The provocative takeaway from a new study of maternal care is easy enough to summarize: Mothers diagnosed with postpartum depression and having undergone a Cesarean section are five times more likely to fill at least two opioid prescriptions in the three months following labor than are mothers without those conditions.
But for this particular study by the Iowa Perinatal Health Research Collaborative, the final conclusion isn’t the end point of the research; it’s just the beginning.
The collaborative — funded by the Iowa Institute of Public Health Research and Policy — was created to improve the health outcomes of children born prematurely or at low birth weight. It brings together groups of researchers, clinicians, and patient advocates to improve access to existing statewide databases and to identify volunteers for studies in outcomes research, quality improvement initiatives, and interventions.
Improving Care for Mothers and Infants
During its first two years, the group’s community engagement efforts have resulted in more than 250 women signing up to be available for various research endeavors.
“These individuals have agreed to be contacted for future studies, so this gives us a good data bank for investigators in the collaborative who may want to dive deeper with additional studies,” says Kelli Ryckman, the leader of the collaborative and an associate professor of epidemiology at the University of Iowa College of Public Health.
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The collaborative has heard from more than 130 Iowa researchers — from obstetrics, gynecology, neonatology, pediatric neurodevelopment, epidemiology, biostatistics, and other fields — who want to work cooperatively to find ways to improve the care of mothers and preterm infants in the weeks, months, and years following birth.
Future research topics will be determined by input from a 10-member community advisory board, but the group’s inaugural study is focused on an emerging issue in maternal care: How opioid-related deaths account for between 11 and 20 percent of pregnancy-associated deaths in the U.S.
New Moms and Opioid Misuse
“There’s been a lot of talk about the opioid crisis, but mothers who have delivered and get opioids for pain are underrepresented in the discussion about opioid misuse,” Ryckman says. “Yet they are at increased risk.”
Ryckman and her colleagues looked at the information available in a statewide insurance claims database managed by the UI Center for Public Health Statistics. All the records in the database are stripped of identifying information to protect the subjects’ privacy. From there, they carved out a cohort of 19,000 mothers who gave birth in Iowa between 2004 and 2015.
By matching a patient’s depression diagnosis with that patient’s pharmacy claims, the researchers looked at the relationship between maternal depression and the number of opioid prescription fills.
The findings — which will be presented during a February 2019 meeting of the Society of Maternal-Fetal Medicine — include:
- Nearly 44 percent of the women in the cohort had at least one opioid prescription, and 12 percent had at least two prescription fills from the time of delivery until three months postpartum.
- Women with a history of depression had about 1.6 greater odds of having an opioid fill and about a two times greater risk of having at least two opioid fills compared to women without a depression history.
- Women who had a Cesarean section and had postpartum depression were five times more likely to fill at least two opioid prescriptions in the first three months after delivery.
“We suggest there is universal screening for perinatal depression that can identify women with probable depression who are at an increased risk for opioid misuse or opioid-related maternal mortality,” Ryckman says.
Ryckman notes she probably could have conducted a similar study without the collaborative in place, but such a study would have required the creation of a narrow data set designed to answer a specific question.
This study, instead, serves as the first of what Ryckman hopes will be many collaborations that make use of the large amount of information already available in the various databases.
It’s now the job of the collaborative’s community advisory board to help the researchers and clinicians brainstorm ways to ensure the information gets to the mothers whose medical and parenting decisions could be most affected by it.
The goal is not only to get the research findings into the peer-reviewed journals read by OB-GYNs and other providers; it’s also to make use of the websites and blogs that parents of preterm and low-birth-weight children turn to for advice and support.
That’s the type of information that Sara Connell, an advisory board member, wishes had been in place eight years ago when, while she was pregnant with her son Jacob, an ultrasound discovered very little amniotic fluid and almost no cord blood flow. The high-risk obstetrics team at UI Hospitals & Clinics diagnosed her with HELLP syndrome, a very severe form of preeclampsia that is life-threatening for both mother and child.
At the time, Connell was somewhat familiar with the risks of preeclampsia, but she had no idea of what the HELLP acronym stood for — hemolysis, elevated liver enzymes, low platelet count — let alone what a huge impact the diagnosis would have on her pregnancy and her later life.
