A Virginia program that started because a local jail was seeking treatment options for pregnant inmates is now working with women referred from a variety of sources, at any stage of their pregnancy. The VCU Health Obstetrical Addiction Program (serving the Richmond area) has worked mainly with pregnant women affected by opioid dependence, though the co-director tells Addiction Professional that cocaine use also is prevalent in the region's population.
Sebastian Tong, MD, emphasizes two critical components of the program, which is just under two years old: It uses an interdisciplinary team approach to address the complexity of health and life issues affecting pregnant women, and it does not adhere to only one treatment strategy.
“This is a chronic disease that really needs to be treated in a holistic manner,” says Tong. “It is not treatable with just psychotherapy or just medication.”
As much as medication-assisted treatment—in this program's case, the Subutex formulation of buprenorphine—is seen as essential to help patients with opioid use disorders handle intense cravings, medication alone is not seen as being able to address the entire scope of an addiction. “We depend also on our psychological team to teach our patients coping mechanisms, and to look at underlying causes,” says Tong, who has a background in both obstetrics and addiction practice.
Addressing barriers to care
Tong says the program, which has seen close to 70 patients since its inception, is receiving referrals from a variety of sources. Criminal justice no longer is the referral source in the majority of cases, although the program began because local jail officials approached VCU Health, a health system that includes an academic medical center and more than 750 physicians, in order to assist pregnant patients in withdrawal.
Some patients in the program had been seeing an obstetrician in the VCU Health system for some time before enrolling. “Some don't admit [substance use] when they first come in,” Tong says. Stigma remains a common barrier, with one manifestation being patients' reluctance to jeopardize custody of their children if they admit to struggling with a substance use problem while pregnant. Tong adds, however, that the custody issue can serve as either a barrier to treatment or an incentive to pursue it, depending on the individual.
Therapeutic services in the program are overseen by a clinical psychologist. A master's-level social worker also is part of the treatment team, and VCU Health nursing staff also work cooperatively with team members, Tong says.
Because the organization does not have an opioid treatment program (OTP) license, it uses buprenorphine as the sole medication treatment for the pregnant patients, and Subutex (buprenorphine without naloxone) is the formulation most supported in research for this population, Tong says.
He says that anecdotally, the comprehensive approach to care is yielding encouraging outcomes. Women with custody issues are reuniting with their children and other loved ones, and pursuing employment, he says. Neonatal outcomes are improving, with fewer newborns affected by neonatal abstinence syndrome. That has been a major concern in the hospital community around Richmond in recent years.
“Some hospitals had been reporting one or two such cases a year in the past, and now they have been seeing them at least monthly, or even weekly,” Tong says.