From eastern Tennessee through the Rust Belt, across Appalachia and into New England, southwestern Pennsylvania finds itself not far from the heart of the opioid epidemic that has ripped through even the smallest of towns.

The opioid crisis has been growing steadily for the past fifteen years, which has resulted in an increased demand for new, innovative ways to improve healthcare and health care services for patients with substance use disorders. With more than 2 million Americans estimated to have a problem with prescription opioids, the CDC reports that older adults (those over the age of 40), and women are two populations significantly affected by opioid misuse. It is younger women, particularly women of reproductive age and women who are pregnant, who make up an increasingly at-risk population—one that is often stigmatized and that faces multiple barriers to comprehensive healthcare services for themselves and their baby. What these women need is not judgment, but comprehensive care to help them and their babies live a safe and addiction-free life.

Rising Numbers Seeking Care

Dr. Elizabeth Krans

The need for improved healthcare services for women affected by opioid use is only growing, according to Dr. Elizabeth Krans, primary investigator at Magee-Womens Research Institute, and research professor at the University of Pittsburgh. Dr. Krans’ work focuses on improving the healthcare delivery process for female patients affected by substance abuse, particularly opioids. The urgency, she says, began rising in 2005.

“We started to see an escalation in the diagnosis of [opioid] use disorder and disorder in pregnancy among women of reproductive age,” explains Krans. Opioid use disorder not only has consequences for mothers, but also puts newborn babies at risk for Neonatal Abstinence Syndrome. “We at Magee will probably see 500 [of these] women this year; more than one a day comes through with a known diagnosis.” Fifteen years ago, she explains, the number was half that.

The rising number of women seeking care highlights a more hopeful outcome overshadowed by the face of the opioid crisis—overdose—which often serves as a point of focus on the news and in profiles of cities like Middletown, Ohio. When it comes to getting addiction treatment, pregnancy can be seen as a “window of opportunity” to intervene.

“We simply have a lot of resources at the time of pregnancy,” says Dr. Krans. As pregnant women seek routine prenatal care, a world of opportunities open for them to get treatment for both themselves and their baby. “From a systems perspective, women become Medicaid eligible during pregnancy which allows us to provide them with a variety of preventative and social support services which will help them significantly in pregnancy.

Helping Moms and Providers Approach Pregnancy and Addiction

Stephanie Bobby, Patient Care Manager, talks to a patient.

This window of increased healthcare engagement is the focus of Dr. Krans’ research. Many women suffering from addiction may not have been receiving healthcare prior to pregnancy, so a visit to an OBGYN is often their first healthcare experience in a long time. This poses particular challenges to providers who may not be trained to manage cases of pregnancy involving substance abuse and addiction.

Knowledge of the treatment paradigm for this population isn’t the only tool providers need, either: seeing the big picture is crucial, as is understanding how to approach addiction and talk to women about their disorder. “[Addiction is] a chronic medical condition that we often only identify in pregnancy,” Krans says. “Thankfully, it is a medical condition that we have adequate and effective treatment for.”

Generally speaking, she explains, comprehensive, high-quality treatment for this population involves engaging the patient in opioid pharmacotherapy—usually methadone or buprenorphine—as well as behavioral health counseling and, ultimately, psychosocial services support. Thirty to forty percent of women initiate opioid pharmacotherapy with methadone or buprenorphine for the very first time in pregnancy, and many require it indefinitely.

Ultimately, it’s critical to foster a patient-provider relationship that facilitates trust and disclosure. Doing so facilitates the recovery process, “which is what we’re really trying to get at. Pregnancy is the beginning of a long-term healthcare process,” Krans says, one that “we need to be able to provide well beyond delivery.”

Bettering The System, Building Resources

The health services research conducted by Dr. Krans and others at Magee-Womens Research Institute aims to improve patient outcomes by integrating additional women-centered preventative health care services, such as  family planning services and Hepatitis C education and treatment, into the existing opioid treatment process.

But the opioid crisis isn’t declining, and it does not just affect people here in Pittsburgh—meaning the research can’t just stay here. As a tertiary care institution, outreach and resource distribution is elemental to Magee’s efforts.

“We hear a variety of stories from low-resource, lower volume hospitals that women are not receiving the care that they should,” says Krans. “As a tertiary care institution, a research institution, a place where we have a lot of knowledge and training, it is our responsibility to reach out to these other obstetric practices and help them in education, training, and service provision to expand the ability to provide high-quality treatments to [pregnant women suffering addiction]. It’s the only way we’re ever going to improve outcomes. We have to be able to come up with ways to replicate or provide this kind of treatment program to outlying hospitals.”

The opioid crisis is a widespread problem, but larger spikes tend to occur in lower resource areas. “We often see the highest prevalence of use in, low-volume obstetric hospitals in rural Pennsylvania,” Krans points out. While Magee’s comprehensive program is supported through its urban resources and care providers, not all prenatal care providers are as fortunate. Which is why Magee’s current initiative is seeking to bridge that gap. “We’re trying to create relationships with outlying prenatal care practices and lower volume hospitals within the UPMC system that don’t have the same kinds of resources,” Krans explains. “We can provide our experience and expertise to those care providers by either assuming some of the necessary roles, linking to them with telehealth/telemedicine technology, or helping to train care providers that are desperate to adequately treat these patients.”

A Hopeful Future

The recovery process for women suffering from opioid addiction is a long one. Successful recovery doesn’t simply mean the ability to discontinue medications once everything is going well. Right now, success is determined primarily by three outcomes. First and foremost is the absence of ongoing illicit opioid use. Secondarily, engagement in treatment for as long as is needed—continuing to receive counseling, behavioral therapy, and opioid pharmacotherapy, if that’s part of a woman’s long-term treatment plan. The third success indicator involves improvement in psychosocial functioning—a pointed effort to ensure the safety and quality of life for a population often affected by isolation, intimate partner violence, family abuse, and dysfunctional environments. Helping these women secure employment, transportation, and housing is also a part of this effort.

Ultimately, the true goal of the program is to help women—new moms—regain control of their lives. Addressing one component of this chronic disease is helpful, but not enough to maintain the recovery process, Krans emphasizes. “This population needs an entire care team, not a single intervention. [We take] a comprehensive approach. You have to look at the entire picture to make longstanding impact and change.”

“This is a mom and her baby. We want to preserve that maternal-infant dyad—creating enduring impacts and promoting recovery so that mom can stay with baby. That is of utmost importance.”

You can help researchers like Dr. Krans improve resources and programs for new mothers in the recovery process. Support medical research and donate to Magee-Womens Research Institute today!