When Jacob was born via Cesarean section at 25 weeks, he weighed 1 pound and 5.5 ounces. With underdeveloped lungs and a hole in his heart, he spent the next 126 days in the Neonatal Intensive Care Unit (NICU) at the UI Stead Family Children’s Hospital and, after being discharged, remained on oxygen until just before his second birthday. The years since have included physical therapy, occupational therapy, and ophthalmology visits as well as high-risk follow up and a host of other issues.
“Prematurity doesn’t end when a child comes home from the hospital,” Connell says.
Since Jacob’s birth, Connell has started the 1,400-member NICU Families of Eastern Iowa Facebook Group and has co-founded the Butterfly Brigade, a mom-to-mom outreach organization of the UI Hospitals and Clinics for women placed on bedrest for the remainder of a pregnancy.
“We like to connect with moms before they even deliver to show them support and to provide them with some informational resources,” she says. “Whenever I go in and talk to these moms — or when I’m engaged in a dialogue in our Facebook group — I’m just letting them know that what they’re feeling is okay. That it’s normal. That this is hard, and we ‘get it.’”
Nichole Nidey, a PhD student in epidemiology and a graduate researcher for the collaborative, says hearing the personal perspectives from parents like Connell is especially beneficial for the many master’s degree and undergraduate students who volunteer with the collaborative.
“Just listening to their stories made me think about how to do research in a different ways,” Nidey says.
Anne Helene Skinstad, clinical professor of community and behavioral health in the University of Iowa College of Public Health, has recently been awarded grants totaling $9.5 million over the next five years to help reduce drug and alcohol addiction among American Indian and Alaska Native populations.
The grants will benefit three initiatives Skinstad oversees in the College of Public Health: the National American Indian/Alaska Native Addiction Technology Transfer Center, which received $4 million; the Tribal Affairs Technology Transfer Center, which received $3 million; and the Tribal Affairs Prevention Technology Transfer Center, which received $2.5 million.
The grants were made by the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration.
Housed in the College of Public Health, the national centers focus on American Indian and Alaska Native communities in Iowa and around the country, educating and training people who provide substance abuse treatment and counseling using culturally appropriate methods. The centers support professionals working with clients suffering from substance use and other behavioral health disorders, prominently including a native behavioral health workforce.
Source: Iowa Now
Native American Heritage Month
“From Whiteclay to Iowa: Healing Revisited”
Wednesday, Nov. 14
12:30 to 1:30 p.m.
Callaghan Auditorium (N110 CPHB)
Frank LaMere is a noted Native American social and political activist from South Sioux City, NE. He is a member of the Winnebago Tribe of Nebraska and is generally recognized as the chief architect of the twenty-year effort to stop the illegal flow of alcohol from Whiteclay, NE onto the dry Pine Ridge Indian Reservation in South Dakota.
Mr. LaMere is the chair of the Community Initiative for Native Children and Families (CINCF) in Sioux City, IA, the associate chair of the Nebraska Democratic Party, a member of the Board of the Siouxland Community Health Center, a member of the Winnebago Health Board, the Mercy Medical Center Patient Advisory Council, and a member of Nebraskans for Peace. He is involved with the Siouxland Street Project Detox Committee in Sioux City that is tackling the need for detox and halfway house availability, alcohol and drug treatment, homelessness, and needed mental health services for Native and non-Native men and women on the streets of Sioux City, IA.
Mr. LaMere has been recognized on numerous occasions for his work in Whiteclay and on many social and political fronts. He has been honored with the Outstanding Peacemaker Award in 2001 by the Nebraskans for Peace, the War Eagle Human Rights Award by the Sioux City Human Rights Commission in 2011, the Good Apple Award by the NE Appleseed Center in 2015, and the FDR Award given by the Nebraska Democratic Party in 2017. He was also honored in 2017 by Project Extra Mile for his Whiteclay work. He has also been honored by Jackson Recovery Center in Sioux City, Iowa, and the City of South Sioux City. In October he was honored for his outstanding community service by the Sioux City Police Department. He was also named Member of the Year in 2016 by the National Indian Child Welfare Association.
