MOms in REcovery (MORE) Study: Defining Optimal Care

Northern New England has among the highest rates of opioid dependence in the U.S, with prevalence highest and growing among those of between the ages of 18-35 years. This region also has among the highest rates of opioid-related deaths in the U.S., with a disproportionate high rate among pregnant women with opioid use disorder. In northern New England (Maine, New Hampshire, \& Vermont), 5-8% of newborns have mothers with an opioid use disorder (OUD), greatly increasing the risk of poor outcomes, including preterm birth and long hospitalization for neonatal withdrawal and other newborn complications. For pregnant women with OUD, medication assisted treatment (MAT) significantly reduces these risks. However, it is sometimes difficult for pregnant women to find MAT providers. As a result, many maternity care providers have begun to prescribe MAT in their own practices. Other practices have maintained the longstanding evidence-based standard of care, referral of patients with OUD to specialty MAT treatment program. Most pregnant women with OUD have other psychosocial needs, ranging from lack of housing and untreated mental health conditions, to need for parenting education and support. There is variability among practices in terms of types of other services provided to patients, whether the practice has integrated MAT or relies on referral. Although pregnancy is a time when women are highly motivated to start MAT, many women are also likely to discontinue MAT postpartum due to loss of insurance coverage, difficulty transitioning to another provider, loss of motivation for treatment, or competing demands on time and resources as a new parent.

The challenge for patients, providers, and other stakeholders is to understand the relative advantage of the two MAT models (receiving MAT as part of maternity care or at a specialty program) for improving key outcomes for baby \& mother. A second challenge is to understand the relative contributions of onsite services such as mental health care, care coordination, \& parenting education to improved outcomes. This question is important to patients \& families who may have a choice of where they receive their maternity care. It is even more important in rural areas, such as northern New England, where obstetric practices \& specialty care services are limited. Patients, providers \& other stakeholders need guidance in choosing the optimal models for building new programs to provide maternity care for women with OUD.

Northern New England has among the highest rates of opioid dependence in the U.S, with prevalence highest and growing among those aged 18-35 years. Regional rates of perinatal opioid use disorders (OUD) reflect this public health crisis; Northern New England region has the highest incidence of opioid-related births in the nation. Perinatal opioid use disorders impact 5-8% of pregnancies in Maine, New Hampshire, and Vermont, three states that have been severely impacted by the current opioid epidemic. Consequences of inadequately treated OUD include premature delivery and other perinatal complications, prolonged newborn hospitalization for neonatal abstinence (NAS), and maternal morbidity and mortality from infectious disease and overdose. In 2013, costs associated with NAS treatment in the U.S. reached $1.5 billion. The epidemic has grown multifold since 2013.

Medication assisted treatment (MAT) with either methadone or buprenorphine is the recommended standard of care during pregnancy. Professionals, including the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics, the Society for Maternal-Fetal Medicine, and the American Society for Addiction Medicine, have called to adopt care models that promote early identification and treatment for pregnant women with OUD. Referral to specialty programs for MAT has been the accepted standard of care, with demonstrated safety for women and their infants. However, in response to the escalating opioid crisis, the ACOG began offering buprenorphine training programs to its members. Consequently, a number of maternity care practices throughout Northern New England now provide integrated MAT services. But even where such integrated programs exist, questions persist on the optimal care model for providing MAT to pregnant women with OUD.

There are patient- and provider- factors associated with variability in effectiveness of what MAT model works best for whom. For women, advantages of buprenorphine over methadone include a lower risk of overdose, fewer drug interactions, the accessibility of office-based treatment delivery in the context of maternity care and demonstrated shorter NAS course. The disadvantages of buprenorphine relative to methadone include potential hepatic dysfunction, lack of long-term data on consequences of fetal exposure for infants, potential limited efficacy in patients with high addiction severity, requirement of moderate withdrawal symptoms prior to initiation to avoid iatrogenic withdrawal, and an increased risk of diversion (i.e., sharing or sale). Despite buprenorphine's demonstrated neonatal advantages, it is not effective for all women. The structure of methadone treatment (daily meeting) may also better align with support needs for some women. For providers, the choice of what medication-assisted approach to offer to patients is often restricted by availability and access to specialty care services.

There is limited literature comparing the effectiveness of integrated versus referral MAT care models for postpartum retention in treatment and women's experiences in these two models. In particular, women with high levels of addiction severity or co-occurring mental health conditions may have prenatal care needs from women with less complex behavioral health concerns. Studies have also not assessed the impact of maternal opioid addiction severity on newborn outcomes and maternal long-term recovery. The best neonatal outcomes will be achieved by providing the most appropriate and effective treatment for mothers.

