Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum during the Global COVID-19 Pandemic

History of Present Illness

At the time of initial presentation to a virtual reproductive psychiatry clinic in April 2020, Ms. Q was a 29-year-old female at approximately 21-weeks’ gestation with her third pregnancy. She presented to treatment through a virtual care platform indicating problems with daily opioid use. Ms. Q was introduced to opioid analgesics following the birth of her second child via emergent cesarean section [c-section]. During her hospital stay following the c-section, she experienced significant postoperative pain and was prescribed Oxycodone with increasing dosages until her pain was adequately controlled. At hospital discharge, she was taking Oxycodone 60 mg per day and given a one-month supply of this medication. Ms. Q continued the medication as prescribed, Oxycodone 15mg Q6 hours. At 2 weeks postpartum she attempted on her own to reduce the dose, but experienced significant pain that interfered with her ability to perform activities of daily living, including being the primary caregiver for her newborn and other child. She resumed the prescribed dose of medication, which was refilled at the same dosage at her subsequent obstetric follow-up appointment. She again attempted on her own to cut back on the dose, but had returned to work at 5 weeks postpartum due to financial necessity and reported “I couldn’t manage the pain and [the stress of] work during the day, being up all night with my daughter, and taking care of my son, and going through withdrawal. The pills made it all work somehow.”

At three months postpartum, she requested another refill of the prescribed medication which was denied by her obstetrician because he believed she was “addicted.” She was instead provided with Oxycodone 5mg, total of 20 tabs and told to taper her medication. Ms. Q began to experience significant withdrawal symptoms while trying to taper her medication but did not reach out for help due to prior experience of being accused of “being addicted” and feared being reported to the Department of Social Services [DSS]. Ms. Q began borrowing oxycodone tablets from a family member and continued to try to taper her medication. She reported feeling significant craving, symptoms of depression, and that she “could not keep up” with demands of home and work while trying to reduce her opioid medication use. At approximately 1-year postpartum, Ms. Q began purchasing Oxycodone tablets from a friend. She stated, “I knew at that point, I had a problem.” Since 2018, she made two attempts to get treatment, but was without health insurance and could not afford the cost. She was referred to a program that offered comprehensive services through a State Opioid Response grant, but the program was over an hour drive from her home and required that she first attend an intensive outpatient program which prevented her from working. Without her income she would not be able to pay her bills and for childcare that she would need to be able to attend this program. When she was unable to afford buying pills, she was offered heroin which was significantly less expensive. She first began snorting heroin, and within a couple of months progressed to daily use and injection.

On presentation for treatment, Ms. Q was using heroin daily, predominately via intravenous administration. “This became the focus of my every day- making sure I had what I needed [to not go into withdrawal] and making sure no one knew [that I was using].” Despite her attempts to conceal her use, her siblings were aware which created significant relationship and family tension. When she learned she was pregnant she attempted to cut down her use but had been unsuccessful due to the return of significant depressive and withdrawal symptoms as well as a lack of instrumental supports to care for children “so I could just get through this [withdrawal]”. When she learned of her third pregnancy, she knew she needed to see an obstetric provider but was scared that DSS would get involved and remove her children from her physical custody. She also feared seeking obstetric services given the threat of COVID-19 and because her city was currently on a stay-at-home order due to the pandemic. She began looking online and accessed a virtual care platform for pregnant or postpartum women with mental health or substance use problems and completed an online screen. She was contacted by phone that same day by a care coordinator, who scheduled her to see a reproductive psychiatrist with addiction training the next morning via home-video visit. The next morning the patient was evaluated via video-conferencing and a treatment plan was initiated including starting suboxone and relapse prevention therapy, as well as connecting her with a trusted obstetrician.

Assessment of Pertinent and Challenging Clinical Issues

Ms. Q’s presentation is consistent with an Opioid Use Disorder [OUD], severe, as evidenced by escalating amounts of opioid use over time, unsuccessful attempts to quit or cut down use, craving, continued use despite persistent interpersonal problems and health consequences, and spending an excessive amount of time obtaining opioids. There are numerous factors that predisposed Ms. Q to developing OUD and perpetuated her continued use as well as prevented her from receiving treatment. Medical professional, psychosocial and economic factors included over-prescribing of opioids at the time of hospital discharge without a clear plan for cessation; lack of medical providers’ knowledge about addiction and how to safely taper prescription opioids; lack of social and instrumental support in the postpartum period; non-paid maternity leave and early return to work; availability of opioids through friends and family members; emergence of depressive symptoms while attempting to taper opioids; lack of health insurance and other gender-specific barriers to care such as childcare responsibilities and legal consequences specific to substance use in pregnancy.

The standard of care for the treatment of perinatal OUD includes pharmacotherapy with either methadone or buprenorphine¹ as part of a comprehensive treatment program including prenatal care, psychological interventions for relapse prevention, treatment of comorbid mental health conditions and addressing psychosocial needs of women and the mother-infant dyad. Barriers to receiving the standard of care for OUD are numerous, including a paucity of available and accessible comprehensive treatment programs. The use of technology such as telehealth has the potential to increase access to and availability of comprehensive specialty services; however, federal and state laws and lack of health insurance coverage for critical components of this care have prohibited wide-spread adoption. Out of necessity to respond to the COVID-19 public health crisis, our health systems have been forced to reconsider and leverage telemedicine to deliver health services. Specific details about exceptions made during the COVID-19 pandemic are discussed below.

