Screening of Pregnant Women with Opioid Use Disorder: Identifying Factors Impacting Implementation of Screening Recommendations Using the Theoretical Domains Framework

Background: Prenatal opioid exposure is a growing problem in the United States with high and increasing rates of opioid use and opioid use disorder during pregnancy. Almost 23% of pregnant women enrolled in Medicaid programs filled an opioid prescription during pregnancy in 2007, marking a 21.1% increase since 2000. Maternal opioid use during pregnancy is associated with a variety of poor maternal, pregnancy and infant outcomes, including overdose, pregnancy-associated death, prematurity, low birth weight and Neonatal Opioid Withdrawal Syndrome. To optimize prenatal care and pregnancy-associated outcomes, the Alliance for Innovation in Maternal Health, in collaboration with The American College of Obstetricians and Gynecologists, released a bundle of practices to be performed by physicians and health care systems to compile clinical recommendations and evidence-based practices as well as to streamline clinical practices, which are publicly available to all practitioners and health systems. However, it is unknown to what extent these bundled practices have been implemented in inpatient and outpatient settings in west-central Florida, what facilitators and barriers to implementation of these bundled practices exist and to what extent hospital policies align with these recommended practices. Purpose: The purpose of this study was to understand clinical obstetric management behaviors and evaluate how and why they may differ from clinical best-practices with regards to screening and identification of opioid use during pregnancy. This study has three aims: (1) describe clinical practice behaviors related to opioid use during pregnancy among physicians who treat pregnant women, (2) identify facilitators and barriers to clinical guideline implementation in both inpatient and outpatient settings and (3) determine the feasibility of obtaining these policies among delivery hospitals in the west-central Florida region and categorize the alignment between obtained written hospital policies with clinical bundle components. Methods: This study utilized an equivalent concurrent mixed-methods approach. To describe clinical practice behaviors, qualitative interviews were performed with clinicians and staff who work with pregnant women, including obstetricians, nurses, mental health providers and community agency staff. To identify facilitators and barriers to clinical guideline implementation, both qualitative interviews and quantitative surveys were completed by clinicians and staff from a variety of patient care settings. Both the qualitative interviews and quantitative surveys were be guided by the Theoretical Domains Framework, an implementation science framework. To categorize alignment between written hospital policies with clinical bundle components, individuals participating in the online survey who work in a hospital setting were asked to submit hospital policies related to bundle components, which were categorized according to their fidelity to the clinical bundle components (e.g., full fidelity, partial fidelity, or no fidelity). Findings from Aim 1, Aim 2, and Aim 3 were triangulated across the topical area of screening and identification of opioid use to inform both future hypothesis generation and potential behavior change interventions to address identified implementation barriers in subsequent research. Results: Between February and September 2020, a total of 60 individuals completed the online survey, among whom 15 participated in an interview through video-conferencing software. The majority of survey participants (66.7%) reported always or very often screening pregnant women for substance use. All interview participants described their drug screening practices. In outpatient obstetric settings, this generally occurs at pregnancy intake appointment, although some practices do not screen out of liability concerns and others may discharge women for positive drug screens or biologic tests. Many facilitators and barriers of screening were identified at the level of the patient, provider, practice, and community. The Maternal Opioid Recovery Effort initiative through the Florida Perinatal Quality Collaborative was identified as a major facilitator to support their screening efforts. Major barriers included the environmental context within the practice, such as staffing, social workers, available time, competing priorities, and customizable electronic medical records. In addition, many providers report training, positive past experiences, and collaborations with other providers and agencies as important facilitators. Only two policies were collected and abstracted by fidelity with recommended screening practices, which brought to light some issues with hospital policy collection. While certain practices, such as universal screening and the use of validated screening tools, were common, other recommended practices lacked specificity to accurately determine fidelity. Implications: Additional training, staffing of, or collaboration with social workers in the outpatient obstetric setting, and having adequate and customizable electronic medical record systems would be beneficial in clinical settings to promote screening. Practices should consider having a more frequent screening routine in addition to the pregnancy intake appointment. Recommended screening practices should be updated to optimize specificity and clarity for institutions and practices to be able to identify their fidelity with best practices. Future research should focus on determining the most salient facilitators and barriers of screening recommendation implementation, which could then be mapped to the most effective behavior interventions for clinicians who work with pregnant women

Associations between Adverse Childhood Experiences (ACEs) and Prenatal Mental Health and Substance Use.

