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BMC Pregnancy and Childbirth

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Open Access 01-12-2021 | Buprenorphine | Research article

“The elephant in the room;” a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia

Authors: Catherine Leiner, Tamara Cody, Nathan Mullins, Melinda Ramage, Bayla M. M. Ostrach

Published in: BMC Pregnancy and Childbirth | Issue 1/2021

Abstract

Background

Diagnoses of perinatal opioid use disorder (OUD) continue to rise in the United States. Patients and providers report obstacles to OUD treatment access. Difficulties include legal ambiguity related to Social Services notification requirements following a birth to people using opioids or in medication-assisted treatment for OUD.

Methods

Through semi-structured interviews, participant-observation, and a focus group conducted in a mostly rural, region of the Southern United States (where perinatal OUD is more prevalent), patients’ and providers’ perspectives about perinatal substance use treatment were initially sought for a larger study. The findings presented here are from a subset analysis of patients’ experiences and perspectives. Following ethics review and exemption determination, a total of 27 patient participants were opportunistically, convenience, and/or purposively sampled and recruited to participate in interviews and/or a focus group. Data were analyzed using modified Grounded Theory.

Results

When asked about overall experiences with and barriers to accessing perinatal substance use treatment, 11 of 27 participants reported concerns about Social Services involvement resulting from disclosure of their substance use during pregnancy. In the subset analysis, prevalent themes were Fears of Social Services Involvement, Preparation for Delivery, and Providers Addressing Fears.

Conclusions

Perinatal OUD patients may seek substance use treatment with existing fears of Social Services involvement. Patients appreciate providers’ efforts to prepare them for this potential reality. Providers should become aware of how their own hospital systems, counties, states, and countries interpret laws governing notification requirements. By becoming aware of patients’ fears, providers can be ready to discuss the implications of Social Services involvement, promote patient-centered decision-making, and increase trust.

Available only for authorised users

Fifteen states are designated as the U.S. South by the U.S. Census Bureau, including all of Southern Appalachia, https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf.

Finnegan scores are assigned by observing a newborn’s level of alertness, feeding patterns, muscle tone, crying, level of perceived agitation, etc.

This information was shared in personal correspondence from an employee with the North Carolina Department of Health and Human Services.

The authors are not allowed to name the specific institutional review board/ethics committee. It was, at the time of the study, the only such ethics committee that reviewed studies for all research conducted at the study site; the ethics committee is based at a hospital where all study participants receive care; thus naming it would risk making the study site and/or participants (who have unique characteristics and attend the only program of its kind in a large geographic region), identifiable. Under the authors’ institutional review board ethics committee approval for this study, both the site and the participants must be kept de-identified. Naming the specific ethics review committee would violate our ethics approval.

Note: All participant names/nicknames/initials are pseudonyms they chose for themselves, and spelled as they indicated.

Warm hand-offs are a recommended strategy in behavioral health and substance use treatment overall that emphasizes direct referrals, preferably with face to face introductions for a patient to another provider or participating team member [47].

Andrilla CHA, Moore TE, Patterson DG. Overcoming barriers to prescribing buprenorphine for the treatment of opioid use disorder: recommendations from rural physicians. J Rural Health. 2019;35(1):113–21 Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/jrh.12328. Cited 2019 Feb 1.CrossRef

Kaltenbach K, O’Grady KE, Heil SH, Salisbury AL, Coyle MG, Fischer G, et al. Prenatal exposure to methadone or buprenorphine: early childhood developmental outcomes. Drug Alcohol Depend. 2018;185:40–9.CrossRef

Saia K, Jones H, Terplan M. Pregnancy and the opioid epidemic. Curr Treat Options Psychiatry. 2017;4(2):184–95.CrossRef

Haight SC. Opioid use disorder documented at delivery hospitalization — United States, 1999–2014. MMWR Morb Mortal Wkly Rep. 2018;67 Available from: https://www.cdc.gov/mmwr/volumes/67/wr/mm6731a1.htm. Cited 2018 Nov 28.

ACOG. Opioid use and opioid use disorder in pregnancy: clinical guidance. 2018. Available from: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy. Cited 2018 Nov 28.

Alexander MB. Denying the dyad: how criminalizing pregnant use harms the baby, taxpayers and vulnerable women. Tenn L Rev. 2014;82:745.

Ramage M, Ostrach B, Fagan B, Coulson CC. Stabilizing the mother-infant dyad for better outcomes from OB to FM caring for patients with perinatal opioid use disorder through the 4th trimester. N C Med J. 2018;79(3):164–5 Available from: http://www.ncmedicaljournal.com/content/79/3/164. Cited 2018 May 7.PubMed

SAMHSA. Medications to treat opioid use disorder during pregnancy: information for providers; 2019. p. 6.

