A movement toward health: a case study of the pregnancy recovery center

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Phylicia Natasha McCalla

B.A., University of Pennsylvania, 2012

Submitted to the Graduate Faculty of

Health Policy and Management

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh




This essay is submitted


Phylicia Natasha McCalla

December 8, 2014

and approved by

Essay Advisor:

Julie Donohue, PhD ______________________________________

Associate Professor

Health Policy and Management

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Jeannette South-Paul, MD ______________________________________

Department Chair, Professor

Family Medicine

School of Medicine

University of Pittsburgh

Essay Reader:

Stephanie Bobby, BSN, RN, CARN ______________________________________

Patient Care Manager

Pregnancy Recovery Center

Magee-Womens Hospital

University of Pittsburgh Medical Center

(If you have an extra reader, add their info; you can adjust the spacing on this page to fit it.)

Copyright © by Phylicia Natasha McCalla



Julie Donohue, PhD


Phylicia Natasha McCalla, MPH

University of Pittsburgh, 2014

In the last decade, the prevalence of opioid dependency in the United States has dramatically increased. Opioid dependency is a form of substance abuse and is characterized by an individual’s inability to stop using opioids. It is a medical disease that, while treatable, is chronic and relapsing. Because dependency creates difficulties in one’s physical, psychological, social, and economic functioning, treatment must be designed to address all of those areas. Research suggests that opioid dependency is best treated in a comprehensive, individualized tailored program of medication therapy integrated with psychosocial and support services. The Pregnancy Recovery Center (PRC) provides the aforementioned services to opioid-dependent pregnant women in the Pittsburgh area and its surrounding communities.

Buprenorphine maintenance, a form of Medication-Assisted Treatment, has become a major public health initiative to treat opioid dependency. All studies have found buprenorphine to be well accepted by mothers and infants, and to be useful in treating opioid dependent pregnant women. Patients have reported improved social functioning, in addition to elimination of illicit-opioid use. Other outcomes include improvements in employment, education, productivity, homemaking, parenting, physical and mental health, and overall quality of life.

The purpose of this case study is to examine and evaluate the development of the Pregnancy Recovery Center - an integrated Medical Home Care Model that provides Medication-Assisted Treatment (MAT) and prenatal care & delivery for opioid dependent mothers in a single program. The Pregnancy Recovery Center is the only comprehensive buprenorphine clinic dedicated to serving pregnant women in Pittsburgh and the surrounding communities of Western Pennsylvania. This local public health initiative provides consistent, collaborative care throughout the patient’s pregnancy and is a movement toward better health for women and infants. In this case study, the PRC is evaluated based on outcome measures in its first 3 months of operations and compared to scholarly literature. Outcome measures support literature findings that suggest buprenorphine maintenance is an effective method in reducing infant length of stay (LOS) and severity of Neonatal Abstinence Syndrome (NAS). Finally, recommendations are made as the Pregnancy Recovery Center continues to expand and provide services.


Acknowledgement 9

1.0 Introduction 1

1.1background 3

1.2Literature review 6

1.2.1Methadone versus Buprenorphine 7

1.2.2Barriers to Treatment 9

1.2.3Management of Opioid Dependence in Pregnancy 10

2.0 the pregnancy recovery center 12

1.3goals & objectives 14

1.4Program design 15

1.4.1Medication-Assisted Treatment 16

1.4.2Prenatal Care & Delivery 18

1.1Program Procedure 19

1.4.3Eligibility 20

1.4.4Assessment 22

1.4.5Consultation 23

1.4.6Induction 25

1.4.7Follow-Up 27

1.4.8Postpartum 28

1.2Treatment outcome measures 29

1.4.9Infant Outcomes 31

1.4.10Maternal Outcomes 34

3.0 Analysis & Discussion 36

1.3Recommendations 39

4.0 Conclusion 42

bibliography 42

Table 1. Maternal and Infant Characteristics and Outcomes 29

Table 2. Finnegan Score (NAS Score) 32

Figure 1. Medical Home Model 12

Figure 2. Clinical Opiate Withdrawal Score (COWS) 24

Figure 3. Profile of Enrolled Patients 35

Figure 4. Gestation Age upon Admission 35

Figure 5. Patient Navigator Relationship 40

Figure 6. Health System Maze 40

I would like to express my deepest appreciation to everyone that supported me throughout the course of my graduate studies. I am truly grateful for every aspiring guidance, invaluably constructive criticism, and friendly advice. Thank you for taking an active interest in my academics as I embark on my career as a health care professional.

I express my warmest thanks to Mrs. Stephanie Bobby for allowing me to actively participate in the Pregnancy Recovery Center. Your dedication to the PRC and its patients is truly remarkable and one that should be modeled.

I would also like to sincerely thank my professor, Dr. Julie Donohue, and my mentor, Dr. Jeannette South-Paul, for their involvement in the development and completion of my MPH Master’s Essay.

