[Skip to Content]
Outline
Claim CME
PDF
Health Informatics

Treatment of Opioid Use Disorder in Pregnant Women via TelemedicineA Nonrandomized Controlled Trial

Educational Objective
To Understand how opioid use disorder treatment outcomes received via telemedicine compares to treatment received in person in obstetric practices
1 Credit CME
JAMA Network Open
Published Online: January 31, 2020
Original Investigation
Constance Guille, MD, MSCR1,2;
Annie N. Simpson, PhD3;
Edie Douglas, MPH1;
Lisa Boyars, MD1;
Kathryn Cristaldi, MD, MHS4;
James McElligott, MD, MSCR4;
Donna Johnson, MD2;
Kathleen Brady, MD, PhD1
Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
  • 2Obstetrics and Gynecology, Medical University of South Carolina, Charleston
  • 3Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston
  • 4Department of Pediatrics, Medical University of South Carolina, Charleston
Read article on JAMA Network

MOC/CME Information

editorial comment icon
Editorial
Comment
 related articles icon
Related
Articles
 author interview icon
Interviews
 multimedia icon
Multimedia
Read Article Claim CME
Key Points

Question  Is opioid use disorder treatment received via telemedicine in obstetric practices associated with similar maternal and newborn outcomes compared with opioid use disorder treatment received in person in obstetric practices?

Findings  In this nonrandomized controlled trial including 98 pregnant women with opioid use disorder, there were no statistically significant differences in rates of retention in treatment between women receiving opioid use disorder treatment via telemedicine vs in person (80.4% vs 92.7%). These findings were also apparent in newborns with neonatal abstinence syndrome (telemedicine: 45.4% vs in person: 63.2%).

Meaning  Telemedicine may provide a scalable solution to making lifesaving treatment available to pregnant women to reduce the maternal morbidity and mortality associated with opioid use disorder and improve maternal and child health.

Abstract

Importance  There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption.

Objective  To compare maternal and newborn outcomes among pregnant women with OUD receiving care via telemedicine vs in person.

Design, Setting, and Participants  A nonrandomized controlled trial including 98 women receiving perinatal OUD treatment in 4 outpatient obstetric practices by telemedicine or in person and followed up until 6 to 8 weeks post partum was conducted from September 4, 2017, to December 31, 2018. Logistic regression with propensity score adjustment was applied to reduce group selection bias and control for potentially confounding variables.

Interventions  Participants were seen weekly for 4 weeks, every 2 weeks for 4 weeks, and monthly thereafter and provided relapse prevention therapy and buprenorphine.

Main Outcomes and Measures  The outcomes were retention in treatment, defined as uninterrupted addiction treatment during pregnancy through 6 to 8 weeks post partum; urine drug screen results at delivery and 6 to 8 weeks post partum; and a neonatal abstinence syndrome (NAS) diagnosis collected via electronic health records.

Results  The mean (SD) age of the 98 pregnant women was 30.23 (5.12) years. Of these, 41 of 44 women (93.2%) in the telemedicine group and 48 of 54 women (88.9%) in the in-person group chose to continue treatment in the program after an initial evaluation. After propensity score weighting and doubly robust estimation, no significant differences were found between groups in retention in treatment at 6 to 8 weeks post partum (telemedicine: 80.4% vs in person: 92.7%; treatment effect, −12.2%; 95% CI, −32.3% to −4.4%). Similarly, after propensity score weighting and doubly robust estimation, there were no significant group differences in rates of NAS (telemedicine: 45.4% vs in person: 63.2%; treatment effect, −17.8%; 95% CI, −41.0% to 8.9%).

Conclusions and Relevance  In this nonrandomized controlled trial, virtually integrated OUD care in obstetric practices produced similar maternal and newborn outcomes compared with in-person care. These findings may have important public health implications for combatting the opioid crisis and its consequences on pregnant women and their families. Future large randomized clinical trials are needed.

Clinical Trial Registration  ClinicalTrials.gov identifier: NCT04049032

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Related Articles

  1. Treating Patients With Opioid Use Disorder in Their Homes – An Emerging Treatment Model

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

See More About

Neonatology Pediatrics Pregnancy Substance Use and Addiction Medicine Opioids Health Care Delivery Models Obstetrics Women's Health Obstetrics and Gynecology Health Informatics
Article Information

Accepted for Publication: December 2, 2019.

Published: January 31, 2020. doi:10.1001/jamanetworkopen.2019.20177

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Guille C et al. JAMA Network Open.

Corresponding Author: Constance Guille, MD, MSCR, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President St, 5 South, MSC861, Charleston, SC 29425 (guille@musc.edu).

