Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic
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At the time of initial presentation to a virtual reproductive psychiatry clinic in April 2020, Ms. A was a 29-year-old single woman at approximately 21 weeks’ gestation with her third pregnancy. She presented to treatment through a virtual care platform and indicated that she had problems with daily opioid use. Ms. A was introduced to opioid analgesics after the birth of her second child via emergent cesarean section in 2017. During her hospital stay after the cesarean section, she experienced significant postoperative pain, described as a constant, severe throbbing, and aching pain in her pelvis and lower back, and she was treated with oxycodone, with increasing dosages until her pain was adequately controlled. At hospital discharge, she was taking 60 mg/day of oxycodone and was given a 1-month supply of the medication. Ms. A continued the medication as prescribed, 15 mg every 6 hours. At 2 weeks postpartum, she attempted on her own to reduce the dose, but experienced significant pain that interfered with her ability to perform activities of daily living, including being the primary caregiver for her newborn and her other child. She resumed the prescribed dosage of medication, which was refilled at the same dosage at her subsequent obstetric follow-up appointment. She again attempted on her own to cut back on the dose, but she had returned to work at 5 weeks postpartum out of financial necessity, and, she reported, “I couldn’t manage the pain and [the stress of] work during the day, being up all night with my daughter, and taking care of my son, and going through withdrawal. The pills made it all work somehow.”
At 3 months postpartum, she requested another refill of the prescribed medication, which was denied by her obstetrician because he believed she was “addicted.” She was told that if she was not able to stop taking the medication she would need “addiction treatment.” She was instead provided with oxycodone 5 mg, a total of 20 tablets, and told to taper her medication. Ms. A began to experience significant withdrawal symptoms while trying to taper her medication but did not reach out for help because of her prior experience of being accused of “being addicted” and fear of being reported to the state’s department of child welfare and social services. Ms. A began borrowing oxycodone tablets from a family member and continued to try to taper her medication. She reported feeling significant craving, symptoms of depression, and being unable to keep up with the demands of home and work while trying to reduce her opioid medication use.
At approximately 1 year postpartum, Ms. A began purchasing oxycodone tablets from a friend. She stated, “I knew at that point, I had a problem.” Since 2018, she had made two attempts to get treatment, but was without health insurance and could not afford the cost. She was referred to a program that offered comprehensive services through a State Opioid Response grant, but the program was over an hour’s drive from her home and required that she first attend an intensive outpatient program, which would have prevented her from working. While an evening intensive outpatient program was also offered for working clients, she was not able to afford the cost of additional childcare needed for attending the program in the evenings.
When she was unable to afford buying pills, she was offered heroin, which was significantly less expensive. She first began snorting heroin, and within a couple of months progressed to daily use and injection.
On presentation for treatment, Ms. A was using heroin daily, predominantly intravenously. “This became the focus of my every day—making sure I had what I needed [to not go into withdrawal] and making sure no one knew [that I was using].” Despite her attempts to conceal her use, her siblings were aware of it, which created significant relationship and family tension. When she learned that she was pregnant, she attempted to cut down her use but was unsuccessful because of the return of significant depressive and withdrawal symptoms as well as a lack of instrumental supports to care for her children long enough “so I could just get through this [withdrawal].”
When she learned of her third pregnancy, she knew she needed to see an obstetric provider but was afraid that child welfare services would get involved and remove her children from her physical custody. She also feared seeking obstetric services given the threat of COVID-19 and because her city was currently on a stay-at-home order. She began looking online and accessed a virtual care platform for pregnant or postpartum women with mental health or substance use problems and completed an online screen. She was contacted by telephone that same day by a care coordinator, who scheduled her for an appointment with a reproductive psychiatrist with addiction training the following morning via home-video visit. At that appointment, Ms. A was evaluated via videoconferencing and a treatment plan was initiated, including starting buprenorphine and relapse prevention therapy, as well as connecting her with a trusted obstetrician.
Ms. A successfully completed a buprenorphine home induction without side effects or precipitated withdrawal. She tolerated buprenorphine well and stabilized on a dosage of 16 mg/day. In addition to weekly medication management, she began weekly relapse prevention therapy via videoconferencing from home. Further evaluation of her mental health history revealed a significant history of major depressive disorder beginning in her early twenties. The patient was monitored for depressive symptoms, which were minimal and could be addressed with weekly psychotherapy.
The clinician provided reassurance regarding child welfare involvement and addressed the patient’s concerns. The clinician explained the South Carolina state-mandated reporting requirements (each state its own legislation related to substance use in pregnancy and the postpartum period). Given her engagement in treatment for opioid use disorder, her response to it, and her ability to care for herself and her children, there was no concern about potential endangerment of her children, and therefore no report to the state child welfare agency was necessary. With reassurance, she was willing to establish care with an obstetrician whom the addiction provider had previously worked with. The patient attended prenatal care both in-person and via telemedicine when appropriate.