Buer L-M, Leukefeld CG, Havens JR. “I’m stuck”: women’s navigations of social networks and prescription drug misuse in central Appalachia. North Am Dialogue. 2016;19(2):70–84.CrossRef

10.

Ostrach B, Leiner C. ‘I Didn’t want to be on Suboxone at first…’–ambivalence in perinatal substance use treatment. J Addict Med. 2019;13(4):264–71.CrossRef

11.

Atkins DN, Durrance CP. State policies that treat prenatal substance use as child abuse or neglect fail to achieve their intended goals: study examines the effect of state policies that treat prenatal substance use as child abuse or neglect on the incidence of neonatal abstinence syndrome and other factors. Health Aff. 2020;39(5):756–63.CrossRef

12.

Knight K. addicted.pregnant.poor. Raleigh: Duke University Press; 2015.CrossRef

13.

Wakeman SE, Jordan A, Beletsky L. When reimagining systems of safety, take a closer look at the child welfare system. Health affairs: Health Affairs Blog; 2020. Available from: https://www.healthaffairs.org/do/10.1377/hblog20201002.72121/full/#.X33PusssAuw.twitter. Cited 2020 Oct 12

14.

Bowers O, Stewart J, Scott C, Thompson T-A, Zuniga C, Paltrow L, et al. SisterReach Report: Tennessee’s Fetal Assault Law, understanding its impact on marginalized women. n.d.. Available from: https://www.sisterreach.org/uploads/1/2/9/0/129019671/full_report.pdf. Cited 2020 Apr 24.

15.

Angelotta C, Weiss CJ, Angelotta JW, Friedman RA. A moral or medical problem? The relationship between legal penalties and treatment practices for opioid use disorders in pregnant women. Women’s Health Issues. 2016;26(6):595–601 Available from: https://linkinghub.elsevier.com/retrieve/pii/S1049386716301694. Cited 2019 Dec 30.CrossRef

16.

O’Rourke-Suchoff D, Sobel L, Holland E, Perkins R, Saia K, Bell S. The labor and birth experience of women with opioid use disorder: a qualitative study. Women and Birth. 2020;33(6):592–7.CrossRef

17.

Goodman D, Whalen B, Hodder LC. It’s time to support, rather than punish, pregnant women with substance use disorder. JAMA Netw Open. 2019;2(11):e1914135.CrossRef

18.

Stone R. Pregnant women and substance use: fear, stigma, and barriers to care. Health Justice. 2015;3(1):2. https://doi.org/10.1186/s40352-015-0015-5 Cited 2019 Nov 15.CrossRefPubMedCentral

19.

Hill PE. Perinatal addiction: providing compassionate and competent care. Clin Obstet Gynecol. 2013;56(1):178–85.CrossRef

20.

Kramlich D, Kronk R, Marcellus L, Colbert A, Jakub K. Rural postpartum women with substance use disorders. Qual Health Res. 2018. https://doi.org/10.1177/1049732318765720.

21.

Treadwell SJ. A paradox of support: the department of children and families and their construction of the “good mother”. Master’s Thesis. Digital Archives, Boston University. Boston: Boston University; 2016.

22.

SAMHSA. A collaborative approach to the treatment of women with opioid use disorders. 2016. Available from: https://store.samhsa.gov/product/A-Collaborative-Approach-to-the-Treatment-of-Pregnant-Women-with-Opioid-Use-Disorders/SMA16-4978

23.

Terplan M, Lawental M, Connah MB, Martin CE. Reproductive health needs among substance use disorder treatment clients. J Addict Med. 2016;10(1):20–5.CrossRef

24.

Moustafa ASZ, Kumar N, Masten M, Bruder A, Rocha F, Adekola H. Effects of methadone and buprenorphine use during pregnancy on neonatal and maternal outcomes [4K]. Obstet Gynecol. 2019;133:118S Available from: https://journals.lww.com/greenjournal/Abstract/2019/05001/Effects_of_Methadone_and_Buprenorphine_Use_During.410.aspx. Cited 2019 Jun 27.CrossRef

25.

Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction. 2016;111(12):2115–28 Available from: http://onlinelibrary.wiley.com.ezproxy.bu.edu/doi/10.1111/add.13462/abstract. Cited 2018 Feb 21.CrossRef

26.

Brogly SB, Saia KA, Walley AY, Du HM, Sebastiani P. Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis. Am J Epidemiol. 2014;180(7):673–86.CrossRef

27.

U.S. Census Bureau. U.S. Census Regions. Available from: https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. Accessed 15 Nov 2019.

28.