Individuals with disabilities are encouraged to attend all University of Iowa-sponsored events. If you are a person with a disability who requires a reasonable accommodation in order to participate in this program, please contact the College of Public Health in advance at 319-384-1500.
Brandi Janssen, CPH clinical assistant professor of occupational and environmental health, has been selected by the Iowa Institute of Public Health Research and Policy (IIPHRP) to establish a new collaboratory that will gather data to help prevent drug overdoses in Iowa.
A collaboratory is a creative group process designed to solve complex problems and brings together collaborators from different backgrounds and disciplines to expand the scope, scale, and impact of critical public health research. Janssen’s team will collaborate on a project titled “Iowa Substance Use Data Set: Preventing Overdoes Through Actionable Data.” The project is intended to be a first step toward developing the Iowa Substance Use Data Set, a multi-stream, multi-sourced, comprehensive data warehouse for partners, and will include information directly from substance users.
“This data base will be different from existing substance use information sources in that its focus is on timeliness, local relevance, and integration of multiple data sets,” Janssen explains. “The team hopes to design a data warehouse infrastructure to manage storing, updating, and sharing pertinent data. In addition, we will identify the data needs of providers and stakeholders regarding substance misuse and abuse and will design the data structure and applications to accommodate those needs.”
In addition to Janssen, the collaborators include:
- Stephan Arndt, PhD, Professor, Carver College of Medicine, Psychiatry; College of Public Health, Biostatistics; Director, Iowa Consortium for Substance Abuse Research and Evaluation
- Ryan Carnahan, PharmD, CPH, Associate Professor, Epidemiology
- Heath Davis, MS ITIL, Lead Application Developer, Bio-Medical Informatics, Institute for Clinical and Translational Science, Carver College of Medicine
- Juan Pablo Hourcade, PhD, Associate Professor, CLAS, Computer Science
- Boyd Knosp, MS, Associate Dean for Information Technology, Carver College of Medicine. Associate Director for Biomedical Informatics Operations, Institute for Clinical and Translational Science
- Anna Merrill, PhD, DABCC, Clinical Assistant Professor, Department of Pathology, Carver College of Medicine; Clinical Chemist, Pathology & Laboratory Medicine, Iowa City VA Health Care System, Pathology & Laboratory Medicine
- Jennifer Sánchez, PhD, CRC, Assistant Professor, CLAS, College of Education, Rehabilitation and Counselor Education
Read more about the IIPHRP collaboratories and their work.
On Feb. 21, Paul Gilbert, CPH assistant professor of community and behavioral health, spoke at the Iowa state capitol as part of the Alliance of Coalitions for Change’s (AC4C) Youth Day on the Hill. AC4C is a statewide network of people committed to substance abuse prevention.
Each year the alliance holds a Day on the Hill to update legislators on prevention successes and unmet needs across Iowa. This year’s focus on “Impairment of Young Minds” highlighted special concerns about young Iowans and the lost opportunities and premature deaths caused by substance abuse.
“I’m glad to lend my voice to the effort as an academic who studies hazardous alcohol use,” says Gilbert. “What’s most impressive, however, are the efforts to involve young people–to hear directly from those most affected.”
The day included advocacy training for youth and opportunities to speak with legislators.
Paul Gilbert is studying how problem drinkers quit without help from rehabilitation programs.
When alcohol consumption causes so many problems that a person decides to quit drinking, some will turn to clinical rehabilitation for help, but others will just put down the bottle and never pick it up again.
Paul Gilbert is interested in those who go cold turkey and how their experiences can provide insight into alcoholism in general. Gilbert, assistant professor of community and behavioral health in the University of Iowa College of Public Health, is studying people in eastern Iowa whose drinking was causing so many problems in their lives that they quit, but did so without entering a clinical treatment program.
EXPLORING PATHS TO RECOVERY
An expert on adult alcoholism who has conducted numerous studies about problem drinking, Gilbert plans to talk to 30 Iowans about their success quitting drinking. Using interviews and surveys, he’ll ask about their life history, their drinking patterns, what prompted them to quit drinking, and how they did it.
