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Melanie Cole, MS (Host): Pregnancy can be such a wonderful and emotional time, but it can also be a very difficult time. Particularly if it’s coupled with an addiction. Here to tell us about the care clinic are my guests in this panel discussion Dr. Hayley Friedman, she’s a Washington University School of Medicine neonatologist at St. Louis Children’s Hospital. And Dr. Jeannie Kelly. She’s a Washington University School of Medicine maternal-fetal medicine high risk obstetrician and the director of the care clinic at Barnes-Jewish Hospital. Dr. Kelly, I’d like to start with you. Tell us a little bit about the current state of opioid use among pregnant women. What’s the prevalence? What are you seeing?

Jeannie Kelly, MD (Guest): So right now there is a known epidemic happening overall in the United States, but among pregnancy we see up to 20% of women who have used or have ongoing use of an opioid during their pregnancy.

Host: Does this usually stem from use before pregnancy for a pain condition, a back problem? Or does it sometimes happen during pregnancy?

Dr. Kelly: We see both. Most people, most patients, what happens is that they’ve had a pain inducing event at some point in their life. They are in a car accident or they had some sort of surgery earlier, and through recovery from that get exposed to opioids. For the women and patients that we have who have chronic pain, they also are chronically taking those opioids to manage their pain.

Host: Dr. Friedman, give us a little background on what happens. What’s the effect of opioid use on baby in utero and out?

Hayley Friedman, MD (Guest): So in the setting of the opioid epidemic that Dr. Kelly mentioned, we are really seeing a significant rise in what is called neonatal abstinence syndrome within our infants that are born to mothers who have opioid use disorder. Neonatal abstinence syndrome is a very complex sort of drug withdrawal syndrome that is secondary to not only opioid use during pregnancy, but also polysubstance exposure, which truly complicates the picture. Ultimately many infants that are exposed to polysubstances in pregnancy are in the setting of the post-partum period going through courses of withdrawal that include symptoms such as feeding dysfunction, tremors, and significant irritability. The challenge is to really do the best we can to keep our mothers and babies together as the baby goes through the course of neonatal abstinence syndrome.

Host: Dr. Kelly, tell us about the care clinic at Barnes-Jewish Hospital. What is it? Who can be treated there?

Dr. Kelly: Sure. So the care clinic is a half a day, once a week clinic of prenatal care, but specifically to this clinic it is there to treat women and patients who have a history of opioid use disorder. So these are pregnant women who have ongoing opioid use, usually due to an addiction or a previous exposure or chronic pain. At this clinic, we provide a ton of medical support. So you have your usual prenatal care that is staffed by myself and two other obstetricians, but in addition to that, we also have a multidisciplinary team to care for these women. So we have therapists, psychiatrists, and neonatologists who are regularly coming to this clinic and seeing our patients and getting them through a healthy as possible pregnancy. We, additionally, prescribe medication to treat opioid use disorder in the clinic directly to our patients. So it’s kind of a one stop shop for these patients while they're pregnant.

Host: Dr. Friedman, when would a pediatrician refer a patient to the clinic or another obstetrician gynecologist. Tell us about some of the challenges or barriers that you see which might limit comprehensive implementation. How do you identify these women?

Dr. Friedman: So the identification of patients is a very diverse approach from the standpoint of our OB colleagues, such as Dr. Kelly and our team in the care clinic, to identify women as early as possible in pregnancy to empower them to maintain their care and participate in our program throughout the duration of their pregnancy. As a pediatrician, I don’t directly refer patients. Sometimes I touch patients in our NICU, for example, or on our labor and delivery floor that come in in the setting of active substance use disorder and do get women connected with our care clinic services. Both Dr. Kelly and I do know very well that from the standpoint of barriers or care, something that we work very hard to do is to diminish the stigma of substance use disorder with our patient population. The goal is to empower our women and empower our families to maintain their health, and to participate in medication therapy throughout their pregnancy to ultimately do what is best to keep the mother-infant dyad together if the infant does end up going through a course of neonatal abstinence syndrome in our NICU.

