By Rachel Crumpler
Suda said treatment required too much of one individual and one specialty. But as more pregnant women presented with substance use disorder in his community, he realized he needed to step up and care for them.
He got certified to prescribe buprenorphine, an FDA-approved medication used to treat opioid use disorder that helps reduce cravings and withdrawal symptoms. Fewer than 2 percent of the 31,000-plus OB/GYNs studied nationwide in 2020 were certified to provide substance use treatment, a significant gap in capacity.
Suda also started approaching community partners in 2015 that could help address mental health and social determinants of health related to substance use disorder — elements out of his wheelhouse.
His ability to treat pregnant women with substance use disorder really changed once a team of 12 community partners in Cabarrus County was assembled to help him holistically treat pregnant women with substance use disorder. The Substance Use Network (SUN) Project launched in 2019 and is the first collaboration of its kind in the state.
“Normally, medicine operates in its silos and this is where it stays,” said Gina Hofert, SUN Project manager working at Cabarrus Partnership for Children. “We’re entering kind of a new model where we’re trying to say medicine needs to work in tandem with all the other sectors around our community.”
The SUN Project is one of a number of treatment programs springing up across the state, trying different models of helping stem the flood of opioid use and the overdoses that have come with it. And it’s showing promise, with collaboration between agencies making care more efficient and effective for patients and providers.
List of SUN Project Community Partners:
- Cabarrus County Partnership for Children
- Cabarrus Health Alliance
- Atrium Health
- Cabarrus Department of Human Services
- NC Department of Public Safety, Division of Adult Correction and Juvenile Justice
- Genesis A New Beginning
- McLeod Addictive Disease Center
- Daymark Recovery Services
- Cardinal Innovations Healthcare
- Partners Health Management
- Rowan County Health Department
- Rowan County Department of Social Services
Scope of substance use during pregnancy
Nationwide, an estimated 5 percent of pregnant women use one or more addictive substances.
In recent years, opioid use — particularly in pregnancy — has escalated, paralleling the epidemic raging through the general population. According to the Centers for Disease Control and Prevention, the number of pregnant women with opioid use disorder at delivery increased by 131 percent from 2010 to 2017.
Additionally, for every 1,000 newborn hospital stays, 6.8 newborns were diagnosed with neonatal abstinence syndrome — a condition that impacts babies exposed to drugs in utero — according to 2018 data from the national Healthcare Cost and Utilization Project.
In North Carolina, the rate is even higher at 10.1 newborns per 1,000 hospital stays.
Non-opioid substance use in pregnancy also remains a public health problem. From 2018 to 2020, 13.5 percent of pregnant women reported alcohol use in the last 30 days and 5.2 percent reported binge drinking, according to data from the CDC.
Women are at the highest risk of developing a substance use disorder between ages 18 to 29 and are at increased risk throughout their reproductive years. Substance use disorder during pregnancy is associated with negative health outcomes for mothers and infants, including preterm birth, stillbirth and fetal development problems such as brain abnormalities.
However, many OB/GYNs aren’t qualified — or willing, the way Suda initially was — to treat this subset of patients for their substance use. It’s a problem that’s even caught the attention of the White House, which released a report last month with a plan for improving care for pregnant women with substance use disorders.
Impacting mothers with substance use disorders
The SUN Project has brought together partners beyond medicine, including social services, criminal justice and recovery services, to form a continuum of care improving outcomes for mothers with substance use disorder and their infants in Cabarrus County.
The project is guided by a patient-centered approach that uses pregnancy as an opportunity to encourage someone into treatment, Hofert said.
And that’s exactly the care Brooke Kennedy said she received when she visited the SUN Clinic at the Cabarrus Health Alliance throughout her pregnancy last year, after finding out she was about seven weeks pregnant during a hospital visit.
Kennedy said she was nervous for the first visit in March 2021 as she was used to feeling stigmatized and judged during medical visits due to her history with addiction. Fear, stigma and systemic barriers are common reasons why many women with substance use disorder are reluctant to receive prenatal care or decide to forgo it.
However, Kennedy said she found a safe space where she could be honest even when she encountered setbacks.
“They told me how proud they were of me, first of all, for taking this step and taking care of myself and my baby,” Kennedy said. “Not ‘Oh, you’re on medicine or you use to do drugs. Forget you, you’re a horrible person.’
“They gave me the right tools to maintain my sobriety through my pregnancy.”
Suda said providing support before the baby is born is key. He said he’s found that a mother will often do more for her recovery while pregnant to protect the child than she may have done for herself alone.
“It is just amazing to see what can come out of a life where a woman is living day to day for a drug and all of a sudden gets pregnant. You would think, ‘Boy, the last thing she needs to be is pregnant,’” Suda said. “I tell you what, it is the number one motivator for life change. Once they hear that they can have a good baby and are told how wonderful they are as a mother for coming in, get out of the way because that train is coming down the tracks.”