Gilbert is conducting this study as preparation for his next major research project, which will explore different paths to recovery. He will recruit a national sample of 600 former problem drinkers and assess how they define recovery, the degree of “recovery capital” available to them, and the various strategies they used to resolve their problems without treatment. Recovery capital refers to the quantity and quality of internal and external resources that a person has to initiate and sustain recovery from addiction.
Gilbert’s goal is to determine whether there are differences in successful strategies for recovery between men and women or by race/ethnicity. The initial Iowa study will provide preliminary information.
He also hopes the lessons learned ultimately will lead to more ways to minimize the harms from drinking even without clinical treatment.
A VARIETY OF STRATEGIES
Gilbert says the number of problem drinkers who use clinical rehabilitation programs after they make the decision to quit drinking is smaller than people might expect, only about 10 to 15 percent. Many of the rest use some sort of support program, such as a 12-step program. Many others use no program at all and just quit drinking.
Ultimately, Gilbert’s goal is to find out how some people can quit without clinical assistance and how their experience might help others who need help. For instance, the data might show that certain types of people benefit from earlier intervention or a different model of intervention. Some could benefit simply from guidance about moderation rather than complete abstinence.
Gilbert already has interviewed a dozen respondents, and though it’s too soon to draw conclusions, he found people use a variety of strategies to quit drinking. Some attend a 12-step program and continue to use it; others started by attending a program, then leaving when their drinking was controlled; yet others just said they were going to stop drinking or reduce the frequency of their drinking and did so with no assistance.
WHY PEOPLE QUIT
In all of his research, Gilbert says he’s found one important consistency in the reason the people wanted to quit in the first place.
“A family crisis or the role of a relationship,” he says. “Sometimes they quit because of a health crisis or a work crisis too, but most often the abrupt change is the result of a relationship. Maybe the person they were in a relationship with threatened to leave them; maybe they’d lose custody of their kids. But losing a relationship often prompts people to make a change.”
He hopes to answer one important question: Do people who quit on their own see quitting differently than people who go through rehab?
“It seems a lot of people who don’t get treatment have a more flexible view of recovery,” he says. “Maybe it doesn’t involve abstinence, so they allow them-selves to keep drinking as long as it’s at low level, or they drink only during special events.”
This story originally appeared in the fall 2017 issue of InSight.
Tribal communities are pushing back against substance abuse with culturally relevant approaches.
In 2012, Brooks Big John spoke to tribal, state, and federal leaders about the devastation the misuse and abuse of prescription painkillers was causing his community. Big John, at the time the tribal chairman of the Lac du Flambeau tribe in Wisconsin, described the growing toll of overdose deaths, including that of a lifelong friend: “He ended up sucking out morphine patches, to the point where he eventually overdosed and died.”
He went on to illustrate the desperate measures people took to obtain drugs. “We had a guy who was sleeping in the ceiling of the tribal center building where the clinic was, six or seven hours until everything closed, so he could break into our clinic and steal these pills.”
Big John delivered his comments at the “Tribal Prescription Drug Abuse Summit: Moving from Information Sharing to Action Plan” held in Bloomington, Minnesota. The need for such a gathering was identified by tribal leaders, who had expressed concerns about an increase in the use and abuse of prescription drugs in American Indian communities. The summit was convened by the Substance Abuse Mental Health Services Administration (SAMHSA) in collaboration with the National American Indian & Alaska Native Addiction Technology Transfer Center (AI & AN ATTC), the Great Lakes ATTC, and other federal, state, and tribal health agencies.
CULTURALLY RELEVANT APPROACHES
National surveys show that substance abuse rates are consistently higher among American Indian/Alaska Natives than other racial groups. The 2013 National Survey on Drug Use and Health shows that 12.3 percent of American Indians were current users of illicit drugs, compared with 9.5 percent of whites, 8.8 percent of Hispanics, and 10.5 percent of African Americans.
Anne Helene Skinstad, program director of the National AI & AN ATTC in the CPH Department of Community and Behavioral Health, says that the rates are likely much higher, noting that data are underreported or not reported at all by tribes due to mistrust of federal agencies.
There is also a hesitancy among tribes to engage in evidence-based treatment practices, Skinstad adds. “Psychosocial treatment and medication are Western methods and not culturally informed,” she says. “They are met with reluctance and concerns.”
