient.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe key to this referral is ensuring that the patient buys in and that the family understands the kind of support a home visiting program can provide. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExplore the availability of warm handoffs to programs prior to discharge. Sometimes a program might be able to do an intake while the patient is still admitted to the hospital.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:43:59.679Z,updatedAt:2020-09-03T21:21:38.950Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386840,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWTA9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--e7ff7cfad891bd32e1f92807af9e9a9854519a61\u002FBP_31.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EWhen Kayla found out she was pregnant at 11 weeks, she was offered a visit with a social worker but declined the meeting at that time. Prior to discharge of Baby M, another referral was made for public health nursing follow-up, and Kayla was able to understand how home visiting services could provide ongoing support to her and Baby M. They received monthly home visits from a public health nurse who supported the dyad in bonding, breastfeeding, and identifying other needs. The home visitor quickly identified that Kayla had challenges with transportation to her treatment appointments and was able to facilitate reliable transportation for her. Additionally, the home visitor was able to facilitate referral to a support group for new moms and provide additional resources for Kayla. The home visitor followed Kayla and Baby M for the entire first two years of Baby M’s life.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EReferring patients to home visiting services allows for evaluation of socioeconomic factors that may impact a patient’s ability to seek care for themselves or their child. By identifying and working with the patient to address these factors, they can meet the dyad’s basic needs, work on goal setting, and identify strengths that the mother already possesses. Additionally, ongoing follow-up with a home visitor can help to facilitate comprehensive and consistent medical care.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:ar,fullName:eI,professionalDesignation:eJ,biography:eK,disclosure:b},{id:Z,fullName:aS,professionalDesignation:aT,biography:aU,disclosure:b},{id:$,fullName:aV,professionalDesignation:aW,biography:aX,disclosure:b},resources:{id:eL,title:dY,description:a,fileUrl:https:\u002F\u002Fcalbudgetcenter.org\u002Fresources\u002Fhome-visiting-is-a-valuable-investment-in-californias-families\u002F},{id:eM,title:d_,description:a,fileUrl:d$},{id:67,title:ea,description:a,fileUrl:eb},{id:dD,title:Local First 5 Commissions.,description:a,fileUrl:ed},{id:dE,title:ee,description:a,fileUrl:ef},{id:dF,title:eg,description:a,fileUrl:eh},{id:dG,title:ei,description:a,fileUrl:ej},{id:dI,title:ek,description:a,fileUrl:el},{id:dJ,title:eo,description:a,fileUrl:ep},{id:dK,title:er,description:a,fileUrl:https:\u002F\u002Fwww.dds.ca.gov\u002FEarlyStart\u002FWhatsES.cfm},{id:dL,title:et,description:a,fileUrl:eu},{id:dd,title:em,description:a,fileUrl:en},{id:de,title:ec,description:a,fileUrl:https:\u002F\u002Fwww.healthyfamiliesamerica.org\u002Four-approach\u002F},references:{id:130,title:Breastfeeding, SB-402. California Legislature. https:\u002F\u002Fleginfo.legislature.ca.gov\u002Ffaces\u002FbillNavClient.xhtml? bill_id201320140SB402. Accessed December 19, 2019.,body:a},{id:di,title:Harrison CL, May A. Home visiting: improving childrens and families well- being. NCSL legisbrief. 2018;26(31):1-2.,body:a},{id:132,title:Heckman, J., Holland, M., Makino, K., Pinto, R., & Rosales-Rueda, M. An analysis of the Memphis nurse-family partnership program. NBER. 2017. https:\u002F\u002Fwww.nber.org\u002Fpapers\u002Fw23610. doi:10.3386\u002Fw23610.,body:a},{id:133,title:Home Visiting. Human Resources and Services Administration. https:\u002F\u002Fmchb.hrsa.gov\u002Fmaternal-child-health- initiatives\u002Fhome-visiting-overview. Accessed December 19, 2019.,body:a},{id:cb,title:ez,body:a},{id:135,title:ACOG committee opinion no. 729: importance of social determinants of health and cultural awareness in the delivery of reproductive health care. Obstet Gynecol. 2018;131(1):e43-e48.,body:a},{id:136,title:ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;131(5):e140-e150.,body:a},{id:137,title:Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorder. https:\u002F\u002Fstore.samhsa.gov\u002F\u002Fsystem\u002Ffiles\u002Fsma16- 4978.pdf. Accessed December 19, 2019.,body:a}},{id:af,title:Ensure referral and linkage to other necessary services\u002Fresources at discharge,description:a,position:af,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EOther community agency referrals are needed to ensure that both the mother’s and newborn’s basic needs are met. These referrals can include WIC, family resource centers, parenting classes, the Department of Social Services, support groups, local treatment centers at a level of care appropriate to the patient’s assessed needs, peer support, and recovery groups. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EA collaborative and multidisciplinary approach to providing support to mothers and newborns affected by opioid use disorder (OUD) is necessary to ensure that the dyad has all basic needs met. Other service providers and agencies can influence a woman’s decisions for care and treatment. A more comprehensive approach to supporting the family is taken when multiple agencies and service providers are engaged. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EEnsure staff training on local resources and eligibility criteria, as well as the referral process. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ERoutinely engage hospital social work to support these activities.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMaintain or ensure access to a comprehensive listing of resources for easy reference when needs are identified. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDetermine if an agency is providing services to the family that include case management and care coordination. \u003Cul\u003E\u003Cli\u003EIf there is an agency that is already involved with the family, ensure access and determine the needs and gaps in services that the family may have. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EIdentify agencies that may be available to address the needs of the family. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMake direct referrals whenever possible; ensure that the referral is received by the agency or program. \u003Cul\u003E\u003Cli\u003EMake follow-up outpatient appointments for postpartum follow-up. \u003C\u002Fli\u003E\u003Cli\u003E“The American College of Obstetricians and Gynecologists recommends a revised approach to postpartum care, including a postpartum visit within the first three weeks postpartum and a comprehensive exam at or before 12 weeks after delivery (ACOG, 2018). However, women with substance use disorders (SUDs) may benefit from additional support. Providers should consider scheduling an initial postpartum visit within 1-2 weeks after delivery, and biweekly until at least 6 weeks” (SAMHSA, 2018; Alliance for Innovation in Maternal Health, 2018). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInform the patient of the referral and provide contact information and information regarding the services to which they are being referred. This includes reporting to CPS. \u003Cul\u003E\u003Cli\u003EWhen there are no safety concerns, the provider should try to openly discuss referrals to Child Protective Services (CPS) and reassure the parent that it may be an opportunity for the family to receive additional support. This should only be done when deemed safe and when the conversation would benefit the family. \u003C\u002Fli\u003E\u003Cli\u003EUtilize warm handoffs. Refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F30\\u003E\u003Cstrong\u003EBest Practice #30\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESchedule follow-up appointments before discharge. \u003Cul\u003E\u003Cli\u003EAppointments should include, but are not limited to: \u003Cul\u003E\u003Cli\u003ERecommended routine maternal appointments at one to two and six weeks postpartum.\u003C\u002Fli\u003E\u003Cli\u003EPublic health and\u002For home health home visit within three days of discharge. \u003C\u002Fli\u003E\u003Cli\u003ERecommended routine newborn appointments within 24-72 hours after discharge.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EWhere possible, provide or engage care navigators to support mothers in accessing service referrals and identifying additional needs. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:44:15.575Z,updatedAt:2020-10-07T14:27:10.768Z,publishedAt:ac,videoUrl:bu,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWTQ9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--05fff7324a7e2bfb7eb3d3932b5998d2671b5f1e\u002FBP%2025_27_29_32.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPrior to discharge, the L&D staff review several community-based resources where Kayla may be able to receive services. Since Kayla is separated from Baby M, who is still in the NICU, the discharge nurse refers Kayla to WIC to obtain a breast pump so that she can establish that her milk supply. When Kayla attends her WIC appointment, she is also provided with lactation support and education. By the time Baby M is discharged from the NICU, Kayla has established her milk supply and is ready to begin breastfeeding Baby M. Additionally, Kayla can schedule a follow-up appointment with WIC for lactation support or any other issues that may interfere with successful breastfeeding.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:ar,fullName:eI,professionalDesignation:eJ,biography:eK,disclosure:b},{id:Z,fullName:aS,professionalDesignation:aT,biography:aU,disclosure:b},{id:$,fullName:aV,professionalDesignation:aW,biography:aX,disclosure:b},resources:{id:bS,title:eC,description:a,fileUrl:bD},{id:bT,title:Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. SAMHSA, 2018.,description:a,fileUrl: https:\u002F\u002Fstore.samhsa.gov\u002Fsystem\u002Ffiles\u002Fsma18-5054.pdf},{id:du,title:Alliance for Innovation in Maternal and Child Health. ,description:a,fileUrl:https:\u002F\u002Fwww.acog.org\u002FAbout-ACOG\u002FACOG-Departments\u002FPatient-Safety-and-Quality-Improvement\u002FWhat-is-AIM?IsMobileSetfalse},{id:183,title:Alliance for Innovation on Maternal Health. AIM Resources. ,description:a,fileUrl:https:\u002F\u002Fsafehealthcareforeverywoman.org\u002Faim-resources-2\u002F},references:},{id:ae,title:Communicate directly with the outpatient primary care provider prior to the newborn leaving the hospital to review the hospital course and discuss follow-up,description:a,position:ae,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe treating physician within the hospital setting should communicate directly with the outpatient primary care provider (pediatric or family medicine provider) prior to the newborn leaving the hospital to review the hospital course, inform the primary care provider of social issues, discuss feeding plans, and ensure timely follow-up appointments are available within 24–72 hours of discharge from the hospital. In addition to the primary care provider, scheduling of home visit(s) by a nurse and\u002For social worker is ideal if available (see \u003Cstrong\u003EBest Practices \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F25\\u003E\u003Cstrong\u003E#25\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003Cstrong\u003E, \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F29\\u003E\u003Cstrong\u003E#29\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003Cstrong\u003E and \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F31\\u003E\u003Cstrong\u003E#31\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ENewborns exposed to illicit or non-medicinal uses of substances during pregnancy are at risk of withdrawal, as well as ongoing neurodevelopmental and other challenges. They require high risk or other close follow-up care to ensure early identification of and intervention for potential adverse outcomes.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPrimary care providers should be aware of the current feeding regimen to ensure that the newborn continues to receive adequate caloric intake for growth and development and to adjust as necessary.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENewborns who are initially breastfed by women on medication assisted treatment (MAT) and whose mothers stop breastfeeding may\u003Cem\u003E \u003C\u002Fem\u003Ebe at higher risk of experiencing a recrudescence of withdrawal symptoms. Although the risk is minor, as breastmilk concentrations of both methadone and buprenorphine are low, primary care providers should be informed. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESubacute signs of neonatal abstinence syndrome (NAS) may last up to six months.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDrug exposure in utero is a marker of environmental risk. Caretaker involvement, family resources, and community resources are protective factors that can improve long-term outcomes for children.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EConsider a NAS discharge checklist for inpatient providers and primary care providers caring for exposed newborns, which should ideally be incorporated into the electronic health record.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:44:29.809Z,updatedAt:2020-10-07T14:27:58.518Z,publishedAt:ac,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446556285,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWTg9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--40a86824bc77c261a3807b2795375a4b625da90d\u002FBP_33.