Author Contributions: Drs Guille and Simpson had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Guille, Cristaldi, McElligott, Johnson, Brady.

Acquisition, analysis, or interpretation of data: Guille, Simpson, Douglas, Boyars.

Drafting of the manuscript: Guille, McElligott, Johnson.

Critical revision of the manuscript for important intellectual content: Guille, Simpson, Douglas, Boyars, Cristaldi, Brady.

Statistical analysis: Guille, Simpson.

Obtained funding: Guille, Cristaldi, McElligott, Brady.

Administrative, technical, or material support: Guille, Douglas, Cristaldi, McElligott, Johnson, Brady.

Supervision: Guille, Boyars, Cristaldi, Brady.

Conflict of Interest Disclosures: Dr Guille reported receiving grants from Duke Endowment, grants from the Health Resources and Services Administration, and grants from the National Institute on Drug Abuse during the conduct of the study. Dr Simpson reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Cristaldi reported receiving grants from the Health Resources and Services Administration National Telehealth Center of Excellence outside the submitted work. Dr Brady reported receiving grants from State of South Carolina during the conduct of the study. No other disclosures were reported.

Funding/Support: Funding support for this study was received from the National Institute on Drug Abuse (NIDA) (R34 DA046730), Duke Endowment (6563-SP), and Health Resources and Services Administration as part of the National Telehealth Center of Excellence Award (U66 RH31458).

Role of the Funder/Sponsor: The funding sources did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, the NIDA, Clinical and Translational Science Awards, HRSA, and Department of Health and Human Services.

Additional Contributions: We acknowledge the women and health care clinicians at the obstetric practices taking part in this study. The Board of Medical Examiners, led by Stephen R. Gardner, MD, and Jeffrey Welsh, MD, and Darra Coleman, JD, approved this telemedicine practice request. The practice proposal was endorsed by director Sara Goldsby, MSW, MPH, director of the South Carolina Department of Alcohol and Other Drug Abuse Services.