Treatment Plan and Course

Ms. Q successfully completed a suboxone home induction without side effects or precipitated withdrawal. She tolerated the medication well and stabilized on a dose of Suboxone 16mg daily. In addition to weekly medication management, she began weekly relapse prevention therapy via video-conferencing from home. Further evaluation of her mental health history revealed a significant history of Major Depressive Disorder beginning in her early twenties. The patient was monitored for depressive symptoms which were minimal and could be addressed with weekly psychotherapy.

The clinician provided reassurance regarding DSS to address patient concerns. Given her engagement in OUD treatment and response and ability to care for herself and her children, there was no concern for potential endangerment to her children and therefore no report to DSS was necessary. Further, since her substance use was prior to 24 weeks gestation, the South Carolina mandated reporting of substance use during pregnancy to DSS was not required. With reassurance she was willing to establish care with an obstetrician that the addiction provider had previously worked with. The patient attended prenatal care both in-person and via telemedicine when appropriate.

DISCUSSION

Epidemiology of Opioid Use Disorder in Pregnancy

Use and misuse of opioids among pregnant women has increased five-fold over the past decade^2–4; over 20,000 opiate-exposed births occur annually.⁵ From 1999 to 2014, the number of pregnant women with OUD in the United States more than quadrupled increasing from 1.5 to 6.5 cases per 1,000 hospital births.⁶ The increasing prevalence of perinatal OUD and its effects on pregnant women and infants are of increasing public health concern due to the significant morbidity and mortality associated with this chronic disease.^7,8 Importantly, rates of relapse are extremely high during in the early postpartum period,⁹ and drug overdose is a leading cause of death in during the postpartum year.¹⁰

Telemedicine in MAT Delivery and Special Considerations for Integration with Prenatal Care

Traditional methods of identification and treatment of OUD in pregnancy occur through the obstetrician/clinician or self-identification. The rate of identification is very low and the rate of treatment is even lower. Only about 25% of pregnant women with OUD receive treatment and fewer receive pharmacotherapy, even though it is the gold standard treatment for OUD.¹¹ Given the limited access to care among pregnant women with OUD, telehealth serves as an effective and plausible treatment, with data indicating that rates of retention in treatment and substance use did not differ between those receiving integrated OUD treatment via telemedicine compared to in-person.¹²

CONCLUSIONS

Critical barriers to uptake and accessibility of treatment for OUD including pharmacotherapy i.e., buprenorphine or methadone [MOUD], particularly for rural and low-resource populations, were recognized well before the COVID-19 pandemic. Buprenorphine treatment, with its lower overdose risk profile and ability to be prescribed beyond traditional opioid treatment program settings (i.e., in primary care settings by waivered physicians) has long been touted as a potential tool for increasing access and uptake of MOUD. However, two key regulatory barriers have limited the potential impact of outpatient buprenorphine on the MOUD treatment landscape: (1) requirement for DATA 2000 prescribing waiver and associated limits to patient census¹³; and, (2) requirement of initial in-person medical evaluation prior to initiation of buprenorphine.¹⁴ Various patient and healthcare advocacy organizations have been lobbying for changes to these requirements since 2015, culminating in the Mainstreaming Addiction Treatment Act that was presented on the Senate floor in July, 2019, but ultimately failed to gain sufficient support.

Due to the nationwide impacts of the COVID-19 pandemic, on March 19, 2020 the Substance Abuse and Mental Health Services Administration (SAMHSA) exempted Opioid Treatment Programs [OTPs] from the requirement that they perform an in-person evaluation prior to initiating buprenorphine treatment.¹⁵ On March 31, 2020 in a joint statement, the Drug Enforcement Administration (DEA) and SAMHSA announced that controlled substance prescriptions could be issued to patients via telemedicine without first conducting the initial in-person evaluation.¹⁶ Since their implementation, calls from various groups including the Cato Institute¹⁷ have recommended that these changes be made permanent to extend in perpetuity beyond the COVID-19 public health emergency.

The aforementioned policy exemptions made the Women’s Reproductive Behavioral Telehealth Program possible. Evaluation data from this program - and data from other creative program implementations - have the potential to apprise reforms to pre-COVID treatment delivery models by prompting an evidence-based reconsideration of restrictions and limitations that have traditionally hampered access to MOUD, while still ensuring the appropriate balance between benefit and risk to the patient. Key datapoints from programs such as the one described in this case study will be important guideposts for future decisions regarding lifting regulations. For example, the Women’s Reproductive Behavioral Telehealth Program intends to collect and report: (1) changes in program access since transition to full virtual (Zipnosis) platform; (2) changes in referral rates from obstetric providers across the state; (3) changes in adverse event counts potentially related to waiver of initial in-person evaluation; (4) treatment engagement and retention rates; and, (5) qualitative patient and provider insights regarding their experience with the full telemedicine program.