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EBaby M no longer needs pharmacologic therapy and will be ready to go home soon. In preparation for that transition, the pediatrician who has cared for Baby M in the hospital calls the pediatrician who will care for Baby M as an outpatient. During the phone call, the pediatrician describes Kayla and Baby M’s social and medical history, summarizes the hospital course, and suggests all aspects of care after discharge.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aa,name:aj,description:ak},authors:{id:u,fullName:G,professionalDesignation:c,biography:H,disclosure:b},{id:A,fullName:I,professionalDesignation:J,biography:K,disclosure:b},{id:v,fullName:L,professionalDesignation:M,biography:N,disclosure:b},{id:s,fullName:O,professionalDesignation:c,biography:P,disclosure:Q},{id:t,fullName:R,professionalDesignation:S,biography:T,disclosure:b},{id:D,fullName:U,professionalDesignation:c,biography:V,disclosure:b},resources:,references:{id:126,title:Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarko L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid- exposed infants. Acta Paediatr. 2013;102(11):1060-1066.,body:a},{id:248,title:Messinger DS, Bauer CR, Das A et al. The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics. 2004;113(6):1677-1685.,body:a},{id:249,title:Bada HS, Bann CM, Whitaker TM et al. Protective factors can mitigate behavior problems after prenatal cocaine and other drug exposures. Pediatrics. 2012;130(6):1479-1488.,body:a}},{id:ao,title:Provide staff and provider education on opioid use disorder,description:a,position:ao,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEducate all providers and administrative staff about opioid use disorder (OUD) in pregnancy, strategies for caring for patients with OUD, and develop protocols that address all team members’ roles. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ETreatment of OUD is a multidisciplinary endeavor that begins with a patient’s first encounter in the health care environment. For this reason, all staff need to have a strong foundational understanding of OUD as a chronic illness and must be provided with adequate training and tools to interact with patients in a way that does not undermine a patient’s effort to seek care. Understanding the underlying stigma and biases that nurses and ancillary staff may unintentionally bring to the treatment of patients should be a primary focus of all inpatient, outpatient, and ambulatory care staff. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EWhile the OUD epidemic affects women from all socioeconomic, racial, and cultural backgrounds, many caregivers and staff members have mistaken ideas about the reality of addiction. These misconceptions often result in a patient being denied needed treatment or alienated from the medical system before she has established care with a provider. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EIn all medical settings, it is important that the first contact a woman with OUD has with the health system is one that is free of stigma and alienating language, incorporates Trauma-Informed Care, and is tailored to the individual woman’s needs. This initial meeting should be one that helps move a patient forward to an empowering relationship with her provider and toward medication assisted treatment (MAT) before her intrapartum period. If a patient is initiating care during the intrapartum period, it is equally important that the care is viewed by all staff as an opportunity to implement the best practices for mothers and newborns included in this toolkit during the postpartum period and beyond. Pregnancy provides a unique window of opportunity when a woman is highly motivated to enter treatment not only out of concern for the health of the fetus but also because during pregnancy, she can envision a different future for herself and her child.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EStaff and provider training is key to disrupting the stigmatizing interactions that women with OUD encounter or perceive when they present for care. Recognizing OUD as a chronic illness is imperative to providing patient-centered care that establishes a trusting and safe environment. The first contact for these women in both inpatient and outpatient settings, often at registration or reception, needs to be free of stigmatizing behaviors and language. The subsequent encounter with a medical assistant or nurse is profoundly influenced by the presentation of the patient from the initial contact. Whether or not a patient has sought prenatal care, her parity, family structure, history, and other factors all influence how she is perceived and received. Many factors can contribute to initial perceptions of patients by staff and nurses, and targeted interventions have been shown to significantly impact how women with substance use disorder (SUD) or opioid use disorder (OUD) are distinguished from other patients presenting for care.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ECreate Awareness of OUD in Pregnancy:\u003C\u002Fstrong\u003E Determine appropriate avenues through which to educate office\u002Fclinic and hospital staff about OUD in pregnancy (e.g., emails, physical bulletin boards, staff meetings) with a focus on mitigation of discrimination and bias toward patients with OUD. Utilize content such as our “Education on OUD Tool” (Refer to the Resources section of this Best Practice).\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ETrain Staff and Providers on Trauma-Informed Care\u003C\u002Fstrong\u003E: Create opportunities for staff and providers to learn about Trauma-Informed Care.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EBe Aware of Local Cultures\u003C\u002Fstrong\u003E: Identify “cultural coaches” to help explain the nuances of local culture that may impact care and treatment.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ETrain Providers on Use of OUD Treatment Protocols\u003C\u002Fstrong\u003E: Create opportunities for providers responsible for evaluating and treating pregnant patients to learn and ask questions about facility-specific OUD treatment protocols and to obtain a waiver to prescribe buprenorphine. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ETrain Nursing on Use of OUD Treatment Protocols: \u003C\u002Fstrong\u003ECreate opportunities for nurses responsible for caring for pregnant inpatients to learn and ask questions about the facility-specific protocol developed as well as how to use the Clinical Opiate Withdrawal Scale (COWS) and the Ramsay Sedation Scale (Ramsay Sedation Scale) in the care of patients with OUD and how to administer buprenorphine and methadone.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:44:44.662Z,updatedAt:2020-09-03T21:22:37.826Z,publishedAt:o,videoUrl:eN,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWkE9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--ecbec2f604c110b7cf77e6b70228e6ac07a361c9\u002FBP%2034_35.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEducating providers and staff about OUD may seem overwhelming at first, especially if the culture of care at your center has historically taken a punitive or judgmental approach to caring for mothers with a substance use disorder. Demystifying the educational “roadmap” can go a long way in giving clinical champions the most important starting points for educating the multidisciplinary health care team. This may consist of the following basic concepts:\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEvery pregnant woman should be verbally screened for substance use at multiple points in care\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EOUD is a chronic medical condition that can be treated\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESubstance use is almost always connected to significant past trauma and\u002For Adverse Childhood Events (ACEs). A Trauma-Informed Care approach that emphasizes empathy and reduces stigma and bias is the standard of care and improves outcomes. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMAT (methadone or buprenorphine) is the standard of care for pregnant women with OUD. Withdrawal is dangerous for both mother and fetus. MAT is linked to better maternal and neonatal outcomes and reduces overdose deaths. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEducation about the signs, symptoms, and treatment of NAS is critical. Non-pharmacologic treatment of NAS such as rooming-in, skin-to-skin contact, swaddling, and reducing external stimuli results in better support of the mother\u002Fbaby dyad, reduced need for pharmacologic treatment, and shorter hospital stays.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ETreatment requires provider, peer, family, and community support. Systems of care for women with OUD should always address transitions from one location of care to another, including comprehensive discharge planning and the development of a Plan of Safe Care that ensures maternal continuation of treatment and recovery, and appropriate medical, developmental, and safety follow-up for the newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EThe overarching goal is to preserve the mother\u002Fbaby dyad. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:aE,fullName:Jennifer Carraher,professionalDesignation:RNC-OB, PHN, MS,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EJennifer Carraher is an obstetric and public health nurse with advanced practice specialization in perinatal womens health. She is also a medical sociologist with an extensive background in social theory and science and technology studies. Her current research includes health disparities, birth equality and intrapartum harm reduction. Jennifer remains a bedside nurse committed to care in San Francisco Bay Area communities.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},resources:{id:dA,title:Confronting the Stigma of Opioid Use Disorder and Its Treatment.,description:a,fileUrl:https:\u002F\u002Fwww.cdph.ca.gov\u002FPrograms\u002FCFH\u002FDMCAH\u002FCHVP\u002FPages\u002Fdefault.aspx},{id:dB,title:AMA Opioid Task Force Resources.,description:a,fileUrl:https:\u002F\u002Fwww.ama-assn.org\u002Fdelivering-care\u002Fopioids\u002Freversing-opioid-epidemic},{id:dC,title:eO,description:a,fileUrl:eP},{id:bQ,title:SAMHSA. Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054, Rockville, MD, 2018. Factsheet #2 Initiating Pharmacotherapy for Opioid Use Disorder. Factsheet #4 Managing Pharmacotherapy Over the Course of Pregnancy.,description:\r\n,fileUrl:bZ},{id:eQ,title:Clinical Opiate Withdrawal Scale (COWS).,description:a,fileUrl:bn},{id:bR,title:Ramsay Sedation Scale.,description:a,fileUrl:bH},{id:eH,title:Education on OUD Tool.,description:a,fileUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBLQT09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--b00a798231ef8f9fd296a9246a5452b5235d62b1\u002FEducation%20on%20OUD%20Tool.pdf},references:{id:123,title:Facing addiction in America: the surgeon generals report on alcohol, drugs, and health. Chap 6: health care systems and substance use disorders. Accessed December 15, 2019. https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fbooks\u002FNBK424848\u002F.,body:a},{id:124,title:Opioid use disorder and pregnancy FAQ. American College of Obstetricians & Gynecologists https:\u002F\u002Fwww.acog.org\u002F- \u002Fmedia\u002FFor-Patients\u002Ffaq506.pdf?dmc1&ts20190509T0049178971.,body:a},{id:125,title:Committee opinion on opioid use and opioid use disorder in pregnancy. https:\u002F\u002Fwww.acog.org\u002FClinical-Guidance-and- Publications\u002FCommittee-Opinions\u002FCommittee-on-Obstetric-Practice\u002FOpioid- Use-and-Opioid-Use-Disorder-in-Pregnancy?IsMobileSetfalse. Accessed December 15, 2019. ,body:a}},{id:ap,title:Educate patients and families about opioid use disorder,description:a,position:ap,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EAddiction is a chronic, relapsing condition. Pregnancy can motivate women to discontinue drug use, but abrupt discontinuation of opioids during pregnancy can have deleterious effects for both the mother and fetus. Patients and their families may not be aware that medication assisted treatment (MAT) is the standard of care for opioid use disorder (OUD) during pregnancy and may adopt risky strategies such as abrupt and complete cessation of opioids without realizing the risk to their pregnancy and to their recovery. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPatients need to be educated on different types of opioids to understand how they will affect their body. Understanding different types of opioids opens the discussion about withdrawal symptoms, warning signs to look for, and when to obtain medical help for withdrawal. Patients and their families need to fully understand the nature of addiction, the potential impact of continued opioid use during pregnancy, the recommended treatment for OUD during pregnancy and beyond, the need to address potential or co-occurring mental health conditions, the members of the treatment team involved in their comprehensive care, and the aim of partnering with them every step of the way. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EEducate the patient on the definition of opioid use disorder (OUD). \u003C\u002Fstrong\u003EPatients should be informed that OUD is defined as a pattern of opioid use characterized by tolerance, craving, inability to control use, and continued use despite adverse consequences. