‘Don’t Quit the Quit’

UND clinical professor of nursing nets part of $10M national grant for rural mothers in recovery from opioid use disorder

Maybe she can’t change the world. But UND’s Maridee Shogren hopes to change one corner of it — and thanks to a significant national grant, she’s getting her chance.

Shogren’s Don’t Quit the Quit program aims to support pregnant and postpartum women in rural North Dakota who are in recovery from opioid use disorder. Medications to treat opioid use disorder are safe and effective, but stigma and other barriers block many people from getting the medications they need, the National Academies of Sciences, Engineering, and Medicine has declared.

One of those stigmatized populations is pregnant and postpartum women with opioid use disorder. Medications are available to help the soon-to-be and new moms quit opioid use. But many women are not aware of medication options or how to access those treatment medications (which include methadone and buprenorphine). This can be especially difficult for pregnant and postpartum women living in the most rural areas of North Dakota.

“The ‘Don’t Quit The Quit’ program supports and encourages mothers to maintain their recovery through these challenges,” said Shogren, clinical associate professor of nursing at UND.

“In other words, we’re saying, ’Don’t quit the hard work you’re doing to maintain your healthy life choices and sobriety.’”

Nineteen out of 443

In March, the nonprofit Foundation for Opioid Response Efforts (FORE) announced $10.1 million in grants to 19 organizations on the frontlines of America’s opioid crisis. The 19 were selected from among 443 organizations in 46 states, FORE said.

And of the 19 recipients, only one was in the upper Midwest: Don’t Quit the Quit at UND.

Shogren is a certified nurse midwife who continues to work in clinical practice while she teaches at UND. She’s working on Don’t Quit the Quit in tandem with Gayle Roux, professor and senior associate to the interim dean at UND’s College of Nursing and Professional Disciplines, and Abby Roach-Moore, program manager at the Mountain Plains Addiction Technology Transfer Center.

“Over the years, I’ve seen an increase in substance abuse among women who are planning pregnancy, pregnant or postpartum,” Shogren said.

“There’s a misconception out there that substance abuse in women is just either not occurring or is not a problem.”

Fortunately, medications have been found that can help those with opioid use disorders quit. The medications don’t provide a high, but help prevent withdrawal symptoms and help people in recovery maintain normalcy and stability.

And as the National Academies of Sciences, Engineering, and Medicine has reported, “patients who receive these medications are less likely to die from overdose or other causes related to their addiction, have higher treatment retention rates and better long-term outcomes.”

Those findings represent real progress in the treatment of opioid use disorder — and they apply to pregnant and postpartum women with the disorder, too. “But we have this awful perception that for some reason, women should not be able to use these medications while they’re pregnant or breastfeeding,” Shogren said.

“I see the same thing happen if a woman presents with depression during pregnancy and wants to start an antidepressant; we immediately start thinking, ‘But what’s it going to do to the baby?’ What we forget is that we have a mother/baby dyad here, and her quality of life is equally as important.”

With that in mind, health care providers balance medications’ safety and effectiveness to provide both mom and baby a good quality of life. But in rural North Dakota and where opioid use disorder is concerned, that’s complicated by not only stigma but also limited access to providers, Shogren said.

Four approaches

Don’t Quit the Quit uses four approaches to overcome those hurdles.

• The first is boosting the number of rural providers who have expertise in both obstetrics and in medications for opioid use disorder. That’s a tall order, because healthcare providers who want to prescribe those medications must be “waivered” — that is, complete additional education and training and apply for a special waiver under the Drug Addiction Treatment Act of 2000.

Only about 100 of North Dakota’s 1,600 practicing patient-care physicians have this waiver, the U.S. government reports. Nurse practitioners, physician assistants, certified nurse-midwives and a few other practitioners also can be waivered, but only about 90 in the state have secured the special waiver.

“Don’t Quit the Quit is collaborating with the Heartview Foundation out of Bismarck, and they are helping us with provider training,” Shogren said.

“Our goal is to encourage more providers in rural North Dakota to either seek their waiver so they can prescribe for women who are pregnant or postpartum; or if they are already waivered, to give them additional clinical support and mentoring so they feel comfortable adding pregnant and postpartum women to their patient panels.”

Heartview is a nonprofit drug and alcohol treatment and education program. With the help of Kurt Snyder, executive director, and Dr. Melissa Henke, medical director, Heartview will offer the additional support and mentoring that newly waivered practitioners in rural ND need, Shogren said.

• Don’t Quit the Quit’s second approach is collaborating with the North Dakota Women, Infants, and Children or WIC program. WIC is a critical resource for women and children who visit these agencies for health screenings and secure access to healthy foods. WIC staff can stay connected to rural families during the entire perinatal period and are an integral part of the public health model of care, Shogren noted.

“So, by increasing WIC staffers’ knowledge and having them learn about opioid use disorder during the perinatal period, we’re really trying to grow and enhance the whole community’s knowledge base, as well as community support.”

• The project’s third component is to introduce postpartum doulas into rural North Dakota. “Doulas provide unbiased support to families during their transition to parenthood. They provide education about infant care and infant feeding, help new mothers with household tasks and healthy recovery, and ultimately increase the confidence of new mothers,” Shogren said.

“It’s very challenging to learn how to be a mother and how to care for another person, especially when you’re still trying to care for yourself. Our hope is that we would grow community experts, so we have local people who really understand postpartum, and whom women are comfortable asking questions of.”

• Last but not least, Don’t Quit the Quit will offer a year of free monthly webinars to women who enroll in the program. “We are going to try to build their knowledge base and increase their awareness of opioid use disorder and optimal health,” Shogren said.

“Our goal is to really empower these moms to maintain their recovery. They can invite their families, their friends, support people, anybody to listen in. And we’re going to use these webinars to help them gain that confidence while they are in treatment for opioid use disorder.

“I really think that adequate education is another key component that’s been missing from treatment.”

Don’t Quit the Quit

Integral to all of this is the understanding that addiction is a chronic disease. “Which means we need to start looking at addiction just as we look at diabetes,” Shogren said.

“People who are have significant and severe diabetes take daily medication. It’s no different if somebody has the chronic disease of addiction and is on a medication to help them achieve that normality and have a good quality of life.

“So if a woman becomes pregnant, she should be able to stay on her medications for opioid use disorder through that pregnancy and through postpartum, in that same way as we would be prescribing insulin for her if she had diabetes.”

That’s how Don’t Quit the Quit came about, Shogren continued.

“The woman has quit her substance use; she’s entered into recovery. And now we want her to not quit the amazing effort that she has already started. That’s our goal.”