Tarayn Fairlie, MD, MPH, Chair – EPIC Breastfeeding Education Program Advisory Committee

Have you noticed that more of your patients are breastfeeding? You aren’t imagining things-breastfeeding rates in Georgia are increasing. However, many mothers still don’t reach their breastfeeding goals, and studies cite lack of support from health care providers as one of the reasons for not meeting them. Georgia families need physicians who can actively support breastfeeding them.  Yet between 43% and 50% pediatricians, neonatologists, obstetricians/gynecologists, and family medicine physicians don’t feel they were adequately prepared for clinical evaluation of breastfeeding problems, and a similar proportion feel that they were inadequately prepared for clinical treatment of breastfeeding problems. This isn’t surprising, as there is little or no formal instruction on breastfeeding and human lactation in medical schools.  The EPIC Breastfeeding Program is here to help fill this gap for practicing physicians and can either jumpstart a big shift for your practice or be the impetus for small improvements. The modules and resources of the EPIC program can help you develop your skills and further develop your practice. EPIC has resources available to assist you to develop, enhance and/or update your skills. Here are some ways EPIC can help you better support breastfeeding families:

Start at the beginning! We know that a mother’s prenatal intention to breastfeed is strongly influenced by input from and support of her physician.  If you see expectant parents, encourage them to breastfeed and answer any questions they might have about breastfeeding. Another good place to start is to track breastfeeding rates in your practice. Knowing what your patient population is doing can be helpful at setting practical goals to help mothers adhere to AAP recommendations for breastfeeding: exclusive breastfeeding until 6 months of age and then continued breastfeeding until at least age 1. Through our modules, we can help train support staff and providers to have open-ended conversations about infant feeding that assesses an expectant mother’s breastfeeding intention in a comfortable, non-pressured way.

Look at your practice environment. What are you currently promoting? Do parents see formula companies represented in your practice? Do you still provide free formula gift packs or have formula marketing materials from your waiting area? Ensuring that your patient education is free of commercial influence is an important step in supporting informed feeding choices for all new families, whether breastfeeding or not.   Our resource kit includes samples of well- designed and up-to-date patient education materials in English and Spanish.

Put it in writing. Collaborate with staff to develop a written breastfeeding policy for your practice.  We can provide examples and guidance. A clear policy can ensure that your staff are supported when they return to work by providing space, time and supplies to express milk for their babies, increasing both their job satisfaction and performance.

Offer culturally competent feeding care. Different cultures have varying beliefs and customs relating to infant feeding.  Knowing them and providing appropriate anticipatory guidance can improve your practice and your customer satisfaction ratings. Do you and your staff encourage breastfeeding in the waiting area and provide a private place if desired? Having posters and signs welcoming and encouraging breastfeeding can help parents feel comfortable and supported.  We provide samples in our Resource Kit.

Triage breastfeeding concerns easily. Your phone triage nurses should be provided with training and resources to provide evidence-based recommendations to families calling for advice.  Our Resource Kit includes the AAP published Breastfeeding Telephone Triage and Advice book, 3^rd edition.  Our one-hour breastfeeding education programs can provide this education, as well as continuing education hours for nurses and physicians, at no cost to your office.

Make it part of the visit. Our training will also help guide you in incorporating breastfeeding into routine care.  Learn what effective breastfeeding looks like, what mothers’ common concerns are, and what strategies to employ that preserve breastfeeding and milk production if/when problems arise.  Learn about milk expression and how to support mothers when they return to work or school. Our program also provides resources on coding, billing, and documentation so you can be paid for the work that you do!

Learn who else can help. When further breastfeeding expertise or peer support is indicated, it’s helpful to be familiar with lactation support in your community and where families can find it.  Also, more and more pediatricians, ob/gyns and family practice physicians whose practices see many newborns are directly hiring or contracting with lactation consultants to provide care in the office.  Accessible breastfeeding support can help your practice attract new and growing families, and Georgia is one of the first states to license lactation consultants.

Schedule your EPIC Breastfeeding Program today.  Let us provide you with resources to make your practice more breastfeeding friendly.  We offer convenient, physician-led, peer-to-peer breastfeeding education in your office or hospital. Our modules are one-hour sessions held during lunch or any time that is more convenient. Each program site receives a free Breastfeeding Resource Kit as part of the presentation, with resources for you, your staff and your patients. There are three topics to choose from: Breastfeeding Fundamentals, Supporting Breastfeeding in the Hospital, and Advanced Breastfeeding Support. Free continuing education is provided.  Complete an online program request form at www.GaEPIC.org or call the program office at 404-881-5068. The EPIC Breastfeeding Program is brought to you by the Georgia Chapter, American Academy of Pediatrics with support from the Georgia Department of Public Health.