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EAssess and educate the patient for potential causes of opioid use disorder, including but not limited to:\u003C\u002Fstrong\u003E\u003Cul\u003E\u003Cli\u003EChronic pain\u003C\u002Fli\u003E\u003Cli\u003EHistory of trauma\u003C\u002Fli\u003E\u003Cli\u003EOpioid misuse\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EAssess the patient for co-occurring mental health conditions. \u003C\u002Fstrong\u003E A preliminary assessment conducted on intake should be followed by a second assessment once patient’s OUD is stabilized on MAT or another course of OUD treatment. For many women with OUD, what appears at first to be significant mental illness may resolve or lessen significantly once the OUD is addressed. Validated screening tools include GAD-7, MDQ, PHQ-9, ACE, and the Edinburgh Postnatal Depression Scale (See the \u003Cstrong\u003EResources\u003C\u002Fstrong\u003E for more tools). Assess patients for:\u003Cul\u003E\u003Cli\u003EDepression\u003C\u002Fli\u003E\u003Cli\u003EHistory of trauma\u003C\u002Fli\u003E\u003Cli\u003EPTSD\u003C\u002Fli\u003E\u003Cli\u003EAnxiety \u003C\u002Fli\u003E\u003Cli\u003EOther psychiatric disorders such as bipolar, schizophrenia, and personality disorders\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EEducate the patient on the different types of opioids.\u003C\u002Fstrong\u003E For short-acting opioids, such as heroin, withdrawal symptoms can occur 4-6 hours after ingestion, can peak at 1-3 days, and gradually subside over 5-7 days. For long-acting opioids, such as methadone or buprenorphine, withdrawal symptoms occur 24-36 hours after ingestion and may last days to several weeks. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EWithdrawal Symptoms:\u003C\u002Fstrong\u003E\u003Cul\u003E\u003Cli\u003EGeneralized pain \u003C\u002Fli\u003E\u003Cli\u003EMuscle pain\u003C\u002Fli\u003E\u003Cli\u003ENausea\u003C\u002Fli\u003E\u003Cli\u003EVomiting\u003C\u002Fli\u003E\u003Cli\u003EDiarrhea\u003C\u002Fli\u003E\u003Cli\u003ESweating \u003C\u002Fli\u003E\u003Cli\u003ERhinorrhea\u003C\u002Fli\u003E\u003Cli\u003ETearing and dilated pupils\u003C\u002Fli\u003E\u003Cli\u003ETremors\u003C\u002Fli\u003E\u003Cli\u003ERestlessness and anxiety \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EEducate patients on why treatment during pregnancy is important and what it involves:\u003C\u002Fstrong\u003E\u003Cul\u003E\u003Cli\u003EBetter outcomes for the patient and her newborn. \u003C\u002Fli\u003E\u003Cli\u003EAbrupt cessation of opioids, and withdrawal, is harmful to the fetus. \u003C\u002Fli\u003E\u003Cli\u003EPlanning for safe care. \u003C\u002Fli\u003E\u003Cli\u003EConnecting mother and newborn to resources to help them after discharge.\u003C\u002Fli\u003E\u003Cli\u003EHelping the mother receive treatment that will help her and that is recommended for her and her newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EDevelop an OUD management plan with the patient and her family:\u003C\u002Fstrong\u003E\u003Cul\u003E\u003Cli\u003EReview dose and appropriateness of current opioid use, and limit opioid prescribing for post-partum pain as detailed in \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F14\\u003E\u003Cstrong\u003EBest Practice #14. \u003C\u002Fstrong\u003E\u003C\u002Fa\u003E\u003C\u002Fli\u003E\u003Cli\u003EDiscuss risks and benefits of opioid use, review treatment goals, review neonatal abstinence syndrome (NAS). \u003C\u002Fli\u003E\u003Cli\u003ETake a thorough history and review the prescription drug monitoring program. \u003C\u002Fli\u003E\u003Cli\u003EEnsure adequate resources for psychosocial support, substance abuse treatment programs, and locally available resources.\u003C\u002Fli\u003E\u003Cli\u003EIf appropriate and resources are available, discuss the potential for outpatient buprenorphine induction (refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F10\\u003E\u003Cstrong\u003EBest Practice #10\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E).\u003C\u002Fli\u003E\u003Cli\u003EDiscuss harm reduction. Have resources available to discuss the use of naloxone, safe injection sites, needle exchange clinics and safe needle handling. See Resources below for an infographic from the CDC regarding the cleaning of syringes.\u003C\u002Fli\u003E\u003Cli\u003EDiscuss dangers of abrupt cessation of opioids. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EEducate patient and family on use of naloxone (Narcan):\u003C\u002Fstrong\u003E\u003Cul\u003E\u003Cli\u003ENaloxone is used, along with other emergency medical treatment, to reverse the life-threatening effects of a known or suspected opioid overdose. Naloxone is in a class of medications called opioid antagonists. It works by blocking the effects of opioids to relieve dangerous symptoms caused by high levels of opioids in the blood. Naloxone will not reverse the effects of non-opioid drugs. \u003C\u002Fli\u003E\u003Cli\u003ENaloxone comes as a liquid solution that can be sprayed into the nose, or as a liquid in a vial that can be injected into muscle. It is usually given as needed to treat opioid overdoses. \u003C\u002Fli\u003E\u003Cli\u003EKeep the nasal spray available at all times to use in case of an opioid overdose. Be aware of the expiration date on the medication and replace it when this date passes. Some harm reduction kits include two doses of naloxone. Explain how the patient can continue to access naloxone so that it is always available.\u003C\u002Fli\u003E\u003Cli\u003ESymptoms of an opioid overdose include excessive sleepiness, not awakening when spoken to in a loud voice or when the middle of the chest is rubbed firmly, shallow or stopped breathing, or small pupils (black circles in the center of the eyes). If someone sees a person experiencing these symptoms, he or she should give the first naloxone dose and then call 911 immediately. After giving the naloxone nasal spray, someone should stay with the patient and watch closely until emergency medical help arrives.\u003C\u002Fli\u003E\u003Cli\u003EA \u003Cstrong\u003E“Guide for Patients and Caregivers”\u003C\u002Fstrong\u003E is available to print in pamphlet format. See the Resources section of this Best Practice.\u003C\u002Fli\u003E\u003Cli\u003EFentanyl: Whether taken knowingly or as a contaminant with other drugs, fentanyl’s increased potency relative to other opioids may require the administration of greater doses of naloxone per overdose event. \u003C\u002Fli\u003E\u003Cli\u003ECall 911 for any suspected overdose event.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:45:00.810Z,updatedAt:2021-02-17T01:12:01.449Z,publishedAt:eR,videoUrl:eN,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWkU9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--13e8367d196dcf055351d7c8b7a23957f32c4ebf\u002FBP%2034_35.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThe midwife at one of Kayla’s prenatal visits reassures her that no baby is born an addict. She educates her about how prenatal exposures to medications can lead to temporary withdrawal within newborns and that for opioid-exposed newborns there is an evidence-based treatment for NAS called Eat Sleep Console that makes her mothering and ability to console her baby the most important part of her newborn’s treatment. Kayla seems relieved after the midwife shares this with her.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe midwife than speaks with her about how substance use is a chronic disease, similar to diabetes or hypertension, and like any other long-term process, it requires a wide-ranging treatment plan to ensure good health outcomes for her and her baby. She shares that the medication buprenorphine prevents relapse, decreases cravings and even helps some of the chronic pain. The midwife also suggests other mind-body techniques to help with chronic pain and substance use, such as counseling, physical therapy, and other manual therapies to decrease her pain and desire for pain pills. Kayla has relaxed more and is even starting to smile and make more eye contact with the midwife. She wants to know how long she’ll have to be on a medicine like buprenorphine or methadone. The midwife tells her that although the medical literature indicates that Medication Assisted Treatment (MAT) is effective and the best treatment for OUD during pregnancy and postpartum, the optimal duration of treatment with MAT is unknown. Just as with other effective medications for chronic conditions, like insulin or blood pressure medicine, MAT is not usually prescribed with an expected end date. The midwife reassures her that breastfeeding is safe with either of these medication options and is in fact strongly encouraged to help diminish the symptoms associated with NAS. Lastly, she points out to Kayla that the clinic has a Seeking Safety group and she may want to attend to learn more about trauma and panic disorders.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:ab,fullName:bz,professionalDesignation:bA,biography:bB,disclosure:b},{id:aq,fullName:eS,professionalDesignation:eT,biography:eU,disclosure:b},resources:{id:dy,title:A Guide for patients and caregivers regarding overdose and naloxone administration.,description:a,fileUrl:https:\u002F\u002Fwww.pharmacy.ca.gov\u002Fpublications\u002Fnaloxone_fact_sheet.pdf},{id:dz,title:CDC infographic on cleaning syringes.,description:a,fileUrl:https:\u002F\u002Fwww.cdc.gov\u002Fhiv\u002Fpdf\u002Flibrary\u002Ffactsheets\u002Fcdc-hiv-clean-your-syringes.pdf},{id:ew,title:eV,description:a,fileUrl:eW},references:{id:db,title:ACOG Committee Opinion No 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017;130: e81-94.,body:a},{id:111,title:Centers for Disease Control and Prevention. Substance Use During Pregnancy. https:\u002F\u002Fwww.cdc.gov\u002Freproductivehealth\u002Fmaternalinfanthealth\u002Fsubstance- abuse\u002Fsubstance-abuse-during-pregnancy.htm. Published July 24, 2019. Accessed December 19, 2019.,body:a},{id:112,title:Substance Abuse and Mental Health Services Administration. A collaborative approach to the treatment of pregnant women with opioid use disorder. https:\u002F\u002Fstore.samhsa.gov\u002F\u002Fsystem\u002Ffiles\u002Fsma16- 4978.pdf. Accessed December 19, 2019.,body:a},{id:ds,title:Substance Treatment Locator. Substance Abuse and Mental Health Services Administration. https:\u002F\u002Ffindtreatment.samhsa.gov\u002Flocator. Accessed December 19, 2019.,body:a},{id:dt,title:Substance Abuse and Mental Health Services Administration. TIP 54: managing chronic pain in adults with or in recovery from. https:\u002F\u002Fstore.samhsa.gov\u002Fproduct\u002FTIP-54-Managing-Chronic-Pain-in-Adults- With-or-in-Recovery-From-Substance-Use-Disorders\u002FSMA13-4671. Accessed December 19, 2019.,body:a},{id:115,title:Opioid Use Disorder and Pregnancy FAQ. The American College of Obstetricians and Gynecologists. https:\u002F\u002Fwww.acog.org\u002F-\u002Fmedia\u002FFor- Patients\u002Ffaq506.pdf?dmc1&ts20190509T0049178971. Accessed December 15, 2019.,body:a},{id:b$,title:Substance Use During Pregnancy. Guttmacher Institute. https:\u002F\u002Fwww.guttmacher.org\u002Fstate-policy\u002Fexplore\u002Fsubstance-use-during- pregnancy. Accessed December 19, 2019.,body:a},{id:cg,title:Naloxone Nasal Spray: MedlinePlus Drug Information. MedlinePlus. https:\u002F\u002Fmedlineplus.gov\u002Fdruginfo\u002Fmeds\u002Fa616003.html. Accessed December 19, 2019.,body:a},{id:118,title:Seeking Safety. Treatment Innovations. https:\u002F\u002Fwww.treatment- innovations.org\u002Fss-description.html. Accessed December 19, 2019.,body:a},{id:cC,title:Lenz AS, Henesy R, Callender K. Effectiveness of seeking safety for co- occurring posttraumatic stress disorder and substance use. J Couns Dev. 2016;94(1):51-61. doi:10.1002\u002Fjcad.1206. https:\u002F\u002Fwww.treatment- innovations.org\u002Fuploads\u002F2\u002F5\u002F5\u002F5\u002F25555853\u002F2016_lenz_et_al_meta- analysis_of_ss.pdf. ,body:a},{id:cD,title:Centers for Disease Control and Prevention. Acetyl fentanyl overdose fatalities--Rhode Island, March-May 2013. Morb Mortal Wkly Rep. 2013;62(34):703–704. https:\u002F\u002Fwww.cdc.gov\u002Fmmwr\u002Fpreview\u002Fmmwrhtml\u002Fmm6234a5.htm.,body:a},{id:121,title:Collier KW, Macafee LK, Kenny BM, Meyer MC. Does co-location of medication assisted treatment and prenatal care for women with opioid use disorder increase pregnancy planning, length of interpregnancy interval, and postpartum contraceptive uptake? J Subst Abuse Treat. 2019;98:73-77. doi:10.1016\u002Fj.jsat.2018.12.001.,body:a},{id:122,title:Screening Tools. SAMHSA-HRSA. https:\u002F\u002Fwww.integration.samhsa.gov\u002Fclinical-practice\u002Fscreening-tools. Accessed December 19, 2019.,body:a},{id:df,title:Prescription Opioids: What You Need to Know. Centers for Disease Control and Prevention. https:\u002F\u002Fwww.cdc.gov\u002Fdrugoverdose\u002Fpdf\u002FAHA-Patient- Opioid-Factsheet-a.pdf. Accessed December 19, 2019.,body:a}},{id:s,title:Educate pregnant women about opioid use disorder in pregnancy and the hospital experience,description:a,position:s,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EThoughts about labor and delivery, for most pregnant women, are riddled with questions and anxiety about the unknown. For the pregnant woman with opioid use disorder (OUD), there is an additional layer of stress, emotions, and anxiety related to childbirth and motherhood associated with her path to wellness and recovery. After having built relationships and trust with her prenatal care team, the thought of transitioning care to a new team of providers in the L&D unit can cause additional stress for the mother with OUD. She may or may not have already met or had an opportunity to build trust and relationships with this staff and may question their motives, feel judged, and begin to worry that her newborn will be taken from her or that her pain will not be managed due to her OUD status.