Interdisciplinary Treatment for Opioid Use Disorder in the

Interdisciplinary Treatment for Opioid Use Disorder in the UAMS Women’s Mental Health Program – A Case Study Michael A. Cucciare, Ph. D and Shona Ray-Griffith, MD Women’s Mental Health Program University of Arkansas for Medical Sciences Text MCUCCIARE 737 to 22333 join 1

Disclosures • Dr. Cucciare has no disclosures. • Dr. Ray-Griffith receives clinical trial support from Neuronetics and has received clinical trial support from Sage Therapeutics. Neither will be discussed today.

Today’s Goals • Briefly describe the UAMS Women’s Mental Health Program (WMHP) • Describe an interdisciplinary approach to treating opioid use disorder • Talk about patient’s outcomes and lessons learned 3

Women’s Mental Health Program (WMHP) • Outpatient psychiatric practice focused on pregnant and postpartum women with neuropsychiatric illnesses, including substance use disorders. 4

Women’s Mental Health Program Psychiatrists Shona Ray-Griffith, MD Jessica L. Coker, MD Psychologist Michael Cucciare, Ph. D Psychology Intern - rotating Program Manager Bettina Knight, RN Research Assistants Amber Thomas Rebecca Stallmann Clinical Services: University Women’s Clinic • General Psychiatry for Pregnant and Postpartum Women (including teenagers) Psychiatric Research Institute • Comorbid mental illness and substance use disorders • Perinatal Mood Disorders Contact Us/Referrals: (501) 526 -8201 Email: slray@uams. edu OR jlcoker@uams. edu

Case Study • • • 22 year old woman, Caucasian 19 weeks pregnant (unplanned, wanted) Not currently employed; some college No pregnancy complications reported at time of intake Referred by Maternal-Fetal Medicine (high risk) Hepatitis C 6

WMHP Intake • Substance use started at age 14 - MJ and alcohol; started using cocaine at 15 • Current drug use = IV heroin (half gram per day), opioids (dilaudid and roxicodone), methamphetamine, MJ, benzodiazepines, and tobacco – Drug use helps “withdrawals and to cope with everything” – UDS: + MOP, THC, BUP, OXY, MET/AMP • Motivation to change 10/10 • Prior residential SUD treatment x 2; reports seeing “lots” of psychiatrists • Longest period of sobriety was two months 7

WMHP Intake Cont’d Mental Health history: • Felt depressed the past two weeks as well as lots of guilt and shame, self-hate, and hopelessness • BDI = 20 (moderate depression) • Treated for insomnia and anxiety in the past • trazodone, hydroxyzine, gabapentin Social history: • Lives with mom, uncle, and siblings • FOB plans to be involved • Siblings and FOB all have substance use problems 8

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Medication Management • Admitted to inpatient women’s unit for detoxification and induction of buprenorphine – 7 day hospitalization – Stabilized on buprenorphine-naloxone 8 -2 mg SL BID • Followed up with WMHP as an outpatient 10

Behavioral Intervention • Skills-based group treatment: learning about, identifying, and avoiding “triggers”; coping with stress and uncomfortable emotions • Individual counseling: – Relapse Prevention: identify high risk situations that can trigger drug use and enhancing skills for coping, managing lapses – Cognitive Behavioral Therapy for anxiety: identify negative thinking and beliefs, helping patients change unhelpful thinking and behavior to improve mood and functioning 11

Pregnancy • “Star” patient • Consistently attended all MWHP appointments • Negative urine drug screens (weekly) for many months • Expressed extreme anxiety about the following: – Potential for DHS involvement – Relapse postpartum 12

Delivery • Described as “horrible” • C-section due to failure to progress • Uncontrolled pain • Baby with no signs of NAS • + breastfeeding 13

Up to 3 Months Postpartum • Frequent rescheduling of med management and individual counseling • Stressors noted by patient: • reasons being not “feeling well” and “being tired” • suboxone not as effective withdrawal symptoms • stress and anxiety taking care of baby; relationship problems • Diagnosed with postpartum depression and started on sertraline (Zoloft) • Starting using with friends to avoid stress • Methamphetamines and opioids 14

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Overdose • Patient did not attend for 1 month – WMHP made check-in phone calls that were not answered – Rumors that she overdosed • 1 month later, she contacted physician – She admitted to overdosing (found by her mom unresponsive). Seen in ER and d/ced. – A few days later, she was admitted to ICU for sepsis X 5 days. – She admits to using heroin daily and methamphetamine occasionally • Admitted to inpatient treatment for detoxification & induction 16

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Postpartum (post overdose) • Attended treatment regularly • Continued to relapse (positive UDS) • Pt reported high stress (due to caregiving, struggling with relationship with FOB and mother) as reasons for continued use. • Due to positive drug screens, patient was tapered off MAT. Discussed other options. Patient did not return to the WMHP. 18

Lessons Learned • Pt. indicated several months prior to delivery concern about relapse – is there something we could have done differently to prevent relapse? • Residential treatment was discussed as an option but not desired by patient – could we have done something differently to help her consider this option? • Other thoughts? 19

QUESTIONS ABOUT THE TOPIC Continuing Education Credit: TEXT: 501 -406 -0076 Event ID: 29152 -24581 20

CASE CONFERENCE AND FEEDBACK Continuing Education Credit: TEXT: 501 -406 -0076 Event ID: 29152 -24581 21