A lot of the work that we’re doing to support our families is actively evolving in the prenatal component of a pregnancy all the way through the course of an infant if they're in the NICU with us being treated for neonatal abstinence syndrome. As well as to continue to provide social services and mental health support post-partum and for the family in my newborn follow up clinic as well once the baby is discharged from the NICU.

Dr. Kelly: I just wanted to add. Pregnancy is a huge motivator for women to become healthy. We see this in women who have poorly controlled diabetes, who are obese and have weight loss that they need to do to achieve their best health. The same thing happens with substance abuse and substance use disorders. Women become pregnant. They know that this is an unhealthy, unsafe behavior, and they choose to seek out the medical system while they're pregnant for their children. So we see women who come into labor and delivery and/or are in central triage unit actively in withdrawal or actively using asking us for help. So those women get directly referred to our clinic in order to start them on treatment. We try to view addiction. We try to review substance use disorder as any other medical disease. There is a very good treatment for it that works extremely well. We really try to remove, like Dr. Friedman said, we really try to remove the stigma that is associated with this disease to achieve the best health for mom and baby.

Our ultimate goal is to get mom into recovery, into treatment lifelong. Not just for the pregnancy, but even after the pregnancy, and maintain custody of their children and keep them together ultimately. We actually have support for our moms for up to two years post-partum, whether they have insurance or not, to continue treating them and seeing them in our clinic with our multi-disciplinary mental health team.

Dr. Friedman: I would also like to add that thank you to this comprehensive model that Dr. Kelly and her team on the OB side really built from the ground up. The involvement of neonatology is truly key in this message as we speak with mothers by their third trimester in the actual care clinic, in the outpatient setting, to do exactly what Dr. Kelly said. The goal is to empower families to stay together and go through the recovery process and get through the pregnancy healthy. So the long term goal of keeping mom and baby together is truly at the forefront of everything that we do.

Host: Thank you ladies for pointing that out about the mothers, and pretty much what it is that their needs are. Now, Dr. Kelly, I feel this is an interesting question given those unique needs of pregnant women with an opioid use disorder. Do you think, in your opinion as the director of the care clinic, that healthcare providers need to consider modifying some elements of prenatal care, such as sexually transmitted disease screening and additional ultrasound examinations to assess fetal weight if there’s a concern for growth. Are there other factors that come into this to meet those clinical needs of that particular patient situation?

Dr. Kelly: That is a great question. So the first thing that I would urge all obstetricians to do, whether they treat specifically this population or not, is to verbally screen your patients for opioid use disorder or misuse. When I say screen your patients, I don’t mean send a urine toxicology on every patient. That comes with a lot of baggage and there’s a lot of controversy there. I think every obstetrician given the known epidemic that is taking over the entire United States, and especially here in St. Louis, we should be asking every woman if they have chronic exposure to opioids or have a history of chronic exposure to opioids. Whether that is through medication like things like pills—Vicodin, Percocet, oxycodone—or other opioids found off the street—namely fentanyl and heroine.

In our clinic, we do send a urine toxicology screen with every patient who has been diagnosed with opioid use disorder. This is very, very transparent with our patients in the very beginning. I try to explain that this is not a punitive measure for our patients. This is just like checking a diabetic’s finger sticks or checking somebody with high blood pressure, checking what their blood pressure is. It’s a way for us to know that our treatment in our clinic is working. Because if we see other substances in their urine toxicology screen, it suggests that the therapy, the medication, something in our treatment is not working well, and we need to change something in order to improve their treatment. So we do send that in our clinic and have very frank discussions about those results with our patients.

In addition to that, if the patient does have ongoing illicit drug use, we will follow the pregnancy closer by monitoring the baby’s weight gain and growth. In the third trimester, we also do extra monitoring of the fetus to make sure that the baby is doing well with no signs of distress in twice weekly fetal monitoring. For our patients who are in recovery, doing well, and taking their medications, they essentially get routine prenatal care because the risks to mom and fetus are quite low, pretty much back to baseline once they are in recovery and doing well.