  1. Introduction

In recent years, the abuse, dependence, and misuse of opioids has become a growing public health concern in the United States. Substance abuse is a major public health problem that impacts society on multiple levels. This includes health care expenditures, lost earnings, and costs associated with crimes and accidents. It destroys families, damages the economy, victimizes communities, and places extraordinary demands on the educational, judicial, and social service systems1. Many of America’s top medical problems can be directly linked to drug abuse, including cancer, heart disease, and HIV/AIDS2. Societal issues, such as violence and child abuse, are also related to drug abuse. Substance abuse places an enormous financial and social burden on many communities, including Pittsburgh, Pennsylvania.

Opioid addiction is a chronic, relapsing disease. Like all chronic diseases, it cannot be cured, but it can be managed. A person with addiction can regain a healthy, productive lifestyle with proper treatment. Research shows that Medication-Assisted Treatment (MAT) is an effective treatment option for opioid addiction3. The Pregnancy Recovery Center provides an interdisciplinary, comprehensive treatment approach for opioid dependency. It specifically targets pregnant women, as there has been a noticeable increase on opioid-dependent pregnant women locally and across the nation. Pregnant women with Substance Use Disorders (SUDs) are often stigmatized within their communities. As a result, they are commonly reluctant to disclose their problems to providers, to seek timely prenatal care, and to adhere to treatment plans. The Pregnancy Recovery Center is an innovative initiative that aims to break down the barriers between opioid-dependent mothers and access to prenatal care. Consequently, these mothers can begin their journey to recovery and toward better health for themselves and their infants.


Opiates are among the world’s oldest known drugs. They are naturally derived from the opium poppy and are highly addictive. The term “opioids” is used to define the entire family of opiates including natural, synthetic, and semi-synthetic4. To date, opioid refers to any painkilling narcotic with opium-like effects. Opioids bind to receptors in the brain causing anesthetic effects by decreasing perception of pain, decreasing reaction to pain, and increasing pain tolerance1. They are well known for their ability to produce a feeling of euphoria, which is a mental and emotional state of intense well-being. Tolerance is a neurological adaptation in which sensitivity of opioid receptors decreases, requiring increasingly larger doses for the same drug effects. Continuous and unregulated use of opioids can lead to opioid dependence, which is defined as a biopsychosocial disorder5. Other examples of biopsychosocial disorders include diabetes type II and cancer because of the intertwining biological, psychological, and social influences over the course of the disease.

Opioid abuse in pregnancy includes the misuse of prescription opioid medications and the use of heroin4. Since the 1990s through to today, there has been a noticeable increase in opioid abuse in North America coinciding with the enormous increase in opioid prescriptions. Shockingly, Americans consume approximately 80% of the world’s opioid supply although Americans only constitute roughly 4.6% of the world’s population6. Statistics from the 2010 National Survey on Drug Use and Health report that the number of persons aged 12 years and older illicitly using prescription pain relievers doubled from 2.6 to 5.2 million between 1999 and 20067. Additionally, the CDC estimates that in 2012, providers wrote over 259 million prescriptions for opioids. From 2007 to 2012, the number of past users of heroin had increased from 373,000 to 669,000 respectively. In 2012, 156,000 people reported using heroin for the first time, which was an increase from the 90,000 people who were first-time users in 2007. Sustained remission from opioid dependence is difficult to achieve, as most users will continue to struggle with dependency for their whole lives.

Opioid use during pregnancy is not uncommon. According to the 2010 National Survey of Drug Use, roughly 4.4% of pregnant women reported using illicit drugs in the past 30 days8. A second study showed that while 0.1% of pregnant women were estimated to have used heroin in the past 30 days, 1% of pregnant women reported nonmedical use of opioid-containing pain medication8. A retrospective study observed an increased risk of birth defects with the use of opioids by women in the month before and during the first trimester of pregnancy4. Not surprisingly, the use of illicit opioids during pregnancy is associated with an increased risk of adverse outcomes. These outcomes are related to the repeated exposure of the fetus to opioid withdrawal and include increased risk for Neonatal Abstinence Syndrome (NAS), premature births, low birth weight, and perinatal death9. According to the findings of Winhusen et al, approximately 55-94% of infants exposed to opioids in-utero developed withdrawal signs of NAS10. Signs of NAS often began within 24-72 hours for methadone-exposed infants and 24-96 hours for buprenorphine-exposed infants.

Not only is NAS associated with adverse health effects for infants, but it is also linked to costly hospitalizations. In 2009, the average length of stay (LOS) for NAS was 16 days and the average cost of treatment was $53,400, equaling over $3,300 per day per infant11. Infants with NAS require specialized care, as the presentation of the syndrome is unpredictable, with individual neonates displaying different symptoms and severity over time12. The current standard of care for pregnant women with opioid dependence is a Medication-Assisted Treatment (MAT) in an opioid treatment program1. It is widely accepted that tapering doses of opioid during pregnancy is not effective and often results in relapse of use. Additionally, abrupt discontinuation of opioid during pregnancy is not advised and can result in preterm labor, fetal distress, or fetal demise4.

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