To make treatment practices culturally relevant, the center spends time with tribal communities and translates the essence of evidence-based practices, Skinstad explains. “We want to respect tribal sovereignty, and we let the tribes decide how they want to implement the practice in a culturally informed way.”
CONNECTING TO CULTURE
In 2013, Lac du Flambeau tribal leaders, including Big John, declared a state of emergency and a “War on Drugs” in the community. Working with law enforcement, courts, schools, elders and spiritual leaders, and others, the community wrote a three-year strategic plan to address the substance abuse crisis, pool local resources, and secure funding.
Although Big John no longer serves on the tribal council, he remains an active community leader. According to Big John, the tribe has addressed the selling of illicit drugs, reduced gang involvement and violence, and strengthened tribal statutes to allow law enforcement to increase safety efforts. The tribe also received support from SAMHSA and the Robert Wood Johnson Foundation to build their own treatment center, allowing tribal members to receive treatment sooner, remain in their community, and connect to their culture. These steps create a sense of belonging, a protective factor for substance misuse.
Culture played a key role in the “State of Recovery,” Big John’s term for progress made over the last few years. The community, already grounded in prayers, gatherings, songs, and Big Drum ceremonies, engaged traditional leaders to support recovery efforts, revitalize language programs, and hold “Wellbriety” pow-wows to widen the “Healing Circle.”
Youth participate in collecting wild rice and making reed mats to connect with their culture. The community also held a youth gathering to offer opportunities for their voices to be heard.
“We need our youth to heal from the oppression they’ve experienced and never forget who they are. Cultural identity is key for our prevention efforts,” Big John explains.
However, numerous barriers remain in tribal communities. “If you’re driving two hours for methadone maintenance treatment every day, how can you hold a job?” Skinstad asks. “Many communities still don’t have access to naloxone (an opioid overdose-reversal drug), so there are fatal overdoses that could be prevented.”
A VISION FOR CHANGE
Many tribal communities are developing action plans to address the opiate problem. Some of the initiatives include distribution of emergency overdose kits, providing secure drop-off sites for unused prescription drugs, and establishing hotlines for those wishing to quit drugs or report traffickers.
“What came out of the summit was a model for the country,” Skinstad notes. “Following the symposium, we held conference call meetings for tribal leaders who wanted to implement a plan in their communities. They are still active. We gave communities tools, they discussed them with their elders, then they implemented them successfully.”
Pushing back against the opioid epidemic is long and hard work, but Big John encourages communities to be patient. “We didn’t get here overnight and the changes we want to make won’t happen overnight, but we are saving lives,” he says. “Good things come when people have the same vision.”
This article contains material written by Connie O’Marra, MSW, of the Training and Technical Assistance Center, that originally appeared in the September 2016 issue of the National AI & AN ATTC newsletter. O’Marra is a close collaborator with the National AI & AN ATTC and a trainer for the center.
This story originally appeared in the fall 2017 issue of InSight.
Researchers and advocates outline priorities for responding to the opioid epidemic in Iowa.
States and communities across the nation are grappling with how best to respond to the surging opioid crisis. In April 2017, the UI Injury Prevention Research Center (IPRC) sponsored a meeting in Des Moines to identify priorities for addressing the opioid epidemic in Iowa. The meeting was part of a larger national project funded by the Centers for Disease Control and Prevention, with the UI IPRC being one of four injury centers in the country participating in the grant.
Carri Casteel, IPRC associate director, led the meeting to discuss recommendations developed by the John Hopkins Center for Injury Research for reducing the opioid epidemic in several areas, including prescription monitoring programs, prescribing guidelines, overdose education, and community-based prevention. One goal of the meeting was to review these evidenced-based strategies and compare them to what is happening in Iowa.
“It was an opportunity for those working in fields affected by opioids to take an inventory of our successes and to identify gaps specific to Iowa that need to be addressed to move forward on this issue,” Casteel says.
Stakeholders at the meeting represented law enforcement, psychiatry, emergency medicine, public health, nursing, non-profit/advocacy, poison control, substance abuse treatment, pharmacy, insurance, drug control policy, elected officials, and others.