The challenge for patients, providers, and other stakeholders is determining the optimal approach for delivering MAT during pregnancy and after delivery to improve outcomes. Currently, regional obstetrical practices provide either: (1) Integrated care, in which MAT and associated psychosocial services are delivered on site with obstetrical care, and (2) Referral-based care, in which women receive MAT and obstetrical care in separate, specialized locations. Both models have different potential advantages and disadvantages for mothers with OUD and their babies regarding access, availability, acceptability and quality of MAT, obstetrics and other needed services, and long term follow up and treatment after delivery. While pregnancy motivates women to initiate MAT, relapse to use of opioids and cessation of MAT frequently occur during the first postpartum year, placing both mother and infant at significant risk. Payers and policymakers are also seeking answers about where to invest healthcare resources to increase access to treatment for pregnant women, especially in the current opioid crisis. A disproportionate number of women with OUD are insured through the Medicaid system; Medicaid policy affects women's access to a wide range of services, from reimbursement for same-day services or care coordination, to whether a woman continues to be eligible for benefits after delivery.

Study Aims: This study aims to answer these important patient, provider, and policy questions by comparing the real-world effectiveness of two models of MAT delivery currently in clinical use in Maine, New Hampshire, and Vermont with respect to patient experience of care and perinatal, neonatal, and longer-term substance use treatment outcomes.

Two main Comparative Effectiveness Research (CER) Patient-Centered Outcomes Research Institute (PCORI) priority questions will be addressed:

1. Do clinical and patient-reported outcomes for pregnant and parenting women differ between integrated and referral-based MAT practice models?
2. Within models, which psychosocial services are most associated with MAT continuation, and for which groups of patients?

To answer these questions, the following specific aims will be addressed:

Aim 1 (Clinical Outcomes). To use clinical record data to evaluate the comparative effectiveness of Integrated and Referral-Based MAT care models on maternal and neonatal outcomes.

Aim 2 (Patient-reported Outcomes). To use patient reported data to evaluate the comparative effectiveness of Integrated and Referral -Based care models on patient-centered outcomes.

Aim 3 (Heterogeneity of Effects). To examine differences in treatment retention within condition by subgroups of patients based on (1) psychiatric comorbidity, (2) type of medication used for MAT and (3) addiction severity.

Aim 4 (Specification of Services). To determine which services (psychosocial services, care coordination, parenting education) are associated with better maternal and neonatal outcomes.

Aim 5 (Provider). To explore how provider attitudes about MAT and care of patients with OUD vary by care model and are associated with maternal outcomes.

Study Description: This study will collaboratively engage 21 practices providing maternity care across Northern New England, with examples of both integrated care and referral-based models. The study population is pregnant women who receive prenatal care from any of these practices and who meet Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria for an opioid use disorder. A cluster-based, prospective observational mixed-methods design will be used to compare outcomes for pregnant women with opioid use disorder receiving prenatal care in obstetric practices that offer MAT through one of two delivery models: Integrated or Referral-based. Clinical records data (n=2000) from pregnant women with OUD receiving prenatal care at a partner practice will be used to examine Aim 1. Aim 2 will be addressed with a patient-report subsample cohort (n=532) recruited in the 3rd trimester of care and followed to 6 months postpartum. Aim 3 will use both kinds of data to explore heterogeneity of treatment effects. For Aim 4, practice-level data will be collected yearly to evaluate services provided across Integrated and Referral-based practices. In Aim 5, survey and qualitative interviews with providers will lend perspective on facilitators and barriers to MAT in both Integrated and Referral-based practice settings. The analytic strategy will account for clustering and patient baseline differences to compare outcomes across assessment points. Whether the effect of treatment type differs according to psychiatric status, type of MAT patients access, or addiction severity will also be tested. Analysis of qualitative data will inform our interpretation of quantitative results and enhance our understanding of patient experience, as well as barriers and facilitators to receiving care within these care models. Patient representatives, practice-partners, state and regional stakeholders, and scientific advisors will actively guide all stages of this study and dissemination of results to relevant partner networks.

Eligibility Criteria:
Inclusion Criteria:

* Age 16 year and older,
* Identified opioid use disorder,
* Receiving prenatal care for current pregnancy at partner practice,
* Clinic-recorded diagnosis of opioid use disorder,
* Willing and able to provide informed consent.

Exclusion Criteria:

* Ward of the State