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EProviding education about expected health care services and processes is associated with social and psychological benefits including reduced fears and anxiety, and provides patients with an opportunity to ask questions, thus increasing a patient’s overall knowledge related to the anticipated experience. Providing education on what to expect in the hospital during a prenatal care appointment can reinforce previously received childbirth education and\u002For facilitate education for those who were unable or chose not to attend. \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EThe “what to expect in the hospital” conversation during a prenatal care appointment is an opportunity to introduce the new L&D team and to discuss goals and options for pain management and institutional screening and drug testing. It is also an opportunity to address and debunk any myths or untruths about the upcoming experience, especially regarding social and child welfare referrals and support. Transparency in the provision of information shows that providers care and facilitates continued engagement by the mother with OUD in the development of a Plan of Safe Care and self-management. Ultimately these efforts increase coping skills and support the increased likelihood of a positive labor experience.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEducation and social support are the best ways to facilitate continued engagement with the Plan of Safe Care, recovery & wellness, positive progression through the continuum of care, and optimal patient experience.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003EInclude “what to expect in the hospital” in the prenatal checklist. The discussion should be scheduled for the third trimester and be expanded to include the following. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ERecognize potentially traumatic events that might occur and help prepare for these possibilities, including:\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ELabor complications\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUnexpected or emergent cesarean delivery\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENeonatal complications, including NICU admission\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInvolvement of child protective services\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExperiences of discrimination or disrespectful treatment\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPerceived lack or loss of control or sense of autonomy\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPresent the topic of postpartum care coordination. The postpartum period represents a time of increased vulnerabilities, and women with OUD relapse and even overdose far more often in the postpartum period than during pregnancy. Relapse is a common part of addiction, and often someone with OUD will relapse several times before successfully quitting. Forty-nine percent of women with OUD treated with medication assisted treatment (MAT) in an initial pregnancy were not in treatment at the start of a subsequent pregnancy, even with specific transition plans for MAT continuation (including warm handoffs). Of those on MAT, only 37% of women had the same MAT provider for both pregnancies. Education for the family and the patient around this is very important. Patients often have “all or none” thinking, but slips and relapses commonly occur, and it doesn’t mean failure. Stressful events are triggers for relapse, including loss of insurance and access to treatment, demands of caring for a new baby, sleep deprivation, and fear of losing child custody.\u003Cul\u003E\u003Cli\u003EDiscuss postpartum information, such as contraception and access to psychosocial support.\u003C\u002Fli\u003E\u003Cli\u003EEmphasize that the first obstetrical follow-up visit is between weeks one and two.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEngage hospital L&D staff and prenatal providers. \u003Cul\u003E\u003Cli\u003ERecruit from both environments (clinic\u002Fprovider office and hospital) to champion the collaboration.\u003C\u002Fli\u003E\u003Cli\u003EDiscuss important workflows and policies and ensure that prenatal care providers are sharing accurate information. \u003C\u002Fli\u003E\u003Cli\u003EDiscuss offering an opportunity to schedule a “meet and greet” that supports a warm handoff.\u003C\u002Fli\u003E\u003Cli\u003EUnderstand the hospital’s intrapartum pain management policies in order to educate the patient on pain control options and encourage transparency regarding OUD for optimal management of pain and symptoms.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDesign an educational “what to expect in the hospital” curriculum unique to your hospital.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:45:22.944Z,updatedAt:2024-05-29T17:08:21.299Z,publishedAt:an,videoUrl:eX,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWkk9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--01793beab487292b3045127774b075de83d24b0e\u002FBP%2036_38.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EKayla is currently receiving prenatal care in an integrated care model. The prenatal care team includes nurse midwives and high-risk obstetricians to provide prenatal information and monitor the status of the pregnancy. Psychiatrists, mental health counselors, and addiction medicine professionals manage Medication Assisted Treatment (MAT) and develop relapse prevention strategies. Because multidisciplinary caregivers are co-located in the same space, Kayla can receive medical services, mental health care, and psychosocial support in one appointment. A streamlined process for scheduling improves retention and keeps Kayla engaged in her own care. Education opportunities are also provided in Kayla’s management and include parenting classes, prenatal education, and classes that prepare her for challenges of caring for a baby who has been exposed to opioids in utero. Her care team prepares her for the hospital experience by aiding in preparation of admission paperwork and involving her in the plan of care for pain management. Kayla has an upcoming appointment with an anesthesiologist to discuss pain management and a tour of the hospital to follow. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:aq,fullName:eS,professionalDesignation:eT,biography:eU,disclosure:b},{id:_,fullName:bi,professionalDesignation:c,biography:bj,disclosure:b},resources:{id:dx,title:NNEPQIN Checklist-Chart- Template (Prenatal Checklist).,description:a,fileUrl:ca},{id:ey,title:eV,description:a,fileUrl:eW},{id:c$,title:Pregnancy and Substance Use: A Harm Reduction Toolkit (Includes sample birth plan) ,description:a,fileUrl:a},references:{id:cG,title:Substance Abuse and Mental Health Services Administration. Clinical guidance for treating pregnant and parenting women with opioid use disorder. https:\u002F\u002Fstore.samhsa.gov\u002Fproduct\u002FClinical- Guidance-for-Treating-Pregnant-and-Parenting-Women-With-Opioid-Use- Disorder-and-Their-Infants\u002FSMA18-5054. Accessed December 19, 2019.,body:a},{id:298,title:White, A., Saxer, K., Raja, S., & Hall, S. L. (2022). A Trauma-informed Approach to Postpartum Care. Clin Obstet Gynecol, 65(3), 550-562. doi:10.1097\u002FGRF.0000000000000730,body:a}},{id:t,title:Provide health care providers with stigma education\u002Fresources,description:a,position:t,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ETreatment of substance use disorder (SUD) is often eclipsed by the misperception that SUD is a personal weakness or a willful choice. Whether or not these misconceptions are consciously employed, they can have a dramatic impact on patient outcomes and adherence to treatment during recovery. Stigma can be experienced across several domains: self, social, and structural stigma. This toolkit focuses on structural stigma oriented toward health care professionals and systems-based approaches.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EProviders who interact with OUD\u002FSUD patients often cite them as their most challenging patients due to expectations of cooperation, aggression, demands, and low rates of treatment completion. It is therefore not uncommon for health professionals who interact with these patients to show unconscious bias whether or not they explicitly report negative attitudes. Stigma can come from staff interactions at all contact points and through materials provided in clinical settings.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ESeveral studies have shown that perceived discrimination and stigma from providers has a significant impact on treatment completion by increasing the likelihood of dropout and decreasing retention. Whether or not adoption of stigmatizing beliefs is conscious, evidence shows that health professionals not trained to interact with patients with SUDs may avoid or shorten appointment visits or express less empathy to these patients. This may reduce quality of care and decrease patient retention. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003E\u003Cstrong\u003EPerform a language audit of all internal (EHR, protocols) and external (brochures, educational pamphlets) materials.\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EDesignate a staff member to review all materials distributed or posted in the clinic regarding OUD\u002FSUD to address any stigma-perpetuating language. An analysis of materials should identify the following terminology, and materials should be updated accordingly: \u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EDiagnosis \u003C\u002Fstrong\u003E- In alignment with DSM - 5, replace older categories of substance “abuse”, “drug habit”, and “dependence” with a single classification of “substance use disorder” (SUD) or “opioid use disorder”. Use clinically accurate terminology which reflects the treatable, clinical, and chronic nature of SUD and moves away from choice-based terminology. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EPerson-first language \u003C\u002Fstrong\u003E– Discussing substance use should follow the accepted standard for discussing people with disabilities and\u002For chronic medical conditions. Replace “abuse”, “abuser”, “addict”, “druggie”, “alcoholic” with “person with SUD” or “person experiencing” with “person struggling.”\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003ETesting and Toxicology \u003C\u002Fstrong\u003E– Replace “clean” and “dirty” urine drug screens with “positive” and “negative” or “expected” vs. “unexpected” and use “consistent with prescribed medications.” “Person in Recovery” focuses on the process and acknowledges the consistent management of symptoms and stable conditions. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EMedications \u003C\u002Fstrong\u003E\u003Cem\u003E– \u003C\u002Fem\u003EAvoid using “replacement” and “substitution” therapy. Preferred are “Medication Assisted Treatment” (MAT), “pharmacotherapy for …”, and specifically “medications for OUD” (MOUD) or “medications for SUD”.\u003Cem\u003E \u003C\u002Fem\u003EAdditionally,\u003Cem\u003E \u003C\u002Fem\u003Eonce an individual is receiving MAT, “medically indicated tapering” or “decreasing of dosage” (from buprenorphine or methadone) conveys that the medications might be noxious toxins leaving the body and should also therefore be replaced. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003E\u003Cstrong\u003EMaternal and Newborn \u003C\u002Fstrong\u003E- Although not commonly employed in medical literature or materials, use of the language “crack baby,” “opioid baby,” or “drug-addicted baby” should be replaced with neonatal abstinence syndrome (NAS), for opioid or heroin exposure, and prenatal cocaine exposure, or colloquially “in utero exposure to substance\u003Cem\u003E …”.\u003C\u002Fem\u003E \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EIndividual identification of stigma \u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EProvide opportunities for individual identification of stigma:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EFormally through Implicit Associations Test– Mental Health, a test for unconscious bias in relation to mental health\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInformally through Stigma Self-Assessments\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cstrong\u003EAddressing stigma: healing stigma through training and intervention\u003C\u002Fstrong\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EBroad education campaigns oriented toward changing public perception have been found to have limited impact on changing attitudes about opioid use disorder. However, targeted intervention with staff, medical personnel, and trainees has been shown to reduce stigmatizing language and behaviors. Contact-based interventions where individuals with SUD can humanize patients has been shown to significantly reduce stigmatizing ideology compared to education alone. When training is not immediately available, the Woll Healing Approach is recommended and has a self-directed workbook. Their approach addresses beliefs and accountability in order to heal the potential trauma and effects of working with OUD and SUD populations. Several training opportunities are available to educate medical professionals and staff, some more informal than others. Potential training opportunities are listed below in order of feasibility and scale: \u003C\u002Fdiv\u003E\u003Cdiv\u003E \u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInformal staff and patient-facing personnel (including health professional) intervention: \u003Cul\u003E\u003Cli\u003EFocus on inadvertent ways personnel may be perpetuating stigma\u003C\u002Fli\u003E\u003Cli\u003EExplore the perceptions personnel may hold towards the SUD population\u003C\u002Fli\u003E\u003Cli\u003EFacilitate discussion on how to adopt alternative language\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEmpathy training or defined stigma curricula: \u003Cul\u003E\u003Cli\u003EMany regional Addiction Technology Transfer Centers have access to CME and CEU credit for completion of their curricula: \u003Cul\u003E\u003Cli\u003EAddiction Technology Transfer Centers Network Center: \u003Ca href\https:\u002F\u002Fattcnetwork.org\u002Fcenters\u002Fglobal-attc\u002Ftraining-and-events-calendar\\u003Ehttps:\u002F\u002Fattcnetwork.org\u002Fcenters\u002Fglobal-attc\u002Ftraining-and-events-calendar\u003C\u002Fa\u003E\u003C\u002Fli\u003E\u003Cli\u003EPacific Addiction Technology Transfer Centers: https:\u002F\u002Fattcnetwork.org\u002Fcenters\u002Fglobal-attc\u002Ftraining-and-events-calendar \u003C\u002Fli\u003E\u003Cli\u003ECalifornia Health care Foundation: \u003Ca href\https:\u002F\u002Fwww.chcf.org\u002Ftopic\u002Fopioid-safety\u002F\\u003Ehttps:\u002F\u002Fwww.chcf.org\u002Ftopic\u002Fopioid-safety\u002F\u003C\u002Fa\u003E \u003C\u002Fli\u003E\u003Cli\u003EAcceptance and Commitment Training (ACT), a cognitive-based approach incorporating flexibility and mindfulness, has shown to significantly increase positive attitudes toward people with SUDs and decrease negative thoughts toward SUD clients among SUD providers. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMedical trainee education:\u003Cul\u003E\u003Cli\u003EIntegrate stigma training in medical curricula. An upstream approach is shown to be among the most effective.\u003C\u002Fli\u003E\u003Cli\u003ETrainee education can be effective in combating stigma by integrating understanding and efficacy into medical residency programming, with particularly positive outcomes for work with pregnant women. Self-reflection techniques and training rotations in specialized prenatal clinics has been shown to significantly increase the comfort level of working with this population and reduce negative ideology.\u003C\u002Fli\u003E\u003Cli\u003EMany clinics and hospitals interact with or supervise clinical trainees. Integrating, introducing, or providing stigma reduction trainings to medical residents, fellows, and post-docs may be an effective tool. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:45:36.834Z,updatedAt:2020-09-03T21:24:17.301Z,publishedAt:o,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386926,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWk09IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--4bfd64e7ccf143587560bb51f23b4feee19c191b\u002FBP_37.pptx,deepDive:b,archetypes:{id:j,name:B,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDuring mid-pregnancy, Kayla’s midwife identifies a pattern of cancelled and missed appointments. It would be useful to explore with Kayla the reason for the pattern. A common assumption might be that she hasn’t prioritized her prenatal care. However, through positive reframes of inquiry, you might uncover that she had a stigmatizing experience that may have included language barriers, rushed appointments, or judgmental attitudes from physicians at another clinic that currently influences her desire to seek health care from an unknown provider. Kayla may also be worried about disclosing her OUD and putting herself at risk for subsequent CPS involvement. Use possible reframes oriented toward determining prior stigmatizing experiences with health care providers and provide Kayla with reassurance. Determining why Kayla hasn’t utilized clinical services can decrease her feelings of judgement at your clinic. It can also inform a more targeted approach for your interaction with Kayla directly, leading to a higher chance of care-seeking for prenatal care. It’s important to understand that your practice operates within a larger health care landscape that stigmatizes and creates disincentives for care-seeking among substance using patients. Investigating your role and other stigmatizing contact points within a patient’s lifetime can better inform care.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:az,fullName:Lauren Caton,professionalDesignation:MPH ,biography:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ELauren Caton, MPH is a Clinical Research Coordinator at the Center for Behavioral Health Services and Implementation Research (CBHSIR) in the Department of Psychiatry & Behavioral Sciences at Stanford University School of Medicine. Her projects at CBHSIR focus on the implementation and sustainment of medication-assisted treatment for opioid use disorders.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,disclosure:b},resources:{id:bM,title:Toward an Addiction-ary; Language, Stigma, Treatment, and Policy.,description:a,fileUrl:https:\u002F\u002Ffacesandvoicesofrecovery.org\u002Fresource\u002Ftoward-an-addiction-ary-language-stigma-treatment-and-policy\u002F},{id:bN,title:eO,description:a,fileUrl:eP},{id:bO,title:Anti-Stigma Toolkit: A Guide to Reducing Addiction-Related Stigma.,description:a,fileUrl:https:\u002F\u002Fwww.montefiore.org\u002Fdocuments\u002FANTI-STIGMA-TOOLKIT-A-Guide-to-Reducing-Addiction-Related-Stigma.pdf},{id:bP,title:Healing the stigma of addiction: A guide for treatment professionals.,description:a,fileUrl:http:\u002F\u002Fwww.williamwhitepapers.com\u002Fpr\u002FWoll%2C%20Healing%20the%20Stigma%20of%20Addiction.pdf},references:{id:eF,title:Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. Drug Alcohol Rev. 2010;29(5):491-7. doi: 10.1111\u002Fj.1465-3362.2010.00173.,body:a},{id:eG,title:Boekel LCV, Brouwers EP, Weeghel JV, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35. doi:10.1016\u002Fj.drugalcdep.2013.02.018.,body:a},{id:99,title:American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Arlington, VA: American Psychiatric Association; 2013.,body:a},{id:100,title:Brener L, Hippel WV, Kippax S, Preacher KJ. The role of physician and nurse attitudes in the health care of injecting drug users. Subst Use & Misuse. 2010;45(7-8):1007-1018. doi:10.3109\u002F10826081003659543.,body:a},{id:101,title:McLaughlin DF, McKenna H, Leslie JC. The perceptions and aspirations illicit drug users hold toward health care staff and the care they receive. J Psychiatr Ment Hlt. 2000;7(5):435-441. doi:10.1046\u002Fj.1365-2850.2000.00329.,body:a},{id:102,title:Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the implicit association test: III meta-analysis of predictive validity. J Pers Soc Psychol. 2009;97(1):17-41. doi:10.1037\u002Fa0015575.,body:a},{id:103,title:Hayes SC, Bissett R, Roget N, et al. The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behav Ther. 2004;35(4):821-835. doi:10.1016\u002Fs0005- 7894(04)80022-4.,body:a},{id:cE,title:Livingston JD, Milne T, Fang ML, Amari E. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. J Addict. 2011;107(1):39-50. doi:10.1111\u002Fj.1360-0443.2011.03601.,body:a},{id:cF,title:Ramirez-Cacho WA, Strickland L, Beraun C, Meng C, Rayburn WF. Medical students’ attitudes toward pregnant women with substance use disorders. Am J Obstet Gynecol. 2007;196(1). doi:10.1016\u002Fj.ajog.2006.06.092.,body:a},{id:257,title:Botticelli, M. P., & Koh, H. K. (2016). Changing the Language of Addiction. JAMA. 316(13), 1361. doi:10.1001\u002Fjama.2016.11874. https:\u002F\u002Fwww.ncbi.nlm.nih.gov\u002Fpubmed\u002F27701667.,body:a},{id:258,title:National Academies of Sciences, Engineering, and Medicine. Ending discrimination against people with mental and substance use disorders: the evidence for stigma change. Washington, DC: The National Academies Press. https:\u002F\u002Fwww.nap.edu\u002Fcatalog\u002F23442\u002Fending-discrimination-against-people- with-mental-and-substance-use-disorders. Published 2016. Accessed December 19, 2019.,body:a}},{id:u,title:Educate pregnant women and families about neonatal abstinence syndrome and the newborn hospital experience,description:a,position:u,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EProvide education to pregnant women and families regarding neonatal abstinence syndrome (NAS), including both short-term effects and long-term consequences. Prepare pregnant women and families for an optimal hospital experience for their substance-exposed newborn by educating them on what to expect during their stay.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEducating pregnant women and families about what signs and symptoms of NAS to anticipate, and how to identify these symptoms in their newborn, can help them be active participants in the newborn’s care immediately after birth.\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EShort-term effects can appear within 1-5 days and most commonly within 2-3 days. Symptoms can include but are not limited to high-pitched cries, tremors, difficulty sleeping, poor feeding, and diarrhea. Depending on the severity, the newborn’s hospital stay may be prolonged.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ELong-term effects can appear within months to years. These consequences may include problems with vision, motor skills, and behavior\u002Fcognition, sleeping disturbances, and ear infections. Early intervention programs can ameliorate these effects and provide surveillance for them.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EOptimizing the newborn hospital experience can decrease the length of stay (LOS) and the need for pharmacotherapy. Evidence-informed practices include rooming-in, skin-to-skin contact, breastfeeding, decreasing environmental stimulation, and functional scoring of the newborn (engaging mothers to participate in scoring objective elements such as quality of cry, stool consistency, and tremulousness can be both empowering and helpful). Pregnant women and families who are informed in advance can be prepared to participate in these practices.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EConduct a prenatal visit to discuss newborn care and the newborn hospital experience. This can be accomplished in a variety of ways, including a pediatric provider appointment, hospital nursery\u002FNICU visit, social worker appointment, group visit, community support group, or public health nurse outreach. Areas of discussion should include the following:\u003C\u002Fdiv\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ERooming-in when available. Encourage close and frequent maternal contact if unable to room-in.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EInitiating early skin-to-skin contact with the newborn which promotes bonding, soothes the newborn, and aids in breastfeeding.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPromoting breastfeeding if the mother is on a stable medication assisted treatment (MAT) regimen and has no contraindications. Breastfeeding is encouraged for mothers taking methadone or buprenorphine regardless of dose, as transfer into milk is minimal. Breastfeeding is associated with decreased severity of symptoms, less need for pharmacotherapy, and shorter length of stay. Refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F9\\u003E\u003Cstrong\u003EBest Practice #9\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more information regarding breastfeeding.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EDecreasing stimulation by having limited visitors, reducing noise, and using low lighting.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EUsing functional scoring to evaluate withdrawal (e.g., ability to eat, sleep, and be consoled). Refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F19\\u003E\u003Cstrong\u003EBest Practice #19 \u003C\u002Fstrong\u003E\u003C\u002Fa\u003Efor more information regarding functional scoring. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPreparing the family for potential escalation of care based on the clinical pathway used by the hospital. Discuss the environment (e.g., NICU or Level 2 nursery), level of family involvement, role of pharmacotherapy, weaning protocol, and discharge criteria.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EExplaining the potential for the newborn to be discharged without treatment if feeding and sleeping well with minimal or no signs of withdrawal after three days for opioids with a short half-life and 5-7 days for opioids with a long half-life. This period allows for adequate identification and monitoring of possible withdrawal symptoms, the onset of which may vary depending on the medication dose, the infants metabolism, and the presence of polysubstance abuse. Refer to Table 1 in Reference #8 for detailed information regarding specific withdrawal patterns by substance. Refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F30\\u003E\u003Cstrong\u003EBest Practice #30\u003C\u002Fstrong\u003E \u003C\u002Fa\u003Efor information on inpatient monitoring of newborns managed with a non-pharmacologic bundle of care. \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPreparing the family for potential involvement of Child Protective Services (CPS). In California, there are no laws mandating that prenatal substance exposure be reported to CPS, unless the required assessment identifies other factors that indicate significant risk to a child. If CPS involvement is warranted, they will determine a safe home environment for the newborn. A safe and permanent home and family is the best place for children to grow up. CPS focuses on building family strengths and provides parents with the assistance needed to keep their children safe so that the family may stay together. CPS efforts are most likely to succeed when patients are involved and actively participate in the process. When concerns about risk factors don’t rise to the level of an investigation by CPS, a Plan of Safe Care is developed upon hospital discharge (or perhaps earlier in the pregnancy when opioid use disorder is identified) to support treatment and recovery for the mother and enhance protective factors for the dyad. Alternatively, if CPS makes an initial determination of child neglect or abuse, they may create an agreement between a parent or caretaker that is called a safety plan and which may restrict a parent from having any contact or unsupervised contact with a child. CPS must make reasonable efforts to develop safety plans to keep children with their families whenever possible, although CPS may refer for juvenile or family court intervention and placement when children cannot be kept safely within their own homes. When children are placed in out-of-home care because their safety cannot be assured, CPS will work to develop a permanency plan as soon as possible.