Comprehensive Treatment for Pregnant and Parenting Women with Substance Use Disorders and Their Children: The UNC Horizons Story.

OBJECTIVES: To describe how the UNC Horizons program, a comprehensive women-centered program for pregnant and parenting women with substance use disorders, and its patient population have changed over time and summarize basic neonatal outcomes for infants born to women in treatment at Horizons. METHODS: Yearly Annual Reports from fiscal years of 1994 to 2017 were abstracted. Patient characteristics and infant outcomes compared to normative North Carolina data were examined. RESULTS: Highlights of findings include: The percentage of women for whom opioids were the primary substance of use increased from 0% in 1995-1996 to 62% in 2016-17, while cocaine decreased from 66 to 12%. Intravenous substance use history increased from 7% in 1994-1995 to 41% in 2016-2017. The number of women reporting a history of incarceration rose from 10-20% in the early years to 40%-50% beginning in 2007-2008. The proportion of women reporting a desire to hurt themselves rose from 20% in 2004-2005 to 40% in 2016-2017. Self-reported suicide attempt history remained consistent at 32% across years. While reporting of childhood physical abuse remained at 38% across years, reporting of sexual abuse and domestic violence trended upward. Horizons did not differ from North Carolina in the likelihood of patients giving birth prematurely [χ2(13) = 20.6,p = .082], or the likelihood of a patient giving birth to a low birthweight infant [χ2(13) = 14.7,p = .333]. CONCLUSIONS FOR PRACTICE: Breaking the cycle of addiction for women and children must focus on helping women with substance use problems develop a sense of hope that their lives can improve, and a sense of feeling safe and nurtured.

Systematic examinations of programs that provide treatment services to pregnant and parenting women with substance use disorders have typically been focused on a limited set of outcomes and have been cross-sectional in nature. The current paper presents a detailed examination of the patient populations over a 23-year period, with particular attention to the changes over time in the women served. The birth weight and prematurity of infants born to the women in this program were likewise examined over time, and in comparison to state-level data.

Beyond opioid prescribing: Evaluation of a substance use disorder curriculum for OBGYN residents.

OBJECTIVE: Amidst the current opioid crisis, there is a need for better integration of substance use disorder screening and treatment across specialties. However, there is no consensus regarding how to best instruct OBGYN trainees in the clinical skills related to opioid and other substance use disorders (SUD). Study objectives were (1) to assess the effectiveness a SUD curriculum to improve self-reported competence among OBGYN residents and (2) to explore its effectiveness to improve attending evaluations of residents' clinical skills as well as its feasibility and acceptability from the resident perspective. METHODS: A pilot 3-session curriculum was developed and adapted to SUD screening and treatment which included readings, didactics, and supervised outpatient clinical experiences for OBGYN post-graduate year 1 (PGY-1) residents rotating through an integrated OBGYN-SUD clinic. Eighteen residents completed pre and post clinical skills self-assessments (SUD screening, counseling, referring, Motivational Interviewing) using an adapted Zwisch Rating Scale (range 1-5). Scores were compared between time points using paired t-tests. Sub-samples also (a) were evaluated by the attending on three relevant Accreditation Council for Graduate Medical Education Milestones (ACGME) milestone sets using the web-based feedback program, myTIPreport (n = 10) and (b) completed a qualitative interview (n = 4). RESULTS: All PGY-1s (18/18) across three academic years completed the 3-session SUD curriculum. Clinical skill self-assessments improved significantly in all areas [SUD Screening (2.44 (0.98) vs 3.56 (0.62), p = <0.01); Counseling (1.81 (0.71) vs 3.56 (0.51), p = < .01; Referring (2.03 (0.74) vs 3.17 (0.71), p = < .01; Motivational Interviewing (1.94 (1.06) vs 3.33 (0.69), p = < .01)]. Milestone set levels assigned by attending evaluations (n = 10) also improved. Qualitative data (n = 4) revealed high acceptability; all curriculum components were viewed positively, and feedback was provided (e.g., desire for more patient exposures). CONCLUSION: A pilot SUD curriculum tailored for OBGYN PGY-1 residents that goes beyond opioid prescribing to encompass SUD management is feasible, acceptable and likely effective at improving SUD core clinical skills.