Why are health care professionals across the nation embracing trauma-informed care? The Center for Health Care Strategies (CHCS) posed this question to clinicians and patients to gather first-hand perspectives on the value of trauma-informed care. Trauma-informed care shifts the focus from “What’s wrong with you?” to “What happened to you?”

A trauma-informed approach to care acknowledges that health care organizations and care teams need to have a complete picture of a patient’s life situation — past and present — in order to provide effective health care services with a healing orientation. Adopting trauma-informed practices can potentially improve patient engagement, treatment adherence, and health outcomes, as well as clinician and staff wellness. It can also help reduce avoidable care and excess costs for both the health care and social service sectors.

Click the links below to explore videos addressing the benefits of trauma-informed care. LEARN MORE 

• What is Trauma-Informed Care? 
• Ignoring trauma in the practice setting can cause patient and provider frustration.
• Trauma-informed care can help improve patient outcomes. 
• Trauma-informed care can improve relationships with patients and patient engagement.
• Trauma-informed care does not have to be a burden to adopt. 

Content provided by the Trauma-Informed Care Implementation Resource Center – Center for Health Care Strategies website

Incorporating Health Care Transition Services into Preventive Care for Adolescents and Young Adults: A Toolkit for Clinicians

Preventive care visits represent an important opportunity to discuss health care transition with adolescents, parents, and young adults. Yet, national survey data reveal that, 85% of youth have not received guidance about health care transition from their health care providers. To address this unmet need, The National Alliance to Advance Adolescent Health/Got Transition with the University of California, San Francisco’s Adolescent and Young Adult Health National Resource Center created a new free online toolkit titled Incorporating Health Care Transition Services into Preventive Care for Adolescents and Young Adults. The toolkit is available in both English and Spanish. Advising Got Transition and the Adolescent and Young Adult Health National Resource Center was a national advisory group of pediatric, adolescent medicine, reproductive health, and internal medicine experts, public health officials, and young adult advocates.

This toolkit provides suggested content for providers to introduce health care transition during preventive visits with early adolescents (ages 11-14), middle adolescents (ages 15-17), late adolescents (ages 18-21), and young adults (ages 22-25), consistent with the American Academy of Pediatrics’ Bright Futures’ age groupings and format. The toolkit includes transition questions and anticipatory guidance for each age group including a motivational interviewing approach to engage youth with and without special health care needs. This toolkit aligns with the clinical report on transition jointly published by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians. According to Dr. Patience White, Co-Director of Got Transition, “This is an exciting addition to Bright Futures, offering practical guidance for busy clinicians working to improve the ability of adolescent and young adults to manage their own health and effectively use health services.”

For more information about health care transition and this toolkit, please visit Got Transition at www.GotTransition.org or contact Annie Schmidt at ASchmidt@TheNationalAlliance.org.

Reproductive Health Care for Women with Opioid Use Disorders

By – Angeline Ti, MD MPH

Assistant Professor, Emory University School of Medicine

Dept of Gynecology and Obstetrics/Family and Preventive Medicine

The impact of the current opioid epidemic is a significant public health issue, particularly for women of reproductive age – negatively impacting their families and communities. According to the Centers for Disease Control and Prevention (CDC), in 2016 21.8 percent of women in the US filled at least one prescription for an opioid and an estimated 15.3 percent of women used illicit drugs or misused prescription drugs. (Centers for Disease Control and Prevention, 2017)

Definitions

Opioids include illegal drugs such as heroin, as well as legal medications such as oxycodone, morphine or hydrocodone. Opioid use can fall on a spectrum ranging from medically-supervised low-risk use to risky use all the way to substance use disorder or “addiction.” The Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5) combines criteria from what was previously known as substance abuse and substance dependence in the DSM-IV into one diagnosis, substance use disorder. People with a substance use disorder can range from mild to moderate to severe, depending on the number and severity of symptoms – which can be related to impaired control, social impairment, risky use and certain pharmacologic criteria (e.g. tolerance or withdrawal). (American Psychiatric Association, 2013)