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProviding pregnant women and families with educational handouts, such as the NAS Parent Brochures developed by the Illinois Perinatal Quality Collaborative (ILPQC) (see Resources below) and others available on the MBSEI website.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EEnrolling the newborn in early intervention programs and developmental follow-up clinics prior to discharge.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:45:55.067Z,updatedAt:2021-02-17T01:14:03.559Z,publishedAt:eR,videoUrl:eX,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWlE9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--617be85ade35d2e184333f72c5753421d55dbba0\u002FBP%2036_38.pptx,deepDive:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPediatric prenatal visits are a critical opportunity for health care professionals to provide pregnant women and their families with information about caring for their newborn. However, this opportunity is highly underutilized. The American Academy of Pediatrics (AAP) reports only 5-39% of all first-time parents and 5% of urban poor pregnant women attend a pediatric prenatal visit (Yogman, et al.). \u003Csup\u003E \u003C\u002Fsup\u003EThese prenatal visits are especially important when opioid exposure is involved as they allow providers to educate families about NAS and to prepare them for what to expect from their newborn’s hospital experience.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EAll pregnant women with OUD should be strongly encouraged by the OB\u002FGYN team to attend a pediatric prenatal visit. Local offerings may dictate the choice of who conducts this visit, and it may be offered individually or in a group setting. A nursery or NICU provider can speak directly to inpatient policies, parent involvement, and hospital treatment options. A pediatrician identified in advance can provide continuity and ongoing support after discharge. Social workers and public health nurses can provide education on available resources. It is best to hold the prenatal visit at the start of the third trimester. Providing educational handouts will allow families to review the information that was shared during the visit after they go home.\u003Cbr\u003E\u003Cbr\u003E\u003Cem\u003EReference: Yogman, et al. The Prenatal Visit. Pediatrics 2018;142(1).\u003C\u002Fem\u003E\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,archetypes:,audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:Y,fullName:aN,professionalDesignation:c,biography:aO,disclosure:b},{id:ai,fullName:bV,professionalDesignation:c,biography:bW,disclosure:b},resources:{id:a_,title:NAS What You Need To Know.,description:a,fileUrl:https:\u002F\u002Filpqc.org\u002Fwp-content\u002Fdocs\u002Ftoolkits\u002FMNO-OB\u002FNAS_WhatYouNeedToKnow.pdf},{id:bL,title:Addiction Free CA.,description:a,fileUrl:https:\u002F\u002Faddictionfreeca.org},references:{id:eq,title:Macmillan KDL, Rendon CP, Verma K, Riblet N, Washer DB, Holmes AV. Association of rooming-in with outcomes for neonatal abstinence syndrome. JAMA Pediatr. 2018;172(4):345. doi:10.1001\u002Fjamapediatrics.2017.5195.,body:a},{id:es,title:Crook K, Brandon D. Prenatal breastfeeding education. Adv Neonat Care. 2017;17(4):299-305. doi:10.1097\u002Fanc.0000000000000392.,body:a},{id:90,title:ACOG Committee Opinion No 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130: e81-94.,body:a},{id:91,title:ex,body:a},{id:92,title:bt,body:a},{id:eA,title:US Department of Health and Human Services. Child Protective Services: A Guide for Caseworkers. https:\u002F\u002Fwww.childwelfare.gov\u002Fpubpdfs\u002Fcps.pdf. Accessed December 19, 2019.,body:a},{id:eB,title:Putnam-Hornstein E, Prindle JJ, Leventhal JM. Prenatal substance exposure and reporting of child maltreatment by race and ethnicity. Pediatrics. 2016;138(3). doi:10.1542\u002Fpeds.2016-1273.,body:a},{id:eD,title:Maguire DJ, Taylor S, Armstrong K, et al. Long-term outcomes of infants with neonatal abstinence syndrome. Neonatal Netw. 2016;35(5):277-286.,body:a},{id:eE,title:Yogman, et al. The prenatal visit. Pediatrics. 2018; 142 (1).,body:a}},{id:v,title:Educate clinical providers and staff about neonatal abstinence syndrome,description:a,position:v,overview:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEducate clinical providers and staff regarding: \u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ENeonatal abstinence syndrome (NAS) identification, evaluation, and treatment of the newborn.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003ESupportive, non-judgmental interactions with parents.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,whyRecommending:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EClinical providers and staff who have a strong foundation of knowledge can educate and support families. Positive provider and staff interactions with families of newborns with NAS contribute to better outcomes and a successful hospital experience. Please refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F34\\u003E\u003Cstrong\u003EBest Practice #34\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E, \u003Cstrong\u003Eand \u003C\u002Fstrong\u003E\u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F37\\u003E\u003Cstrong\u003EBest Practice #37\u003C\u002Fstrong\u003E\u003C\u002Fa\u003E for more information about provider and staff education on opioid use disorder (OUD). \u003Cbr\u003E\u003Cbr\u003EClinical providers and staff who have a strong foundation of knowledge can educate and support families. Positive provider and staff interactions with families of newborns with NAS contribute to better outcomes and a successful hospital experience. Please refer to \u003Ca href\https:\u002F\u002Fnastoolkit.org\u002Fexplore-the-toolkit\u002Fbest-practice\u002F34\\u003E\u003Cstrong\u003EBest Practice #34\u003C\u002Fstrong\u003E \u003C\u002Fa\u003Efor more information about provider and staff education on OUD.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,strategiesForImplementation:\u003Cdiv class\trix-content\\u003E \u003Cul\u003E\u003Cli\u003ECME and in-service training can provide the information and skills needed to educate clinical providers and staff.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EFamilies can play a valuable role in the care team. They should be encouraged to initiate skin-to-skin contact and participate in other aspects of care.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EMothers should be encouraged to breastfeed if on a stable medication assisted treatment (MAT) dose. Breastfeeding is discouraged if the mother is using marijuana, and mothers should be counseled about the potential risk of exposure during lactation. Breastfeeding is contraindicated if the mother is taking illicit drugs or is infected with HIV.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EPatient care and communication of clinical information should be clear and consistent.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProvider and staff interactions with families should be supportive and non-judgmental (see Resources section below). \u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003Cdiv\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cul\u003E\u003Cli\u003EProviders and staff should be aware of external factors involved, such as a parent dealing with the disease of addiction and its treatment.\u003C\u002Fli\u003E\u003C\u002Ful\u003E\u003C\u002Fdiv\u003E,specialConsideration:b,createdAt:2020-02-14T20:46:11.088Z,updatedAt:2020-10-07T14:30:45.915Z,publishedAt:ac,videoUrl:https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446557301,powerpointUrl:https:\u002F\u002Fadmin.nastoolkit.org\u002Frails\u002Factive_storage\u002Fblobs\u002FeyJfcmFpbHMiOnsibWVzc2FnZSI6IkJBaHBBWlU9IiwiZXhwIjpudWxsLCJwdXIiOiJibG9iX2lkIn19--cde9c1483233e801747c2b5960f7a051ce1f95cc\u002FBP_39.pptx,deepDive:b,archetypes:{id:C,name:aD,content:\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDuring Baby M’s hospitalization for NAS, Kayla reflects on both the positive and negative experiences she has had with providers and staff in the hospital. She notices that the interactions would set the tone for her mood that day and be reflected in the enthusiasm and confidence she had in caring for Baby M. She really liked when the hospital’s policies and protocols were made clear to her, and she appreciated when providers and staff encouraged her to take a large part in Baby M’s care. It made her feel successful when some of the nurses commented that Baby M was so much calmer when Kayla was holding him. On the other hand, Kayla felt less confident when the staff did not seem to know about the disease and treatment of OUD and could not relate to all the conflicting feelings she was experiencing. She became upset when she sensed that providers and staff were judging her negatively because of her OUD. She just wanted them to treat her respectfully as Baby M’s mother and help her learn the best ways she could help care for him.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E},audiences:{friendlyId:w,name:x,description:y,color:z},{friendlyId:k,name:l,description:m,color:n},{friendlyId:f,name:g,description:h,color:i},category:{friendlyId:aw,name:aI,description:aJ},authors:{id:Y,fullName:aN,professionalDesignation:c,biography:aO,disclosure:b},{id:ai,fullName:bV,professionalDesignation:c,biography:bW,disclosure:b},resources:{id:aP,title:Language Matters Information Sheet.,description:a,fileUrl:http:\u002F\u002Fwww.nationalperinatal.org\u002Fresources\u002FPictures\u002F2018%20Conference\u002FLanguage_%20infographic.pdf},{id:aY,title:Refer to Best Practice #34 (Educate patients and families about OUD) for resources relevant to educating families.,description:a,fileUrl:https:\u002F\u002Fnastoolkit.org\u002Fstart-your-journey\u002Fbest-practice\u002F34},references:{id:dX,title:Atwood EC, Sollender G, Hsu E, et al. A qualitative study of family experience with hospitalization for neonatal abstinence syndrome. Hosp Ped. 2016;6(10):626-632.,body:a},{id:dZ,title:bt,body:a}}},pdf:{pdfs:{id:j,subjectableType:e,subjectableFriendlyId:b,position:j,subjectableId:j,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_1_2023-08-18.pdf,pdfType:d},{id:C,subjectableType:bv,subjectableFriendlyId:as,position:b,subjectableId:j,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fcategory_screening-assessment-level-of-care-determination_2024-05-29.pdf,pdfType:d},{id:E,subjectableType:bX,subjectableFriendlyId:w,position:b,subjectableId:j,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Faudience_outpatient_2024-05-29.pdf,pdfType:d},{id:al,subjectableType:bX,subjectableFriendlyId:k,position:b,subjectableId:C,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Faudience_labor-delivery_2024-05-29.pdf,pdfType:d},{id:X,subjectableType:bX,subjectableFriendlyId:f,position:b,subjectableId:E,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Faudience_nursery-nicu_2024-05-29.pdf,pdfType:d},{id:bC,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fall_best_practices_2024-05-29.pdf,pdfType:all_best_practices},{id:aQ,subjectableType:e,subjectableFriendlyId:b,position:C,subjectableId:C,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_2_2020-10-07.pdf,pdfType:d},{id:aR,subjectableType:e,subjectableFriendlyId:b,position:al,subjectableId:E,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_4_2020-09-04.pdf,pdfType:d},{id:Y,subjectableType:e,subjectableFriendlyId:b,position:X,subjectableId:al,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_5_2024-05-29.pdf,pdfType:d},{id:aE,subjectableType:e,subjectableFriendlyId:b,position:aQ,subjectableId:X,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_7_2023-09-15.pdf,pdfType:d},{id:az,subjectableType:bv,subjectableFriendlyId:p,position:b,subjectableId:C,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fcategory_treatment_2024-05-29.pdf,pdfType:d},{id:ab,subjectableType:e,subjectableFriendlyId:b,position:aR,subjectableId:aQ,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_8_2023-09-15.pdf,pdfType:d},{id:W,subjectableType:e,subjectableFriendlyId:b,position:aF,subjectableId:aR,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_15_2023-09-15.pdf,pdfType:d},{id:am,subjectableType:e,subjectableFriendlyId:b,position:Y,subjectableId:Y,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_9_2024-05-29.pdf,pdfType:d},{id:aF,subjectableType:e,subjectableFriendlyId:b,position:j,subjectableId:aE,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_1_2020-02-27.pdf,pdfType:d},{id:aq,subjectableType:e,subjectableFriendlyId:b,position:az,subjectableId:ab,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_11_2024-05-29.pdf,pdfType:d},{id:au,subjectableType:e,subjectableFriendlyId:b,position:ab,subjectableId:W,