Advanced Practice Provider-Led Medication for Opioid Use Disorder Programs for Pregnant and Parenting Women.

This article describes 2 innovative models of advanced practice provider-led medication for opioid use disorder treatment programs offering comprehensive, interprofessional care for pregnant patients and provides implications for broader adaptation of practice. Increasing the number of midwives and nurse practitioners waivered to prescribe buprenorphine and able to connect pregnant patients with opioid use disorder to appropriate community-based resources, treatment, and self-help programs could address alarming substance use trends including overdose deaths and other sequelae associated with the opioid epidemic.

Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder.

BACKGROUND: Unintended pregnancies are prevalent among women with opioid use disorder (OUD). The Sex and Female Empowerment (SAFE) project developed a social-cognitive, theory-driven intervention to increase acceptance of and adherence to contraceptive practices among women receiving medication for OUD (MOUD). This study evaluated the feasibility and acceptability of two SAFE interventions (Face-to-face and Computer-adapted) compared to usual care as well as their efficacy to improve contraception utilization. METHODS: This pilot randomized trial enrolled 90 heterosexual, non-pregnant, reproductive-age women receiving MOUD. Participants were randomized into either a: SAFE Face-to-face intervention, SAFE Computer-adapted intervention, or usual care (UC) condition (n = 30 each) and followed for 6 months. Outcome measures included intervention completion, intervention satisfaction, attendance at a contraception consultation appointment, and long-acting reversible contraceptive (LARC) method receipt. A generalized linear model was used for inferential testing and to estimate least squares means (predicted probabilities for binary outcomes) and their standard errors. RESULTS: Compared to the UC condition, both the SAFE Face-to-face and the SAFE Computer-adapted intervention had higher intervention completion [Means (Standard Errors) = 0.97 (.03) and 0.97 (.03), respectively, vs. 0.53 (.09); ps<.001], higher intervention satisfaction [Ms (SEs) = 3.7 (.11) and 3.8 (.11), respectively, vs. 3.1 (.11); ps<0.001), higher contraception consultation visit attendance [Ms(SEs) = 0.80 (.07) and 0.73 (.08) vs. 0.33 (.09); p < .001], and greater LARC receipt [Ms(SEs) = 0.77 (.08) and 0.73 (.08) vs. 0.23 (.08); p < .001). CONCLUSIONS: SAFE appears feasible and efficacious for supporting women in contraception decision-making. Integrating SAFE into women's comprehensive OUD treatment services holds promise to increase contraceptive decision-making and initiation of a chosen method.

Improving access to care through Advanced Practice Registered Nurses: Focus on perinatal patients with Opioid Use Disorder.

Perinatal substance use disorders, and all of the associated sequelae, continue to be a national health crisis that is further impacted by shifts in access to obstetrical care, particularly in rural areas. Opioid Use Disorder (OUD) specifically presents as a medical condition for which evidence-based guidelines support the use of medication treatment for opioid use disorder (MOUD) in the form of Methadone or Buprenorphine for both non-pregnant and pregnant women. However, the overall rates of access for those treatment modalities remain sparse. There is a public call to increase access to MOUD in the pregnant population affected by OUD. This article discusses the history of the Advanced Practice Registered Nurse (APRN) and how across legislative differences, these professionals are perfectly positioned to answer this call.

Bundled Payments for Care Improvement: Health System Experience With Lower Extremity Joint Replacement at Higher and Lower Volume Hospitals.