IDENTIFYING IOWA’S PRIORITIES
Among the barriers stakeholders identified were lack of training for health care providers on opioid addiction and treatment, lack of timely state data on opioid supply and overdose, and limited and unequally distributed addiction treatment services in Iowa.
The top five priorities for Iowa that stakeholders identified were:
- Provide physicians with evidence-based training in pain management and opioid prescribing.
- Educate physicians, nurses, pharmacists, and other practitioners to recognize patients at high risk for opioid abuse and addiction.
- Make the Iowa Prescription Monitoring Program a more accurate and effective tool.
- Strengthen opioid overdose surveillance and prescription opioid monitoring among multiple organizations and agencies.
- Improve health coverage for medical-assisted treatment and evidence-based behavioral interventions.
IPRC published the report “The Prescription Opioid Crisis: Policy and Program Recommendations to Reduce Opioid Overdose and Deaths in Iowa” that contains details about the five priorities, county-level statistics on opioid overdose death rates and prescribing practices in Iowa, along with highlights of initiatives in Iowa communities that have had some success in slowing the epidemic. The report is available online at cph.uiowa.edu/iprc.
The report was sent to Iowa policy makers and other state leaders, and the proposals were discussed with a legislative interim study committee tasked with evaluating Iowa’s response to the opioid epidemic. This committee submitted a report with its findings and recommendations to Iowa Gov. Kim Reynolds and the general assembly to inform possible action during the next legislative session.
REDUCING HARM AND STIGMA
Community-based prevention efforts that focus on education, advocacy, and harm reduction strategies are also garnering attention. The national organization Harm Reduction Coalition defines harm reduction as “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. … Harm reduction incorporates
a spectrum of strategies from safer use, to managed use, to abstinence, to meet drug users ‘where they’re at,’ addressing conditions of use along with the use itself.”
“Much like substance use, harm reduction has a long but stigmatized history,” says Paul Gilbert, CPH assistant professor of community and behavioral health. “People often thought it was too permissive or even encouraged drug use. But high-quality, rigorous evaluations have shown that harm reduction strategies are associated with substantial benefits, such as fewer wounds and abscesses, reduced hepatitis and HIV infections, and lower risk of overdose and death. Given the scientific evidence that’s accumulated, it belongs in our repertoire of public health responses to substance use.”
Kim Brown of Davenport, Iowa, is president and co-founder of Quad Cities Harm Reduction (QCHR). She helped form the nonprofit organization after losing her 33-year-old son Andy to an unintentional heroin overdose in May 2011.
“All of these overdose deaths are preventable,” says Brown, who is a registered nurse. “Addiction is a medical disorder. It should be firmly entrenched in public health. As long as we criminalize a medical condition, we have shame and stigma. We need true, realistic drug education.”
Andy’s death was shrouded in stigma, Brown recalls. “Nobody would talk to me about what happened to my son. But I wanted to do something to bring awareness to the community and legislators and law enforcement.”
INCREASING NALOXONE ACCESS
Brown has been advocating since 2012 for increased naloxone access in Iowa. Naloxone is a medication administered as a nasal spray or injection to reverse the effects of an opioid overdose.
In late 2016, a new Iowa law coupled with a standing order issued by Dr. Patricia Quinlisk, Iowa Department of Public Health Medical Director, allows naloxone to be purchased at a pharmacy without a prescription. Pharmacists are authorized to dispense naloxone to individuals at risk of opioid overdose, a family member or friend in a position to assist an at-risk person, and first responders.
More recently, University of Iowa emergency medicine physician and CPH alumnus Chris Buresh (12MPH) provided a standing order that allows QCHR and the Iowa Harm Reduction Coalition in Iowa City to dispense naloxone without prescription to Iowans at little to no cost. The standing order went into effect June 1, 2017.
But Brown would like to see even more done. “The state needs a standing distribution order to community and harm reduction organizations. We need a syringe exchange program to prevent people from getting HIV or hepatitis C and to keep used needles out of public bathrooms and off the ground.
“We need to get naloxone to the folks who really need it,” she continues. “Overdoses are often reversed by friends and family. I can’t have my son back, but I can help others keep their children alive.”
This story originally appeared in the fall 2017 issue of InSight.