Gender-specific considerations

Research findings suggest women experience opioid use and opioid use disorders differently than men. Women have higher rates of chronic pain and use prescription opioids at higher doses and for longer periods compared to men. Women also tend to progress to physical dependence more quickly and at smaller drug amounts. Moreover, women appear to have different social risk factors for substance use compared to men. For women, histories of trauma, including intimate partner violence, sexual abuse, and childhood traumas have been associated with the initiation of substance use and the development of substance use disorders. (Office on Women’s Health, 2017)

In addition to the risk of death from overdose, opioid intoxication can cause slowed reaction time and confusion, as well as reduced consciousness thus increasing vulnerability to assault, including sexual assault. For women, prolonged opioid use can result in the decrease of certain hormones, leading to oligo or amenorrhea and infertility. While opioid use during pregnancy has not been clearly linked to any birth defects, it is associated with neonatal abstinence syndrome, or neonatal withdrawal. (American College of Obstetricians and Gynecologists, 2017)

Clinical considerations

• While pathways to opioid misuse are complex, health care providers must recognize their role in primary prevention by using evidence-based practices for prescribing opioids, including following prescribing guidelines from the CDC and utilizing Prescription Drug Monitoring Programs (Centers for Disease Control and Prevention, 2017).
• Universal screening, including screening of women and pregnant women, is crucial for identifying patients who have or are at risk for substance use disorders. A single question such as “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” may be used as the initial screen, followed by a more detailed questionnaire for those who screen positive (Shapiro, Coffa, & McCance-Katz, 2013). The Substance Abuse and Mental Health Services Administration (SAMHSA) has guidance on Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based approach to addressing substance use disorders in primary care (Substance Abuse and Mental Health Services Administration, 2017).
• Medication-assisted treatment (MAT) remains the prominent treatment for opioid use disorders which involves the supervised use of medications such as methadone or buprenorphine to prevent withdrawal and reduce cravings, in combination with counseling and support. Another important medication that is used to prevent overdose is naloxone, an injectable or inhaled opioid antagonist. MAT has been associated with improved patient survival and functionality, as well as improved birth outcomes for pregnant women. (Substance Abuse and Mental Health Services Administration, 2015)
• For women of childbearing age with opioid use disorder, family planning is a critical part of routine care. While there are not specific guidelines for this population, the CDC has multiple resources to guide evidence-based family planning care. The Quality Family Planning guidelines provide recommendations on how to provide family planning services, including what services to offer and how they should be offered. The US Medical Eligibility Criteria provide guidance on the safety of contraception for women with medical comorbidities that may be associated with opioid use disorder, including depression, sexually transmitted infections, viral hepatitis, and other chronic conditions. The US Selected Practice recommendations provide guidance on issues related to initiation and use of certain contraceptive methods, including necessary exams and tests prior to initiation, providing same-day or quick start contraception, and managing certain side effects. (Centers for Disease Control and Prevention, 2017)
• Pregnant and postpartum women with opioid use disorder have specific health care needs and vulnerabilities. Routine prenatal care should be tailored to the woman’s individual medical and social needs. MAT is recommended to optimize maternal and infant outcomes. Though initiation of MAT during pregnancy is safe, it must be done under close supervision, either inpatient or outpatient. Medically supervised withdrawal is not recommended, as it is associated with higher rates of relapse, however it may be considered if the woman is unwilling or unable to initiate MAT. Opioid use and MAT alone do not preclude breastfeeding, which should be encouraged if the mother is otherwise healthy. In labor, women with opioid use disorder should be offered the full range of options for anesthesia, however may require higher doses for adequate pain control. Women who are on MAT should continue their medications. More detailed clinical guidance should be consulted for those caring for pregnant women with opioid use disorder. (American College of Obstetricians and Gynecologists, 2017)(Substance Abuse and Mental Health Services Administration, 2018)

Citations

American College of Obstetricians and Gynecologists. (2017). Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. Obstet Gynecol, 120, e81-94.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Centers for Disease Control and Prevention. (2017, September 18). Retrieved from CDC Contraceptive Guidance for Health Care Providers: https://www.cdc.gov/reproductivehealth/contraception/contraception_guidance.htm

Centers for Disease Control and Prevention. (2017). Annual Surveillance Report of Drug-Related Risks and Outcomes- United States, 2017. Surveillance Special Report 1. Department of Health and Human Services.

Centers for Disease Control and Prevention. (2017, August 29). CDC Guideline for Prescribing Opioids for Chronic Pain. Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html

Centers for Disease Control and Prevention. (2017, October 3). What States Need to Know about PDMPs. Retrieved from https://www.cdc.gov/drugoverdose/pdmp/states.html

Office on Women’s Health. (2017). Final Report: Opioid Use, Misuse and Overdose in women. Washington, DC: US Department of Health and Human Services.