Gale MS, John A, Hansen MS, Elbaum Williamson MPAM. Rural opioid prevention and treatment strategies: the experience in four states. Portland: Maine Rural Health Research Center; 2017. (Research & Policy Briefs). Report no.: PB-63-2 April 2017

29.

Hand DJ, Short VL, Abatemarco DJ. Substance use, treatment, and demographic characteristics of pregnant women entering treatment for opioid use disorder differ by United States census region. J Subst Abuse Treat. 2017;76(Supplement C):58–63 Available from: http://www.sciencedirect.com/science/article/pii/S0740547216303361. Cited 2018 Jan 6.CrossRef

30.

Andrilla CHA, Coulthard C, Larson EH. Barriers rural physicians face prescribing buprenorphine for opioid use disorder. Ann Fam Med. 2017;15(4):359–62 Available from: http://www.annfammed.org/lookup/doi/10.1370/afm.2099. Cited 2018 Mar 22.CrossRef

31.

Kaiser Family Foundation. Births financed by Medicaid. 2016. Available from: https://www.kff.org/medicaid/state-indicator/births-financed-by-medicaid/

32.

Patrick SW, Buntin MB, Martin PR, Scott TA, Dupont W, Richards M, Cooper WO. “Barriers to Accessing Treatment for Pregnant Women with Opioid Use Disorder in Appalachian States.” Substance Abuse 40, no. 3. 2019. https://doi.org/10.1080/08897077.2018.1488336. Accessed 15 Nov 2018.

33.

Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol. 2014;123(5):997.CrossRef

34.

Hansen H, Skinner ME. From white bullets to black markets and greened medicine: the neuroeconomics and neuroracial politics of opioid pharmaceuticals. Ann Anthropol Pract. 2012;36(1):167–82.

35.

Hatcher AE, Mendoza S, Hansen H. At the expense of a life: race, class, and the meaning of buprenorphine in pharmaceuticalized “care”. Subst Use Misuse. 2018;53(2):301–10 Available from: https://www.tandfonline.com/doi/full/10.1080/10826084.2017.1385633. Cited 2018 Apr 30.CrossRef

36.

Saloner B, Cook BL. Blacks and Hispanics are less likely than Whites to complete addiction treatment, largely due to socioeconomic factors. Health Aff (Millwood). 2013;32(1):135–45 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570982/. Cited 2019 May 29.CrossRef

37.

Singer M, Ziegler J. The role of drug user stigmatization in the making of drug-related syndemics. In: Lerman, Ostrach, Singer, editors. Foundations of biosocial health: stigma and illness interactions: Lexington Books, Rowman & Littlefield; 2017.

38.

National Advocates for Pregnant Women. Understanding CAPTA and state obligations. 2018. Available from: http://advocatesforpregnantwomen.org/CAPTA%20requirements%20for%20states_NAPW.pdf

39.

Lloyd MH, Luczak S, Lew S. Planning for safe care or widening the net?: A review and analysis of 51 states’ CAPTA policies addressing substance-exposed infants. Child Youth Serv Rev. 2019;99:343–54 Available from: http://www.sciencedirect.com/science/article/pii/S0190740918309848. Cited 2019 May 31.CrossRef

40.

Howard H, Clark K. Interprofessional-shared decision making for pregnant women with opioid use: results from a provider training. 2017; Available from: https://www.ingentaconnect.com/content/ben/cwhr/2017/00000013/00000002/art00010. Cited 2019 Nov 27.

41.

Zimmermann-Baer U, Nötzli 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):524–8.CrossRef

42.

Appalachian Regional Commission. Appalachian subregions. 2002. Available from: http://www.arc.gov/images/maps/22512_Subregions.pdf

43.

Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. Lanham: Rowman Altamira; 2011.

44.

Creswell JW. Qualitative inquiry and research design: choosing among five approaches. London: Sage Publications Ltd.; 2012.

45.

Ostrach B. Health policy in a time of crisis: abortion, austerity and access. London: Routledge Press; 2017.

46.

Charmaz K. Constructing grounded theory: a practical guide through qualitative research. London: SagePublications Ltd; 2006.

47.

Calvo N, Cannon-DeKreek S, Dahms E, Kinkle SA, May B, Whalen S. Two perspectives on use of 4P’s plus© to screen pregnant women for alcohol and other drugs. Source. 2010;2(2):21.

Title: “The elephant in the room;” a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia
Authors: Catherine Leiner
Tamara Cody
Nathan Mullins
Melinda Ramage
Bayla M. M. Ostrach
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Buprenorphine
Opioids
Opioids
Anxiety
Published in: BMC Pregnancy and Childbirth / Issue 1/2021
Electronic ISSN: 1471-2393
DOI: https://doi.org/10.1186/s12884-021-03596-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

“The elephant in the room;” a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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