Kennedy’s son, who was delivered full-term, will turn one later this month. She credits her success to the SUN Clinic, where all her needs were met. She received prenatal care and counseling as well as a prescription for buprenorphine all within the SUN Clinic location at the Cabarrus Health Alliance.
“I don’t know where I would be without them,” Kennedy said. “They saved my life and I have my son.”
Other SUN Project patients have had similar outcomes. Since the project’s launch, more than 40 patients have been treated. Hofert said the current caseload is around 20 patients.
Notably, 91.4 percent of patients delivered at 35 weeks or later. Program participants receiving buprenorphine also generally stuck with their medication-assisted treatment and participants with “moderate to high adherence” to MAT had higher birth weights and higher gestational age at delivery.
Furthermore, the integrated approach of the program has led to about 61 percent of participants’ other social needs being met.
For Jennifer Yates, a mother in recovery who is a member of the SUN Project’s governance group, the collaborative, multidisciplinary approach to care is critical, especially as there are few places for pregnant women with substance use disorder to go for treatment.
“I think that they do a great job of pairing needed resources and doing the medication management to help you get clean and stay clean,” Yates said.
The SUN Clinic at the Cabarrus Health Alliance offers the following services all at one location:
- Prenatal care by an OB/GYN with specialized training in addictions
- Ultrasound, lab and fetal monitoring
- Medication-assisted treatment in the form of buprenorphine
- Mental health and substance use therapy services
- Nutritional counseling
- Case management services
- Recovery supports
- Peer support specialist services
- Dental care
- Newborn care
A shield and a sword
Bringing together a collaborative team has been a years-long, complicated process.
In May 2015, Suda started approaching outpatient treatment programs, psychiatric offices, primary care doctors, emergency rooms, the county department of social services and others to pitch his idea for a team approach to care for pregnant patients with substance use disorder.
But in 2018, after three years of going to appointment after appointment, he said it looked like his idea was dying. People kept saying that policy and confidentiality laws would not allow the collaboration and information sharing Suda desired.
But the project got renewed energy when Ann Benfield, executive director at the Cabarrus Partnership for Children, helped secure funding that allowed a project manager to be hired.
With the dedicated funds and position, the SUN Project started to come together in early 2019. Shortly after, Suda met Mark Botts, a professor of public law and government at UNC-Chapel Hill’s School of Government who specializes in mental health law. Botts concluded that information sharing between agencies was possible with the permission of the patient.
“Confidentiality law is both a shield that prevents the sharing of information to protect the privacy interests of the patient and that’s generally how agencies subject to confidentiality laws perceive them — as a shield,” Botts said. “But I like to say the law is also a sword that can empower the patient to authorize the sharing of information. So while the shield is there to protect them, the sword is there to help the patient and treatment providers and others to cut through the red tape.”
Botts and a colleague went to work reading the laws governing each agency participating in the project. From there, they wrote a release of information form and a memorandum of understanding form that could be used to facilitate information sharing between all the agencies.
The forms took about a year to create and continue to evolve. Hofert said they have been a game changer.
“If you don’t have information exchange happening easily, then what you have is fragmentation of care and a lot of systemic barriers to care,” she said.
For example, Hofert said before the information sharing agreement, Suda would refer a patient that came to see him in a mental crisis for a psychological consult. Then he would call to check that his patient arrived and would be unable to get any confirmation. Now that information sharing is in effect, Suda can call the office to see if his patient arrived and get an answer. He can even hear what they were able to do for her.
Then Suda can proceed to follow up from there, enhancing continuity of care.
The challenge of working through the legal implications of such a partnership is a main reason that the SUN Project is the first of its kind in the state. Botts said other counties can similarly navigate the confidentiality laws too, though it will take effort. In fact, Botts said he would like to see policymakers at the state level look at laws affecting information sharing and see how it can potentially be made easier.
“The laws may not have been constructed with the intent to make collaboration very difficult,” he said. “But that is the effect.”
A model for others
The General Assembly allocated $1 million in funding to expand the work taking place in Cabarrus County to neighboring Rowan and Stanly counties, Hofert said. She said the counties do not have a provider serving pregnant women with opioid use disorder, so people come to Cabarrus County to be treated by Suda.
But, these patients do not yet receive the full collaborative set of services because the network of partnerships available in Cabarrus County have not been formed elsewhere.
Hofert will spend the next year replicating the network in Rowan and Stanly counties.
“I genuinely believe that it is in the best interest of our clients to have their care coordinated collaboratively,” she said. “I also think that it’s in the best interest of our partners.”
Suda also hopes to see other places across the state adopt such collaborative approaches to make care more efficient and effective.
“I’m hoping that maybe somebody will take our model and replicate it in their community and then do things to make it better and we learn from them and do what they’re doing,” he said. “We can build on this model and really turn lives around.”
For Suda, he observed that life change directly when he ran into a mother and baby together following a birth — both still healthy.
“I said to her, “Now, are you using any street drugs at all?’ and she pointed to her baby and goes, ‘There’s my drug.’”