BACKGROUND: The Bundled Payments for Care Improvement (BPCI) initiative was introduced in 2013 to reduce Medicare healthcare costs while preserving or enhancing quality. We examined data from a metropolitan healthcare system comprised of 1 higher volume hospital and 4 lower volume hospitals that voluntarily elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2, beginning July 1, 2015. Stratifying the data by hospital volume, we determined how costs changed during the 16-month period when all 5 hospitals participated compared to the 1-year period preceding BPCI participation, where savings were achieved, and how the hospitals were rewarded. METHODS: The Medicare data included the 90-day target for each episode and actual part A and part B spending for the anchor hospitalization plus all post-acute payments including inpatient rehabilitation, skilled nursing, home health, outpatient physical therapy, and hospital readmissions. RESULTS: The mean episode of care cost decreased by 11.1% (from $21,324 to $18,953) at the higher volume hospitals and by 8.3% (from $25,724 to $23,584) at the lower volume hospitals during BPCI participation compared to the preceding year. The savings were achieved by reducing the use of inpatient rehabilitation, shortening the length of stay at skilled nursing facilities, and decreasing readmission rates. Although the higher volume hospital achieved an increased mean savings of $230 per episode compared to the lower volume hospitals ($2371 vs $2141), it was penalized $490 per episode after reconciling the actual Medicare expenditures with the BPCI targets while the lower volume hospitals received a mean reward of $315 per episode. CONCLUSION: The BPCI initiative decreased costs and readmissions within our healthcare system. Despite substantial savings compared to the preceding year, the higher volume hospital's low target derived from its 2009-2012 baseline costs was not achieved which resulted in a penalty and led it to withdraw from the BPCI initiative in October 2016.

Models of care for opioid dependent pregnant women.

As the opioid crisis continues to exist in the United States, opioid use in pregnancy is becoming a more common occurrence. Left untreated, it may result in an increased risk for adverse outcomes for both the mother and her unborn child. Unfortunately, women with opioid use disorders often face numerous barriers when trying to access prenatal care services including limited availability or treatment options, stigma, legal consequences, co-morbid psychiatric disorders, and trauma exposure. A care model that integrates prenatal care, medication assisted treatment and behavioral health services delivered in a trauma-informed environment can improve prenatal care attendance and thus have far-reaching positive implications for both the woman and her newborn child.

Psychometric assessment of the Neonatal Abstinence Scoring System and the MOTHER NAS Scale.

BACKGROUND AND OBJECTIVES: The present study examined the psychometric characteristics of the Neonatal Abstinence Scoring System (NASS; "Finnegan Scale") and the MOTHER NAS Scale (MNS). METHODS: Secondary analysis of data from 131 neonates from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a randomized trial in opioid-dependent pregnant women administered buprenorphine or methadone. RESULTS: Both the NASS and MNS demonstrated poor psychometric properties, with internal consistency (Cronbach's αs) failing to exceed .62 at first administration, peak NAS score, and NAS treatment initiation. CONCLUSIONS: Findings support the need for development of a NAS measure based on sound psychometric principles. SCIENTIFIC SIGNIFICANCE: This study found that two frequently used measures of neonatal abstinence syndrome suffer inadequacies in regard to their basic measurement characteristics. (Am J Addict 2016;25:370-373).

Neonatal Abstinence Syndrome: Presentation and Treatment Considerations.

This clinical case conference discusses the treatment of a pregnant woman with opioid use disorder in a comprehensive care program that includes buprenorphine pharmacotherapy. The presentation summarizes common experiences that pregnant women who receive buprenorphine pharmacotherapy face, and also what their prenatally opioid-exposed children confront in the immediate postpartum period. It describes the elements of a successful comprehensive care model and corollary neonatal abstinence syndrome treatment regimen. Expert commentary is included on issues that arise in the buprenorphine induction and maintenance throughout the prenatal and postpartum periods and in the treatment of co-occurring mental health problems during both the prenatal and postpartum periods, particularly the treatment of depression. There is also expert commentary on the care of opioid-exposed neonates, with attention to the treatment for neonatal abstinence syndrome.

Measurement of neonatal abstinence syndrome: Evaluation of short forms.

OBJECTIVES: 1) How well do the short forms previously developed from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) neonatal abstinence syndrome (NAS) scale (MNS) discriminate between neonates untreated and treated for NAS? (2) Can a short form be developed that is superior to other short forms in discriminating between the two groups? DESIGN/PARTICIPANTS: This secondary analysis study used data from 131 delivered neonates in the MOTHER study, a randomized controlled trial comparing neonatal and maternal outcomes in opioid-dependent pregnant women administered buprenorphine or methadone. SETTING: Comprehensive care was provided at seven university hospitals. OUTCOME MEASURES: A 19-item instrument measuring neonatal abstinence signs. RESULTS: A five-item index proved superior to the previous indices (ps < 0.01) and discriminated between the treated and untreated NAS groups as well as did the MNS total score (p=0.09). CONCLUSIONS: A short form developed from the MNS shows promise as a possible screening measure.