Adverse childhood experiences (ACEs) are common and increase the risk of poor health outcomes. Resilience may offer protection against the impacts of ACEs. This study examined the association between maternal ACEs and mental/behavioral health outcomes during pregnancy overall and by resilience. The sample comprised pregnant patients in two pilot studies screened for eight ACEs and resilience during standard prenatal care in Kaiser Permanente Northern California from 1 March 2016 to 30 July 2016 (Study 1, medical centers A, B) and from 1 April 2018 to 31 March 2019 (Study 2, medical centers A, C). Early pregnancy outcomes included anxiety and depressive disorders, depression symptoms, intimate partner violence (IPV), and substance use. Multivariable logistic regression was used in this cross-sectional study to examine associations between maternal ACEs (0, 1-2, ≥3) and mental/behavioral health outcomes overall and among those with low and high resilience. Patients (n = 1084) averaged 30.8 years (SD 5.1); 41.7% were non-Hispanic White; 41.7% experienced ≥1 ACE, and 40.3% had low resilience. Patients with 1-2 ACEs or ≥3 ACEs (versus 0 ACEs) had higher odds of anxiety and depressive disorders, depressive symptoms, IPV, and any prenatal substance use (OR 1.44-4.40, p < 0.05). Each individual ACE was associated with ≥2 mental/behavioral health outcomes. In stratified analyses, having ≥1 ACE (vs. 0) was associated with a greater number of mental/behavioral health outcomes among patients with low versus high resilience. ACEs were associated with prenatal mental/behavioral health conditions, particularly in the context of low resilience, highlighting the importance of trauma-informed prenatal care and the need to study resilience-building interventions during pregnancy

Multilevel Factors Associated with Length of Stay for Neonatal Abstinence Syndrome in Florida’s NICUs: 2010–2015

To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida. The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS. The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P \u3c 0.001), gestational age at birth (P \u3c 0.001), maternal age (P = 0.002), maternal race and ethnicity (P \u3c 0.001), maternal education (P = 0.032), and prenatal care adequacy (P \u3c 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor. NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors

Perceptions about cannabis following legalization among pregnant individuals with prenatal cannabis use in California.

Importance: As rates of prenatal cannabis use increase and cannabis legalization spreads across the US, studies are needed to understand the potential impacts of legalization from the perspectives of pregnant individuals who use cannabis. Question: Is cannabis legalization for adult use associated with cannabis use behaviors among pregnant individuals? Findings: This qualitative study of 53 pregnant individuals who used cannabis found consistent beliefs that legalization led to easier cannabis access (via retailers and delivery), greater acceptance (including reduced stigma, more patient-clinician discussions about prenatal cannabis use, and fewer concerns about Child Protective Services involvement), and trust in cannabis retailers (including safety and effectiveness of diverse products sold and perceptions of employees as knowledgeable, nonjudgmental, and caring). Meaning: These findings suggest that pregnant individuals perceive legalization as having reduced barriers to prenatal cannabis use, which creates challenges and opportunities for supporting the health of pregnant individuals

Trends in cannabis polysubstance use during early pregnancy among patients in a large health care system in Northern California.

Question: Is prenatal cannabis use increasing more rapidly over time among pregnant patients without vs those with co-occurring prenatal substance use? Findings: In this cross-sectional time-series study using data from 367 138 pregnancies among 281 590 unique pregnant patients screened for prenatal substance use during early pregnancy as part of routine prenatal care in Kaiser Permanente Northern California, rates of prenatal use of only cannabis increased faster than rates of use of cannabis and 1 other substance, while rates of use of cannabis and 2 or more substances decreased. Meaning: This study suggests that increases in prenatal cannabis use may be associated in part with pregnant individuals who use only cannabis and no other substances, which could reflect growing acceptability of cannabis use and decreasin

Quantitative multiparametric MRI in uveal melanoma: increased tumor permeability may predict monosomy 3

Introduction: Uveal melanoma is a rare intraocular tumor with heterogeneous biological behavior, and additional noninvasive markers that may predict outcome are needed. Diffusion- and perfusion-weighted imaging may prove useful but have previously been limited in their ability to evaluate ocular tumors. Our purpose was to show the feasibility and potential value of a multiparametric (mp-) MRI protocol employing state of the art diffusion- and perfusion-weighted imaging techniques. Methods: Sixteen patients with uveal melanoma were imaged with mp-MRI. Multishot readout-segmented echoplanar diffusion-weighted imaging, quantitative dynamic contrast-enhanced (DCE) MR perfusion imaging, and anatomic sequences were obtained. Regions of interest (ROIs) were drawn around tumors for calculation of apparent diffusion coefficient (ADC) and perfusion metrics (Ktrans, ve, kep, and vp). A generalized linear fit model was used to compare various MRI values with the American Joint Commission on Cancer (AJCC) tumor group and monosomy 3 status with significance set at P < 0.05. Results: mp-MRI was performed successfully in all cases. MRI tumor height (mean [standard deviation]) was 6.5 mm (3.0). ROI volume was 278 mm3 (222). ADC was 1.07 (0.27) × 10–3 mm2/s. DCE metrics were Ktrans 0.085/min (0.063), ve 0.060 (0.052), kep 1.20/min (0.32), and vp 1.48 % (0.82). Patients with >33 % monosomy 3 had higher Ktrans and higher ve values than those with disomy 3 or ≤33 % monosomy (P < 0.01). There were no significant differences between ADC (P = 0.07), kep (P = 0.37), and vp with respect to monosomy 3. Conclusion: mp-MRI for ocular tumor imaging using multishot EPI DWI and quantitative DCE perfusion is technically feasible. mp-MRI may help predict monosomy 3 in uveal melanoma