Issue Five: Evaluate and Recommend Policies and Procedures for Improved Access and More

Issue Five: evaluate and recommend policies and procedures for improved access and more effective opioid abuse treatment and prenatal care for pregnant women with substance abuse issues, including but not limited to clarifying current services available to these women, increasing the number of providers properly trained to provide care to this group, and effective ways to achieve treatment over incarceration.

I. BACKGROUND INFORMATION a. Louisiana ranked 7th nationally for opiate prescriptions (PCR, 6) b. The number of infants insured through Louisiana Medicaid born with NAS quadrupled over ten-year period (2003-2013) (PCR, 3) c. In the same period, the state experienced a six-fold increase in expenditures to treat these infants (PCR, 3) d. According to Medicaid data, the majority of NAS births were to women over the age of 25 (PCR, 4) e. Of all substances identified in NAS births, opioid are the most commonly identified (PCR, 4) f. Louisiana as a whole lacks a sufficient mental health infrastructure to assist families struggling with drug dependence (PCR, 4) g. There is a lack of standard protocols for recognition and treatment of NAS (PCR, 7) h. II. CURRENT POLICIES a. Other states successfully utilize prescription drug monitoring programs (PCR, 6) b. Louisiana passed legislation in 2014 requiring a prescriber to access a database prior to initial prescription of any Scheduled II drug; database is underutilized (PCR, 6) c. Lack of use of universal screens for substance use during pregnancy in Louisiana hospitals (PCR, 7) d. Louisiana has prohibited Medicaid reimbursement for the use of narcotics —including Methadone—in the treatment of substance use disorders (PCR, 9) e. Louisiana is home to only ten state-sanctioned, privately owned, and licensed Methadone clinics (PCR, 9) f. The Drug Enforcement Agency (DEA) only allows 72 hours of admission time to transition pregnant women to methadone in a general hospital setting (PCR, 9) III. BEST PRACTICES a. Preventing opioid addiction (PCR, 5) b. Preventing unintended pregnancy (PCR, 5) c. Ensuring providers and patients are aware of the risks associated with pregnancy and opioid use (PCR, 5) d. Use of national Quality Family Planning Guidelines (PCR, 7) e. Use of simple verbal screening tool for substance use during pregnancy (PCR, 7) f. Use of Finnegan scoring tool to assess severity of NAS (PCR, 7) g. National guidelines from SAMHSA have not found compelling evidence supporting reduced maternal methadone dosages to avoid NAS; Methadone and Suboxone are currently the drugs of choice for transitioning pregnant women into treatment for addiction (PCR, 9) IV. FINDINGS AND RECOMMENDATIONS (SHORT TERM) a. All care providers to women of reproductive age utilize the national Quality Family Planning Guidelines (PCR, 7) b. Verbal screening for substance use conducted in the primary care and obstetric settings (PCR, 8) c. Universal screening for substance use be conducted for reproductive age individuals, using validated screening tool like the SBIRT (PCR, 8) d. Use of substance disorder toolkit, forthcoming from the Medicaid Innovator Accelerator Program (IAP) (PCR, 8) e. Universal screening for pregnancy conducted in prescribing provider’s office (PCR, 8) f. Prescribing providers facilitate linkage to high quality reproductive health services (PCR, 8) g. Public and private managed care organizations develop a preferred network of physicians or advanced care providers who are experienced not only in routine obstetrical care but also the management of opioid maintenance (PCR, 10) h. State birthing facilities obtain authorization from DEA to allow birth hospitals at least 72 hours or longer to transition pregnant women to MAT (PCR, 10) i. Listings of care providers experienced in the care of women whose babies are at risk for NAS be listed in conspicuous areas in prenatal care and opioid maintenance clinics (PCR, 10) j. Providers and clinics that participate in the care of women of reproductive age who is prescribed opioids during the course of treatment or is on MAT for addiction, encourage and offer pregnancy testing during all visits (PCR, 10) k. Birthing facilities define protocols to identify and treat NAS (PCR, 11) V. FINDINGS AND RECOMMENDATIONS (LONG TERM) a. Develop comprehensive guide of best practices for opiate abuse prevention for prescribers: “Clinical Practice Guidelines on Prescribing Opiates” (PCR, 6) b. Conduct study to determine if the 2014 changes to Louisiana’s prescription drug monitoring program database have had any effect c. Research conducted to identify the personal, social, and structural influences that increase NAS risks (PCR, 6) d. NAS Should be incorporate into curricula for medical students, residents, and other medical providers (PCR, 7) e. The public should be made aware of the effects of substance use prior to and during pregnancy (PCR, 7) f. DHH Office of Behavioral Health is working with Louisiana Medicaid to seek federal CMS approval for Medicaid reimbursement of Methadone treatment for pregnant women (PCR, 9) g. Voluntary evidence-based home visitation programs be supported as they provide comprehensive management for families struggling with NAS and/or substance abuse issues (PCR, 11) h. Improve training for providers who care for NAS-affected families (PCR, 11) i. Further review and research of referral pathways within and across state and local systems to ensure access to follow-up care for families (PCR, 11) j. Healthcare payors, including government and private, consider adequately reimbursing for care and care coordination services associated with high- risk pregnancies (PCR, 11) k. Coordinated care model implemented at substance abuse treatment centers (PCR, 10) l. Medical home model implemented for infants with NAS (PCR, 11) m. Further study conducted into ways to continue to support and expand evidence-based home visiting programs and home-based mental health services (PCR, 12) n. Systematic environmental scan be conducted to identify existing local level practices and innovative models that are effectively coordinating care and supports throughout pregnancy and early childhood (PCR, 12) o. Further study be conducted into ways to develop a more extensive workforce that is well trained to identify and provide culturally competent interventions for prenatal substance exposure and resultant conditions (PCR, 12) VI. MISCELLANEOUS a. People often assume prescription pain relievers are safer than illicit drugs (PCR, 5) b. The availability of earlier high-quality mental healthcare may divert people on the pathway to substance abuse (PCR, 6) c. Federal Child Abuse Prevention and Treatment Act (CAPTA) mandatory reporting requirements (PCR, 9) d.