Vulvar skin atrophy induced by topical glucocorticoids.

Steroid-induced skin atrophy is the most frequent and perhaps most important cutaneous side effect of topical glucocorticoid therapy. To date, it has not been described in vulvar skin. A patient presented with significant vulvar skin atrophy following prolonged steroid application to treat vulvar dermatitis. The extensive atrophy in the perineum resulted in secondary "webbing" and partial obstruction of the genital hiatus and superimposed dyspareunia. Prolonged use of topical steroids may result in atrophic changes in vulvar skin. Further research in clinical correlates of steroid-induced atrophy in the vulvar region is warranted.

Genitofemoral and perineal neuralgia after transobturator midurethral sling.

BACKGROUND: Midurethral slings successfully treat stress urinary incontinence through a minimally invasive vaginal approach. Postoperative pain related to sling placement can occur and poses both diagnostic and treatment dilemmas. CASE: Four years after transobturator midurethral sling placement, the patient presented with complaints of left labial pain and dyspareunia since surgery. Using sensory mapping and a nerve stimulator, the problem was identified in the distribution of the genitofemoral nerve. Conservative therapy with a centrally acting neuromodulatory drug and nerve block relieved the pain. CONCLUSION: Postsling neuralgia diagnosis using sensory mapping and a nerve stimulator aids in indentifying the nerve involved and in successful conservative treatment with a nerve block.

Use of the impedance threshold device improves survival rate and neurological outcome in a swine model of asphyxial cardiac arrest*.

OBJECTIVE: To assess whether intermittent impedance of inspiratory gas exchange improves hemodynamic parameters, 48-hr survival, and neurologic outcome in a swine model of asphyxial cardiac arrest treated with active compression-decompression cardiopulmonary resuscitation. DESIGN: Prospective, randomized, double-blind study. SETTING: Laboratory investigation. SUBJECTS: Thirty healthy Landrace/Large-White piglets of both sexes, aged 10 to 15 wks, whose average weight was 19 ± 2 kg. INTERVENTIONS: At approximately 7 mins following endotracheal tube clamping, ventricular fibrillation was induced and remained untreated for another 8 mins. Before initiation of cardiopulmonary resuscitation, animals were randomly assigned to either receive active compression-decompression cardiopulmonary resuscitation plus a sham impedance threshold device (control group, n = 15), or active compression-decompression cardiopulmonary resuscitation plus an active impedance threshold device (experimental group, n = 15). Electrical defibrillation was attempted every 2 mins until return of spontaneous circulation or asystole. MEASUREMENTS AND MAIN RESULTS: Return of spontaneous circulation was observed in six (40%) animals treated with the sham valve and 14 (93.3%) animals treated with the active valve (p = .005, odds ratio 21.0, 95% confidence interval 2.16-204.6). Neuron-specific enolase and S-100 levels increased in the ensuing 4 hrs post resuscitation in both groups, but they were significantly elevated in animals treated with the sham valve (p < .01). At 48 hrs, neurologic alertness score was significantly better in animals treated with the active valve (79.1 ± 18.7 vs. 50 ± 10, p < .05) and was strongly negatively correlated with 1- and 4-hr postresuscitation neuron-specific enolase (r = -.86, p < .001 and r = -.87, p < .001, respectively) and S-100 (r = -.77, p < .001 and r = -0.8, p = .001) values. CONCLUSIONS: In this model of asphyxial cardiac arrest, intermittent airway occlusion with the impedance threshold device during the decompression phase of active compression-decompression cardiopulmonary resuscitation significantly improved hemodynamic parameters, 24- and 48-hr survival, and neurologic outcome evaluated both with clinical and biochemical parameters (neuron-specific enolase, S-100).

Erythema and burning pain in the vulva: a possible phenotype of erythromelalgia.

We report a case of burning vulvar pain accompanied by erythema responding to an oral combination of a benzodiazepine and a beta blocker. The positive response to two medication classes used in the treatment of erythromelalgia supports the possibility of a localized manifestation of this disorder in the genital region.