Dr. Friedman: I’d also like to add that in the setting of the opioid epidemic, we’re seeing a significant increase of hepatitis C. Our comprehensive program at the care clinic with all of the work that Dr. Kelly and her OB colleagues are doing are truly helping us as pediatricians provide comprehensive care for mothers who have hepatitis C in the setting of substance use and IV substance use in their past. So from the standpoint of the pediatric side, knowing maternal history of hepatitis C and having mom treat it and follow it closely in pregnancy helps us as pediatricians identify infants. As infants who are delivered to moms who have hepatitis C, there is a risk for transmission. As pediatricians, something we’re doing is trying to improve our screening of infants born in this setting. So having information prenatally helps identify our infants and continue following them closely and screening them by hepatitis C by 18 months of life.

Dr. Kelly: Dr. Friedman makes a great point there. We definitely send very thorough infectious disease workups on our patients, especially if they have a previous or ongoing history of needle sharing. That really helps us once the patients are in recovery and post-partum. They can actually be treated and cured of hepatitis C at this point. So those are referrals for us to make as well for our patients as well post-partum to hepatology or the hepatitis C specialists for full treatment.

Dr. Friedman: I'd also like to add that this is a public health emergency without our country. I think that our care clinic is one example of a model that is really making a huge difference in the lives of mothers, families, and babies. It’s really just a privilege to be a part of the care team as a pediatrician and many pediatricians are actively participating in efforts such as this one as it’s something that’s effecting all of our communities.

Host: Dr. Friedman, first last word to you as we wrap up this very fascinating topic and what a great clinic that you both have. So tell other referring physicians what you would like them to know about the care clinic at Barnes-Jewish Hospital, and about spotting and screening women with opioid use disorder that are either thinking about getting pregnant or that already are.

Dr. Friedman: Well, thank you again for having me today. I would say, as Dr. Kelly said, from the standpoint of screening pregnant women, what I really think hard about and try to relate to my colleagues and all of us who are learning more and more about this every day is have a compassionate comprehensive approach to caring for women with substance abuse in pregnancy. The goal is to get our families on a path of recovery, to ultimately provide a woman the ability to be with her baby, breastfeed her baby, participate in her baby’s care in an active and healthy way. That is the goal, and that is truly the impetus for all that we’re doing here. I'm incredibly proud of this program. It’s truly setting an incredibly positive tone in our community, and it’s an accessible resource with an incredible solid, compassionate team that wants what is absolutely best outcome for the mother-infant dyad with in-utero opioid exposure. I really am proud of being a part of this and am also actively working on growing an outpatient newborn follow up clinic that continues to provide care to focus on the developmental piece of neonatal abstinence syndrome as we’re learning a lot more about the future of our infants and what their needs are. So it’s an incredible resource. I'm very proud of it. We are always open to providing support and services to families in our community.

Dr. Kelly: I would just like to echo Dr. Friedman’s thoughts here as well. I really, really encourage all of our providers to screen every patient. When we look at the statistics of who has an opioid disorder, it is not by race, socioeconomic status, zip code. It is pretty much across the board affecting multiple people in our lives. I think most of us probably know personally somebody who is effected by the opioid use disorder epidemic that is growing in Missouri and in the United States. So I encourage everybody to screen their patients, all of them, and remember that substance use disorder is a disease, not a moral weakness or failing. That we do have resources and medications that work extremely well, just like any other disease. So I really have been personally and professionally proud of our patients who come to us and who really turn around their lives during their pregnancy because it is such a powerful motivator for them to become healthy and stay in recovery for the sake of their children.

Host: Thank you both for being with us today and for all of the great work that you're doing on behalf of pregnant women and their babies with opioid use disorder. Thank you, again, for joining us. To consult with a specialist or to learn more about services offered at St. Louis Children’s Hospital, please call the children’s direct physician access line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information and resources available at St. Louis Children’s Hospital, please visit stlouischildrens.org. I'm Melanie Cole.