References
1.
Haight  SC, Ko  JY, Tong  VT, Bohm  MK, Callaghan  WM.  Opioid use disorder documented at delivery hospitalization—United States, 1999–2014.  MMWR Morb Mortal Wkly Rep. 2018;67(31):845-849. doi:10.15585/mmwr.mm6731a1PubMedGoogle ScholarCrossref
2.
Maeda  A, Bateman  BT, Clancy  CR, Creanga  AA, Leffert  LR.  Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes.  Anesthesiology. 2014;121(6):1158-1165. doi:10.1097/ALN.0000000000000472PubMedGoogle ScholarCrossref
3.
Winkelman  TNA, Villapiano  N, Kozhimannil  KB, Davis  MM, Patrick  SW.  Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014.  Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520PubMedGoogle Scholar
4.
Patrick  SW, Faherty  LJ, Dick  AW, Scott  TA, Dudley  J, Stein  BD.  Association among county-level economic factors, clinician supply, metropolitan or rural location, and neonatal abstinence syndrome.  JAMA. 2019;321(4):385-393. doi:10.1001/jama.2018.20851PubMedGoogle ScholarCrossref
5.
Armstrong  MA, Gonzales Osejo  V, Lieberman  L, Carpenter  DM, Pantoja  PM, Escobar  GJ.  Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes.  J Perinatol. 2003;23(1):3-9. doi:10.1038/sj.jp.7210847PubMedGoogle ScholarCrossref
6.
Goler  NC, Armstrong  MA, Taillac  CJ, Osejo  VM.  Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard.  J Perinatol. 2008;28(9):597-603. doi:10.1038/jp.2008.70PubMedGoogle ScholarCrossref
7.
Saia  KA, Schiff  D, Wachman  EM,  et al.  Caring for pregnant women with opioid use disorder in the USA: expanding and improving treatment.  Curr Obstet Gynecol Rep. 2016;5:257-263. doi:10.1007/s13669-016-0168-9PubMedGoogle ScholarCrossref
8.
Ecker  J, Abuhamad  A, Hill  W,  et al.  Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.  Am J Obstet Gynecol. 2019;221(1):B5-B28. doi:10.1016/j.ajog.2019.03.022PubMedGoogle ScholarCrossref
9.
Clemans-Cope  L, Lynch  V, Howell  E,  et al.  Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016.  Drug Alcohol Depend. 2019;195:156-163. doi:10.1016/j.drugalcdep.2018.12.005PubMedGoogle ScholarCrossref
10.
Jones  HE, Kaltenbach  K.  Treating Women With Substance Use Disorders During Pregnancy: A Comprehensive Approach to Caring for Mother and Child. Oxford, United Kingdom: Oxford University Press; 2013.
11.
Jones  CM, Campopiano  M, Baldwin  G, McCance-Katz  E.  National and state treatment need and capacity for opioid agonist medication-assisted treatment.  Am J Public Health. 2015;105(8):e55-e63. doi:10.2105/AJPH.2015.302664PubMedGoogle ScholarCrossref
12.
Rosenblum  A, Cleland  CM, Fong  C, Kayman  DJ, Tempalski  B, Parrino  M.  Distance traveled and cross-state commuting to opioid treatment programs in the United States.  J Environ Public Health. 2011;2011:948789. doi:10.1155/2011/948789PubMedGoogle Scholar
13.
WAMI Rural Health Research Center. Changes in the supply of physicians with DEA DATA waiver to prescribe buprenorphine for opioid-use disorder. Data brief #162. https://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2017/05/RHRC_DB162_Andrilla.pdf. Updated 2017. Accessed April 30, 2019.
14.
Lacktman  NM, Ferrante  TB. Congress proposes change to Ryan Haight Act to allow telemedicine prescribing of controlled substances. Healthcare Law Today website. https://healthcarelawtoday.com/2018/03/05/congress-proposes-change-to-ryan-haight-act-to-allow-telemedicine-prescribing-of-controlled-substances/. Published March 5, 2018. Accessed April 30, 2019.
15.
Zheng  W, Nickasch  M, Lander  L,  et al.  Treatment outcome comparison between telepsychiatry and face-to-face buprenorphine medication-assisted treatment for opioid use disorder: a 2-year retrospective data analysis.  J Addict Med. 2017;11(2):138-144. doi:10.1097/ADM.0000000000000287PubMedGoogle ScholarCrossref
16.
Weintraub  E, Greenblatt  AD, Chang  J, Himelhoch  S, Welsh  C.  Expanding access to buprenorphine treatment in rural areas with the use of telemedicine.  Am J Addict. 2018;27(8):612-617. doi:10.1111/ajad.12805PubMedGoogle ScholarCrossref
17.
Guille  C, Jones  H, Abuhamad  A, Brady  KT. Shared-decision making tool for the treatment of perinatal opioid use disorder [published online January 8, 2019].  Psychiatric Res Clin Pract. doi:10.1176/appi.prcp.20180004
18.
Harder  VS, Stuart  EA, Anthony  JC.  Propensity score techniques and the assessment of measured covariate balance to test causal associations in psychological research.  Psychol Methods. 2010;15(3):234-249. doi:10.1037/a0019623PubMedGoogle ScholarCrossref
19.
Rosenbaum  PR, Rubin  DB.  The central role of the propensity score in observational studies for causal effects.  Biometrika. 1983;70(1):41-55. doi:10.1093/biomet/70.1.41Google ScholarCrossref
20.
Xu  S, Ross  C, Raebel  MA, Shetterly  S, Blanchette  C, Smith  D.  Use of stabilized inverse propensity scores as weights to directly estimate relative risk and its confidence intervals.  Value Health. 2010;13(2):273-277. doi:10.1111/j.1524-4733.2009.00671.xPubMedGoogle ScholarCrossref
21.