Shapiro, B., Coffa, D., & McCance-Katz, E. F. (2013). A Primary Care Approach to Substance Misuse. Am Fam Physician, 88(2), 113-121.

Substance Abuse and Mental Health Services Administration. (2015, September 28). Retrieved from Medication and Counseling Treatment: https://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

Substance Abuse and Mental Health Services Administration. (2017, September 20). Resources for Screening, Brief Intervention, and Referral to Treatment (SBIRT). Retrieved from https://www.samhsa.gov/sbirt/resources

Substance Abuse and Mental Health Services Administration. (2018). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Naloxone: More than Just a Rescue for Opioid Overdose

Michael Crooks, PharmD., Medication Safety Lead – Alliant Quality, Georgia’s Medicare Quality Improvement Organization

The Surgeon General Takes a Stand: In April 2018, Dr. Jerome Adams gave voice to the call for broad availability of the opioid overdose reversal agent naloxone in a recent advisory statement calling for more Americans to keep the medicine on-hand.  Naloxone can temporarily reverse the effects of opioid overexposure, including respiratory depression, by blocking the activity of opioids at receptors in our central nervous system.

The Surgeon’s General statement was clear: more people should carry and learn to use the medicine – not just opioid users.  Beyond those prescribed high doses of opioids and those misusing opioids, including heroin or fentanyl, the recommendation identifies friends and family members of opioid users along with health care providers and community members who encounter at-risk opioid users.

Opioid Prescribers and Dispensers Should be Naloxone Prescribers and Dispensers: Putting naloxone in the hands of every person included in this recommendation may be impractical – the cost alone for such a supply is prohibitive.  Prescribers should, however, consider which of their opioid-using patients ought to be prescribed or counseled on the use of naloxone. Recommendations vary by care setting or specialty, but generally identify dose, duration, drug combinations and personal factors that can increase risk of opioid related harm.

Georgia Law accommodates several means of increasing access to naloxone by defining prescribing protocols and curtailing personal liability through the Medical Amnesty Law and implementing a standing order for pharmacies to initiate dispensing without a patient-specific prescription.

Naloxone is just a part of the opioid risk conversation: Recommending naloxone to patients can be beneficial, even if the medicine is not dispensed.  A study in several primary care clinics showed reduction in opioid-related hospitalizations and emergency department use for individuals counseled on the use of naloxone versus those who were not.  This improvement was independent of patients actually filling the naloxone prescription and occurred without significant change in the dose of opioids used.  Patients, family members and caregivers are too often under informed on the risks of medication use, and a conversation about the possible benefit of another medicine as a “rescue” really brings the point home: opioids can be dangerous, even deadly.

Thomas Creger, PhD, MPH – University of Alabama at Birmingham, Division of Infectious Diseases

Tenesha Wallace, MA – Communication and Public Health Manager, Georgia Academy of Family Physician

Congenital Syphilis in Georgia

Over the past 5 years, syphilis cases among women in the US have been increasing. This has led to an increasing number of cases of congenital syphilis cases in the US and in Georgia. There were 628 cases of congenital syphilis reported to CDC in 2016 and 21 of them were from Georgia (ranked 9^th in the US). Congenital syphilis is preventable if infection is diagnosed and treated early but screening is critical since most women are asymptomatic. Since 2015, screening for syphilis in pregnancy has been required by law in Georgia (OCGA 31-17-4.2) at the initial prenatal visit and during the 3^rd trimester (ideally between 28-32 weeks). It is recommended that women in high incidence areas be tested again at delivery.

Syphilis infection in pregnancy can lead to stillbirth, congenital syphilis, neonatal death and low birthweight. The management of syphilis in pregnancy is similar to non-pregnant women with benzathine penicillin 2.4 million units (MU) intramuscular (IM) administered once for early infection (acquired within the past 12 months) and 2.4 MU IM once weekly for three weeks for latent infection or syphilis of unknown duration.

Clinicians and public health providers should work together in order to ensure diagnosis, treatment, partner therapy and follow up of syphilis-exposed infants. The best way to reduce rates of congenital syphilis is to remind patients about the importance of early and frequent engagement in prenatal care. Increased awareness among providers who care for pregnant women about how to diagnose and manage this preventable infection is also necessary in order to decrease the adverse outcomes of syphilis in pregnancy.

For more information contact:

Office of STD

Georgia Department of Public Health

404-657-4226

404-657-3133 (Fax)