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_12_2024-05-29.pdf,pdfType:d},{id:_,subjectableType:e,subjectableFriendlyId:b,position:W,subjectableId:am,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_13_2023-09-15.pdf,pdfType:d},{id:F,subjectableType:e,subjectableFriendlyId:b,position:am,subjectableId:aF,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_14_2020-10-07.pdf,pdfType:d},{id:ag,subjectableType:e,subjectableFriendlyId:b,position:aq,subjectableId:aq,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_16_2020-09-04.pdf,pdfType:d},{id:$,subjectableType:e,subjectableFriendlyId:b,position:au,subjectableId:au,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_17_2024-05-29.pdf,pdfType:d},{id:Z,subjectableType:e,subjectableFriendlyId:b,position:_,subjectableId:_,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_18_2020-09-04.pdf,pdfType:d},{id:ad,subjectableType:e,subjectableFriendlyId:b,position:F,subjectableId:F,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_19_2024-05-29.pdf,pdfType:d},{id:at,subjectableType:e,subjectableFriendlyId:b,position:ag,subjectableId:ag,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_20_2020-09-04.pdf,pdfType:d},{id:ah,subjectableType:e,subjectableFriendlyId:b,position:$,subjectableId:$,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_21_2020-10-07.pdf,pdfType:d},{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oolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fbest_practice_40_2020-02-28.pdf,pdfType:d},{id:bQ,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fexecutive_summary_2020-10-08.pdf,pdfType:executive_summary},{id:eQ,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fimproving_care_2020-10-08.pdf,pdfType:improving_care},{id:bR,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fcurrent_state_2020-10-08.pdf,pdfType:current_state},{id:bS,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fimplementation_guide_2020-10-08.pdf,pdfType:implementation_guide},{id:bT,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Facronyms_2020-10-08.pdf,pdfType:acronyms},{id:eL,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fabout_the_toolkit_2020-10-08.pdf,pdfType:about},{id:eM,subjectableType:b,subjectableFriendlyId:b,position:b,subjectableId:b,fileUrl:https:\u002F\u002Fnas-toolkit-prod.s3.amazonaws.com\u002Fpdfs\u002Fmbsei_toolkit_2024-05-29.pdf,pdfType:mbsei_toolkit}}},serverRendered:true,routePath:\u002F,config:{}}}(,null,MD,best_practices,best_practice,nursery-nicu,Nursery\u002FNICU,Loaclation in a hospital for baby care after birth.,0000ff,1,labor-delivery,Labor and Delivery,Location in a hospital where babies are delivered.,009933,September 3rd, 2020,treatment,Treatment,This is a description 2,36,37,38,39,outpatient,Outpatient,A patient who receives medical treatment without being admitted to a hospital.,ff0000,40,Kayla,2,41,3,19,Alexandra Iacob,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Alexandra Iacob is a Neonatal-Perinatal Fellow at University of California, Irvine (UCI) based out of UCI Medical Center and Miller Childrens and Womens Hospital Long Beach. While in fellowship, she is also pursuing a Master in Public Health at Johns Hopkins University. She is passionate about improving neonatal outcomes across all socioeconomic classes via both quality improvement projects and policy efforts. She is particularly interested in neonatal abstinence syndrome and the impact it has on the mother, the baby, and the family as a whole.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Angela Huang,MPH, RNC-NIC,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EAngela Huang is a clinical nurse in the Neonatal Intensive Care Unit at Santa Clara Valley Medical Center, where she is also a nurse coordinator managing and leading quality improvement and research projects. She is actively involved in hospital-wide and county-wide opioid use reduction initiatives, specifically outcome improvement for mother\u002Finfant dyads with a history of substance use and exposure. Angela is also the co-chair for the CPQCC Maternal Substance Exposures Workgroup which is assessing the statewide scope of NAS and NAS management practices.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Kathryn Ponder,MD, MMS,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Ponder is a neonatologist with East Bay Newborn Specialists, working in the neonatal intensive care units at the UCSF Benioff Children’s Oakland, John Muir Walnut Creek, and Alta Bates hospitals. She is also the director of the John Muir High Risk Infant Follow-Up clinic. She has revised her practice’s guidelines for the care of infants with Neonatal Abstinence Syndrome and is leading a quality improvement initiative at John Muir to implement these changes. She has previously conducted research and published in the fields of developmental\u002Fplacental biology and maternal health. She continues to be interested in the developmental origins of disease and optimizing neurodevelopmental outcomes for infants.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Lisa Chyi,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Lisa Chyi is a practicing neonatologist at Kaiser Walnut Creek. She is co-chair for the CPQCC Maternal Substance Exposures Workgroup which is assessing the statewide scope of NAS and NAS management practices. She also helped develop the NAS management guideline and oversees NAS patient care for the Kaiser Northern California region.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EResearch Grant ; I currently have a Kaiser Research grant evaluating NAS assessment tools. As we have not collected any data yet for the study, the results had no bearing on the opinionss in the toolkit. In addition, the opinions on NAS infant management in the toolkit were a collective opinion from the expert group and do not reflect my opinion alone.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Pamela Aron-Johnson,RN,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EPamela has been at UCI Medical Center in Irvine, California for 35 years in several roles including staff nurse in the NICU for 17 years, Outpatient Nurse Manager for Primary and Specialty Services, and currently the Quality and Patient Safety Advisor for the NICU and OB departments. She is also a member of the Data Committee Advisory Group for CPQCC, and is the data nurse coordinator at UCI for both CPQCC and CMQCC. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Priya Jegatheesan,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Priya Jegatheesan is the Chief of Newborn Medicine and the Regional NICU Director for Santa Clara Valley Medical Center in San Jose, California, an institution committed to the medically underserved. Her main area of interest is outcomes and data-driven quality improvement. She established a comprehensive computerized database system in the SCVMC NICU that enables prospective data collection for quality improvement and research. She also actively participates in CPQCC’s Perinatal Quality Improvement Panel and chaired the QI infrastructure sub-committee for 2 years. She became a member of the Society for Pediatric Research in 2014 and has actively participated in clinical research. She is currently the study site Principal Investigator for a NIH funded multi-center study evaluating ondansetron (5HT3 antagonist) for prevention of neonatal abstinence syndrome in newborns born to mothers who had chronic opioid use during pregnancy. She is a passionate champion for optimizing care of newborns exposed to substances during pregnancy to prevent neonatal abstinence syndrome by promoting mother-infant couplet care.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,13,5,9,22,18,21,transition-of-care,12,October 7th, 2020,23,33,32,20,25,31,Transition of Care,This is a description 3,4,14,May 29th, 2024,34,35,16,29,screening-assessment-level-of-care-determination,24,17,28,education,Screening, Assessment and Level of Care Determination,This is a description 0,11,Tipu V. Khan,MD, FAAFP, FASAM,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liaison service and outpatient specialty clinic at Ventura County Medical Center. He is the medical director of Prototypes Southern California which has hundreds of residential treatment beds as well as medical-withdrawal (detox) beds throughout Southern California. Dr. Khan is the Medical Director of the Ventura County Backpack medicine group, and Primary Care Hepatitis C Eradication Project. His niche is managing SUD in pregnancy and is a national speaker on this topic. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Baby M,10,15,30,27,Education,This is a description 4,43,MD, FACOG,MD, MPH,Jadene Wong,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Jadene Wong is Clinical Associate Professor of Pediatrics at Stanford University School of Medicine. She has practiced as a neonatal hospitalist at Lucile Packard Children’s Hospital Stanford for more than 10 years, and practiced in primary care outpatient community settings for more than 20 years. She is a member of the task force for the joint CMQCC\u002FCPQCC Mother & Baby Substance Exposure Initiative. She is also the Newborn Clinical Lead for this project and mentors Central California hospitals participating in the initiative.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,44,7,8,Jacqueline Rad,MSN, RN,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EJacqueline Rad is the nurse manager for the Family Birth Center at Sutter Lakeside Hospital where she provides patient-centered care to mothers and newborns exposed to opioids, and teaches providers and nurses about the challenges these families face.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Mimi Leza,BSN, RN, PHN, IBCLC ,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EMimi Leza is the Perinatal Services Coordinator for Ventura County Public Health and currently the co-chair of the Perinatal Substance Use Taskforce of Ventura County. Her background is in Pediatric nursing with extensive experience in caring for NICU babies with NAS and children with prenatal substance use exposure. As a Public Health Nurse, she specialized in providing case management for pregnant and parenting women with SUD and recruiting and training perinatal providers in the SBIRT process.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,45,26,46,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446555352,Elliott Main,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Main is the Medical Director of the California Maternal Quality Care Collaborative (CMQCC) and has led multiple state and national quality improvement projects. He is also the Chair of the California Pregnancy-Associated Mortality Review Committee since its inception in 2006. For 14 years, he was the Chair of the OB\u002FGYN Department at California Pacific Medical Center in San Francisco. He is currently clinical professor of Obstetrics and Gynecology at Stanford University. Dr. Main has been actively involved or chaired multiple national committees on maternal quality measurement. In addition, he helps direct a number of national quality initiatives with ACOG, the CDC and Maternal Child Health Bureau (HRSA) including the multi-state AIM project. In 2013, Dr. Main received the ACOG Distinguished Service Award for his work in quality improvement.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Holly Smith,MPH, MSN, CNM,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EHolly Smith is a certified nurse-midwife with 20 years experience in diverse practice settings. She is the project manager for the CMQCC\u002FCPQCC Mother and Baby Substance Exposure Initiative. Previous to this role, she was a the lead editor for the CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, and a clinical lead for the CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans, a large-scale quality improvement project with over 90 California hospitals. Her primary role as clinical lead focused on assisting southern California hospitals with the implementation of evidence-based practices to reduce cesarean. She is a hospital coach and steering committee member for the American College of Nurse-Midwives Reducing Primary Cesareans Project, and expert consultant on various national and state quality improvement and health policy initiatives. Additionally, she chairs the Health Policy Committee of the California affiliate of the American College of Nurse-Midwives and is a health policy consultant to the California Nurse-Midwives Foundation. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,MD, FAAP,Helen DuPlessis,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Helen DuPlessis is a Physician Principal at Health Management Associates.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EShe has a rich history of involvement in healthcare administration for a variety of organizations, expertise in program and policy development, practice transformation, public health, maternal, and child health policy, community systems development, performance improvement, and managed care. Prior to joining HMA, Dr. DuPlessis served as the chief medical officer with St. John’s Well Child and Family Center. Other notable professional experiences include her work as senior advisor to the UCLA Center for Healthier Children, Families and Communities where she provided leadership, research, program development support, counsel and representation to local, state and national efforts, and community level systems transformation. She also trained and mentored students in various disciplines and educational levels.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Martha Tesfalul,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Martha Tesfalul is currently a Maternal-Fetal Medicine Fellow at at the University of California, San Francisco. Having served as the Quality Improvement (QI) Chief in her final year of residency, she has a professional interest in health systems strengthening and health equity. She has received local, regional and national recognition for her efforts in clinical care, education, and research including awards from the Pacific Coast Obstetrical and Gynecological Society and the Foundation for the Society for Maternal-Fetal Medicine. In addition to her commitment to improving the care of pregnant patients in California, Dr. Tesfalul engages in QI-focused research in in the East African country Eritrea.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Pamela Flood,MD, MA,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Pamela Flood is Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University. Her research interests include prevention and reduction of pain and opioid use in women after delivery. She divides her clinical time between labor and delivery and her outpatient pain management clinic. She clinical work is directed toward compassionate weaning of high dose opioids and management of pelvic pain syndromes.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,https:\u002F\u002Fwww.drugabuse.gov\u002Fsites\u002Fdefault\u002Ffiles\u002Ffiles\u002FClinicalOpiateWithdrawalScale.pdf,Mark Zakowski,MD, FASA,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Mark Zakowski is Chief of Obstetrical Anesthesiology, Fellowship Director and Professor of Anesthesiology at Cedars-Sinai Medical Center in Los Angeles. He has also served as President of the California Society of Anesthesiologists, the Society for Obstetric Anesthesia and Perinatology, and numerous committees at the state and national level as an advocate for pregnant women and their newborns. Dr. Zakowski has authored many chapters, articles and a book for pregnant women about cesarean sections.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EOwner, Quantum Birthing LLC\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446555328,Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547-561.,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443386290,category,Candy Stockton-Joreteg,MD, FASAM,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Stockton is Board Certified in both Family Medicine and Addiction Medicine. Candy’s passion is providing patient-centered care to pregnant and parenting women with addiction as well as addressing the upstream causes of addiction in her community. She is Chief Medical Officer at the Humboldt IPA, and is a practicing physician at their Priority Care Center. In her role at the IPA, she oversees the developing School Based Health Center Program and is the clinical champion for the Humboldt RISE Project (a county-wide Perinatal Substance Use Disorder project) and Humboldt County’s Jail MAT program. She serves as a consultant for the implementation of the Hub and Spoke project in Northern California and for California’s Opioid Response Network, based out of UCLA. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Carrie Griffin,DO,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Carrie Griffin is a family medicine physician who specializes in maternal, child and reproductive health and practices in Humboldt County. She completed her residency at Maine Dartmouth Family Medicine Residency and fellowship at the University of New Mexico. Perinatal substance use is her clinical area of interest and expertise; she currently serves as a mentor for CMQCCs Mother Baby Substance Exposure initiative and the Humboldt RISE project, a community initiative to promote screening and case management services for women with substance use disorders in pregnancy.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,6,https:\u002F\u002Fncsacw.samhsa.gov\u002Ffiles\u002FCollaborative_Approach_508.pdf,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443385354,COWS: A clinical opioid withdrawal scale designed to monitor signs of opioid withdrawal.,Ramsay Sedation Scale: Designed for use in critically ill adults that has broad applicability in evaluation of the range between agitation and over sedation in response to sedatives and analgesics.,https:\u002F\u002Fpalliative.stanford.edu\u002Fpalliative-sedation\u002Fappendices\u002Framsay-sedation-scale\u002F,Considerations for Administration of Buprenorphine and Methadone.,Considerations for Treatment of Opioid Use Disorder in Pregnancy.,42,47,48,50,51,52,60,62,63,64,Grossman MR, Berkwitt AK, Osborn RR, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139(6).,Katherine Weiss,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Katherine Weiss is a neonatologist at Rady Childrens Hospital-San Diego and an assistant professor of pediatrics at UC San Diego. Previously, she was a clinical assistant professor of pediatrics for the University of Arizona.\u003Cbr\u003E\u003Cbr\u003E\u003C\u002Fdiv\u003E\u003Cdiv\u003EHer areas of interest are in quality improvement, education and international health.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,audience,AIM Opioid Screening Tools.,https:\u002F\u002Fstore.samhsa.gov\u002Fsystem\u002Ffiles\u002Fsma18-5054.pdf,ACOG committee opinion No 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017; 130: e81-94. doi: 10.1097\u002FAOG.0000000000002235.,116,http:\u002F\u002Fwww.nnepqin.org\u002Fwp-content\u002Fuploads\u002F2019\u002F03\u002FToolkit-for-Perinatal-Care-of-Women-with-Substance-Use-Disorders_Final-2019.pdf,134,142,Scott Haga,MPAS, PA-C,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EScott Haga is Senior Consultant wiht Health Management Associates and is a passionate patient advocate with a focus on motivational training, evidence-based treatment, collaboration and tackling the national opioid crisis head-on. He is an experienced medical provider who co-founded and co-led an interdisciplinary complex care intervention for high frequency emergency department utilizers. He has been recognized as a subject matter expert on addiction, medication assisted treatment for substance use disorders, and building well-functioning interdisciplinary treatment teams.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,117,147,145,161,NNEPQIN Opioid Use Disorder Clinical Pathway.,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443384281,David Golembeski,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. David Golembeski is a neonatologist at Rady Childrens Hospital-San Diego and a professor of pediatrics at UC San Diego School of Medicine. He is medical director of Rady Childrens NICU at Palomar Medical Center and of the NICU at Pomerado Hospital. Dr. Golembeski is a mentor for the CMQCC\u002FCPQCC Mother & Baby Substance Exposure Initiative where he assists hospitals in improving patient-centered care to mothers and babies with substance exposure. \u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,David Kim,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. David Kim is Associate Medical Director of the NICU at CHOC at Mission Hospital. He is also the Physician Leader for Quality Improvement in the management of Neonatal Abstinence at CHOC at Mission Hospital, Hoag Hospital, and Pomona Valley Hospital Medical Center.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Robert Castro,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Castro is a Board-Certified Pediatric physician with a specialization in Neonatal-Perinatal Medicine. Dr. Castro is currently the Director of the LPCH-affiliated NICU in Monterey County, CA and a Clinical Professor of Pediatrics at Stanford University School of Medicine. He has completed a term as the President of the Southern Society of Pediatric Research and is a Fellow of the American Academy of Pediatrics (AAP). He served on the AAP Perinatal Section Executive Committee and completed a six-year term on the AAP NeoReviews Journal Editorial Board. More recently, he is a member of the CPQCC Advisory Board and in 2016, he was elected to the California Association of Neonatologists Board of Trustees. In 2019, Dr. Castro was selected to serve on the American Board of Pediatrics-Subboard Neonatal Perinatal Medicine.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,Vaneet Kalra,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EDr. Vaneet Kumar Kalra is a neonatologist and Associate Clinical Professor of Pediatrics (Neonatology) at UC Davis Children’s Hospital. He is also the Medical Director of Newborn Medicine at Adventist Health Lodi Memorial Hospital.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,State of Vermont Guidelines for Screening for Substance Abuse During Pregnancy.,http:\u002F\u002Fcontentmanager.med.uvm.edu\u002Fdocs\u002Fdefault-source\u002Fvchip-documents\u002Fvchip_screening_for_preg_subabuse.pdf?sfvrsn2,214,Worley J. Identification and management of prescription drug abuse in pregnancy. J Perinat Neonatal Nurs. 2014; 28(3): 196-203. doi: 10.1097\u002FJPN.0000000000000039.,215,Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012; 129(2): e540- 560. doi: https:\u002F\u002Fdoi.org\u002F10.1542\u002Fpeds.2011-3212.,Committee opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015; 125(6): 1529-1537. doi: 10.1097\u002F01.AOG.0000466371.86393.9b.,Bogen DL, Whalen BL, Kair LR, Vining M, King BA. Wide variation found in care of opioid-exposed newborns. Acad Pediatr. 2017; 17(4): 374-380. doi: 10.1016\u002Fj.acap.2016.10.003.,119,120,104,105,106,107,168,169,170,153,155,156,157,159,160,163,164,171,172,173,174,175,176,178,227,228,109,110,179,180,181,216,ED Bridge. Buprenorphine Quick Start in Pregnancy Algorithm.,223,131,150,151,152,Sample Evaluation of Opioid Use Disorder (OUD) in Pregnancy Checklist.,Sample Inpatient Medication-Assisted Treatment Induction Algorithms.,Sample Outpatient Buprenorphine Induction Algorithm.,226,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F443385553,49,113,114,182,https:\u002F\u002Filpqc.org\u002Fwp-content\u002Fdocs\u002Ftoolkits\u002FMNO-Neo\u002FILPQC_Newborn_Care_Diary_final.pdf,https:\u002F\u002Fwww.neoqicma.org\u002Fhospital-resources,54,55,56,57,58,59,68,69,70,71,Davis et al. Comparison of safety and efficacy of methadone vs morphine for treatment of neonatal abstinence syndrome: a randomized control trial. JAMA Peds. 2018;172(8).,72,74,75,76,191,192,79,80,81,82,83,84,85,86,87,77,California Budget and Policy Center Report: Home Visiting is a Valuable Investment in California’s Families.,78,Helping Hands: A Review of Home Visiting Programs in California.,http:\u002F\u002Fthenextgeneration.org\u002Ffiles\u002FHelpingHands.pdf,Nurse Family Partnership.,https:\u002F\u002Fwww.nursefamilypartnership.org\u002Fabout\u002F,Healthy Families America.,http:\u002F\u002Ffirst5association.org\u002Fabout-first-5\u002Fcounty-commissions\u002F,National Head Start Association.,https:\u002F\u002Fwww.nhsa.org\u002Fmaternal-infant-early-childhood-home-visiting,Early Head Start.,https:\u002F\u002Feclkc.ohs.acf.hhs.gov\u002Fprograms\u002Farticle\u002Fearly-head-start-programs,California Head Start.,https:\u002F\u002Fwww.benefits.gov\u002Fbenefit\u002F1899,CalWORKS.,http:\u002F\u002Fwww.cdss.ca.gov\u002Finforesources\u002FCalWORKsHomeVisitingInitiative,Comprehensive Perinatal Services Program.,https:\u002F\u002Fwww.cdph.ca.gov\u002Fprograms\u002Fcfh\u002Fdmcah\u002Fcpsp\u002Fpages\u002Fdefault.aspx,Healthy Start.,https:\u002F\u002Fmchb.hrsa.gov\u002Fmaternal-child-health-initiatives\u002Fhealthy-start,88,Early Start.,89,Palomar Home Health Services.,https:\u002F\u002Fwww.palomarhealth.org\u002Fabout-us\u002Fpalomar-home-health-services,146,148,Hudak ML, Tan RC. Neonatal drug withdrawal. Pediatrics. 2012;129(2):e540- 560.,149,MCPAP for Moms Toolkit. Massachusetts Child Psychiatry Access Project. www.mcpapformoms.org.,93,94,A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders.,95,96,97,98,143,Emillie R. Feenan,BSN, RN-BC, PHN,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003EEmillie began working in Lake County Public Health in 2015 as a Public Health Nurse in the California Children’s Services Program and Home Visitation Program, and has worked in different capacities in the department for the last five years. She currently provides oversight to the Maternal Child and Adolescent Health Program and the Nurse Home Visiting Program. As the MCAH Director, Emillie has works with a number of community stakeholders to address perinatal substance use in Lake County, and to create a recovery ecosystem where there is no wrong door into accessing services.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,65,66,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446556581,Words Matter: How Language Choice Can Reduce Stigma.,https:\u002F\u002Fpreventionsolutions.edc.org\u002Fsites\u002Fdefault\u002Ffiles\u002Fattachments\u002FWords-Matter-How-Language-Choice-Can-Reduce-Stigma.pdf,61,February 17th, 2021,Lorena Watson,FNP,\u003Cdiv class\trix-content\\u003E \u003Cdiv\u003ELorena Watson is a Family Nurse Practitioner. Her focus is rural health and providing compassionate patient-centered care in Lake County, CA. She coordinates and provides care for mothers with OUD through pregnancy and postpartum. Before becoming an FNP, Lorena was a labor and delivery nurse for 16 years.\u003C\u002Fdiv\u003E\u003C\u002Fdiv\u003E,MBSEI Resource Library.,https:\u002F\u002Faddictionfreeca.org\u002Fresource-library,https:\u002F\u002Fplayer.vimeo.com\u002Fvideo\u002F446557060));/script>script src/_nuxt/6fef26f.js defer>/script>script src/_nuxt/b686de7.js defer>/script>script src/_nuxt/5162251.js defer>/script>script src/_nuxt/5f8396d.js defer>/script>script src/_nuxt/3cf4bd1.js defer>/script> /body>/html>
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