Austin  PC, Stuart  EA.  Moving towards best practice when using inverse probability of treatment weighting (IPTW) using the propensity score to estimate causal treatment effects in observational studies.  Stat Med. 2015;34(28):3661-3679. doi:10.1002/sim.6607PubMedGoogle ScholarCrossref
22.
Haffajee  RL, Frank  RG.  Making the opioid public health emergency effective.  JAMA Psychiatry. 2018;75(8):767-768. doi:10.1001/jamapsychiatry.2018.0611PubMedGoogle ScholarCrossref
23.
Volkow  ND, Frieden  TR, Hyde  PS, Cha  SS.  Medication-assisted therapies—tackling the opioid-overdose epidemic.  N Engl J Med. 2014;370(22):2063-2066. doi:10.1056/NEJMp1402780PubMedGoogle ScholarCrossref
24.
Massachusetts Department of Public Health. Legislative report: chapter 55—an assessment of fatal and non-fatal overdoses in Massachusetts (2011-2015). https://www.mass.gov/files/documents/2017/08/31/legislative-report-chapter-55-aug-2017.pdf. Published August 2017. Accessed April 30, 2019.
25.
The Massachusetts Maternal Mortality and Morbidity Review Committee. Substance use among pregnancy-associated deaths—Massachusetts, 2005–2014. https://www.mass.gov/files/documents/2018/05/02/ma-maternal-mortality-and-substance-use-april-2018.pdf. Published Spring 2018. Accessed April 30, 2019.
26.
Johnson  E.  Models of care for opioid dependent pregnant women.  Semin Perinatol. 2019;43(3):132-140. doi:10.1053/j.semperi.2019.01.002PubMedGoogle ScholarCrossref
27.
Lefebvre  L, Midmer  D, Boyd  JA,  et al.  Participant perception of an integrated program for substance abuse in pregnancy.  J Obstet Gynecol Neonatal Nurs. 2010;39(1):46-52. doi:10.1111/j.1552-6909.2009.01083.xPubMedGoogle ScholarCrossref
28.
Substance Abuse and Mental Health Services Administration (SAMHSA).  A Collaborative Approach to the Treatment of Pregnant Women With Opioid Use Disorders. HHS Publication No (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016.
29.
Minozzi  S, Amato  L, Vecchi  S, Davoli  M.  Maintenance agonist treatments for opiate dependent pregnant women.  Cochrane Database Syst Rev. 2008;2(2):CD006318. doi:10.1002/14651858.CD006318.pub2PubMedGoogle Scholar
30.
Conners  NA, Bokony  P, Whiteside-Mansell  L, Bradley  RH, Liu  J.  Addressing the treatment needs of children affected by maternal addiction: challenges and solutions.  Eval Program Plann. 2004;27(2):241-247. doi:10.1016/j.evalprogplan.2004.01.014Google ScholarCrossref
31.
Ordean  A, Kahan  M.  Comprehensive treatment program for pregnant substance users in a family medicine clinic.  Can Fam Physician. 2011;57(11):e430-e435.PubMedGoogle Scholar
32.
Peles  E, Schreiber  S, Bloch  M, Dollberg  S, Adelson  M.  Duration of methadone maintenance treatment during pregnancy and pregnancy outcome parameters in women with opiate addiction.  J Addict Med. 2012;6(1):18-23. doi:10.1097/ADM.0b013e318229bb25PubMedGoogle ScholarCrossref
33.
Substance Abuse and Mental Health Services Administration (SAMHSA).  Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018.
34.
Faherty  LJ, Matone  M, Passarella  M, Lorch  S.  Mental health of mothers of infants with neonatal abstinence syndrome and prenatal opioid exposure.  Matern Child Health J. 2018;22(6):841-848. doi:10.1007/s10995-018-2457-6PubMedGoogle ScholarCrossref
35.
CDC Foundation. Capacity to Review and Prevent Maternal Deaths: report from nine maternal mortality review committees, 2018. https://www.cdcfoundation.org/sites/default/files/files/ReportfromNineMMRCs.pdf. Published 2018. Accessed December 19, 2019.
36.
Quesada  O, Gotman  N, Howell  HB, Funai  EF, Rounsaville  BJ, Yonkers  KA.  Prenatal hazardous substance use and adverse birth outcomes.  J Matern Fetal Neonatal Med. 2012;25(8):1222-1227. doi:10.3109/14767058.2011.602143PubMedGoogle ScholarCrossref
37.
Lund  IO, Fitzsimons  H, Tuten  M, Chisolm  MS, O’Grady  KE, Jones  HE.  Comparing methadone and buprenorphine maintenance with methadone-assisted withdrawal for the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes.  Subst Abuse Rehabil. 2012;3(suppl 1):17-25.PubMedGoogle Scholar
38.
Dooley  R, Dooley  J, Antone  I,  et al.  Narcotic tapering in pregnancy using long-acting morphine: an 18-month prospective cohort study in northwestern Ontario.  Can Fam Physician. 2015;61(2):e88-e95.PubMedGoogle Scholar
39.
Jones  HE, Kaltenbach  K, Heil  SH,  et al.  Neonatal abstinence syndrome after methadone or buprenorphine exposure.  N Engl J Med. 2010;363(24):2320-2331. doi:10.1056/NEJMoa1005359PubMedGoogle ScholarCrossref
40.
Brogly  SB, Saia  KA, Walley  AY, Du  HM, Sebastiani  P.  Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis.  Am J Epidemiol. 2014;180(7):673-686. doi:10.1093/aje/kwu190PubMedGoogle ScholarCrossref
41.
Zedler  BK, Mann  AL, Kim  MM,  et al.  Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child.  Addiction. 2016;111(12):2115-2128. doi:10.1111/add.13462PubMedGoogle ScholarCrossref
42.
Wilder  C, Lewis  D, Winhusen  T.  Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder.  Drug Alcohol Depend. 2015;149:225-231. doi:10.1016/j.drugalcdep.2015.02.012PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
Want full access to the AMA Ed Hub?
Become an AMA member now
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue