The goal of SOFAR (Supporting Our Families through Addiction and Recovery) is to create a medical home in the pediatric primary care clinic for mothers in recovery and their children.
Eileen Costello, MD, shares an overview of SOFAR for families to maximize their ability to successfully navigate parenting and substance use recovery.
Eileen Costello, MD
Dr. Costello is the Chief of Ambulatory Pediatrics at BMC. As a primary care physician, her special interests include providing primary care to children on the autism spectrum and with mental health disorders. In 2017, she established a new program called SOFAR – supporting our families through addiction and recovery.
Melanie Cole (Host): The goal of SOFAR, Supporting Our Families through Addiction and Recovery, is to create a medical home in the pediatric primary care clinic for mothers in recovery and their children. My guest is Dr. Eileen Costello, she's the Chief of Ambulatory Pediatrics at Boston Medical Center, and the Medical Director of the SOFAR Clinic. Dr. Costello, give us a little background on the effects of the opioid epidemic on women, and specifically pregnant women. What are you seeing today?
Dr. Eileen Costello, MD (Guest): Well first of all, I'd like to thank you so much for having me, because this is a topic that's very dear to me. We started the SOFAR Clinic in July of 2017, so it's not even a year old, but it's been a really dramatic experience for us in pediatrics at Boston Medical Center. So BMC has a long history of caring for people with substance use disorders and trouble with addiction, but most of that has been focused on adults. And historically opioid use was much more of a male problem but now women are equally affected as men, and young women of childbearing age are using opioids, and not insignificant numbers, and we are very concerned about trying to help these women get into recovery as quickly as possible as soon as they realize that they're pregnant to minimize any potential deleterious effects on their infant.
Melanie: Do we have a certain group that's more at risk than others?
Dr. Costello: Well I think any young woman who is suffering with an opioid use disorder is at risk just by definition of addiction itself. Once she becomes pregnant, then she is at higher risk for poor outcomes if she's not engaged in treatment. And so we have a program at Boston Medical Center called Project RESPECT, which is for pregnant women with opioid use disorder, addiction. It's at the hospital, they get moved over to a medication assisted treatment and then managed very closely for the remained of their pregnancy. So far it was developed to provide that same level of care for the mother / infant days after the baby is born because that's a very stressful period for absolutely everyone. Having a baby is a big deal, and it's harder than we think it's going to be. And if you are not only a new mother, but in early recovery, and frequently these women are doing this on their own, the stresses are overwhelming.
So we wanted to create a medical home environment for mothers of infants so that they had a safe place to come to be seen often themselves as well as their baby in the same visit, and that every one of our primary care visits includes a wellness check for the mom. Because what we know is taking care of parents is the same as taking care of babies. If you take care of a mom and she's doing better, then her baby is going to thrive. If your focus is only on the baby but not on the baby's mom, then that baby has not as good a prognosis as if you care about the mom as well as the baby.
Melanie: How do you think universal screening during pregnancy is providing an important opportunity for you providers to identify and treat these women with opioid use disorder? I mean if a pregnant woman comes in for a prenatal visit, is that when you find out about their disorder, about their addiction? Is it through the universal screening for pregnant women?
Dr. Costello: Well that's a really good question, and I actually don't care of the women while they're pregnant. I only take care of the mother / infant dyad after the baby is born. And so often women, at least in our hospital, will self-refer. They'll come in and say, "I am a heroin addict and I need help, and I'm pregnant," and they will immediately get enrolled into Project RESPECT and be brought into the hospital to help them.
I think in other settings there's a lot of guilt and shame associated with opioid use for young women who are pregnant, and I think in other settings people are not as open to hearing about it, and are not as able to help as we are. So I think that we're doing a good job being open, and as one of my moms in clinic said to me, "Everyone knows if you're a heroin addict and you're pregnant, you need to go to BMC."
Melanie: Wow, that's really very interesting. So tell us about some of the services, and your team which includes a multi-disciplinary team of various and sundry clinical professionals. Tell us about them.
Dr. Costello: Yeah, yeah it's a really rewarding experience for me as a pediatrician and running this team. So at this time we have two primary care pediatricians, myself and Dr. Sara Stulac. We have a nurse who works in our clinic. We have other team members like a patient navigator who helps us get appointments for patients. These poor moms have so many darn appointments after they go home from the hospital. The babies need some specialty appointments, the mom needs post-partum care, sometimes they need mental health appointments, Hepatitis C care, primary care for themselves, and we work hard to make sure that the mom doesn't fall through the cracks.
A lot of times once the baby is born, the focus is all on the baby and nobody cares about the mom, but we are trying to really make sure that Mom has her therapist lined up, that Mom- if she needs to be on meds, has her addiction care lined up. But she has a primary care doctor that if she has Hepatitis C, which about 70% of our moms do, that we can get her engaged in curative care.
So that's what our team is for. We have a social worker who's deeply embedded in our team because at Boston Medical Center, every mother who goes through Project RESPECT is reported to Child Protection Services when the baby is delivered for an evaluation to make sure that it's safe for the baby to go home with the mom. In the vast majority of cases, any mom who came through Project RESPECT who's strong in her recovery does go home with her baby, but we need to be able to support her recovery so that that mother / infant care can stick together, and that's what we're very devoted to doing in our clinic.
Melanie: So what about that psychosocial care, Dr. Costello, for the families to maximize that ability to successfully navigate that very difficult world of parenting and substance use recovery? Are these women afraid to get help or to be reported? And how do they react? How do you help them through this difficult time?
Dr. Costello: Well I think all of the things you just mentioned are absolutely true. There is a lot of fear and anxiety which makes total sense. If you have other children and you have lost custody of them because of your history, it's terrifying to imagine that happening with the new baby. So yes, we do a lot to support parents through that time and through their sort of anxiety and fear about that happening again.
If we know our moms really well, which we do because we see them monthly, it's really great for them to have a team that's paying attention to them, that's making sure they're doing everything they need to do, they're keeping every appointment, the baby is growing and thriving and looking great, they're maintaining a strong recovery. It really takes a lot for a baby to be taken away, and my moms that are very strong in their recovery who have lost other children to the DCS system will tell me, "I know I was too sick to take care of my kids, and now I'm not," and that is really powerful- those are powerful words when you hear a mom say, "I understand why that happened, and I'm desperate for it to not happen again," and we're desperately trying to help women maintain their recovery through the very challenging first couple of years post-partum.
When one in five women, even without an opiate use disorder, is at risk for post-partum depression, imagine if you have a history- a mental health history, or a trauma history, and an addiction history, how high the risk is for you, and that's why we're here to kind of catch people when they feel like they're falling down.
Melanie: Wow, your description is so inspiring, Dr. Costello. And how do you involve the patient and family engagement? And the providers on your team, how do they get maybe other siblings and the children involved in these visits?
Dr. Costello: Well it's such a great question. So I have a number of families now where the sort of index patient was a newborn, but then Mom is reunited with her older kids, and they come back to Mom, and then those children become patients also because we're trying to do a medical home model where all the children in one family will be followed either by me, or by Dr. Stulac, in a regular kind of primary care setting with some additional support in place for these families. Because it's kind of like the elephant in the room. If you have a mom in the room with three small children and she's in recovery, the most important thing in that room is that the mom maintains her recovery for the good of her kids. Her kids will thrive if she can do it, and it's not easy. It's not easy for anybody, and sometimes there are lapses without relapses, and we try to support people through it, and as long as we maintain really open and frank conversations, the prognosis is quite good.
Melanie: So wrap it up for us with really your best information, what you want the listeners to know about Project RESPECT, and so far, the clinic that is helping so many women and their children in recovery, and stay together.
Dr. Costello: Right, well I think one thing that I would say as a pediatrician and a human being and a mother myself, is that a lot of the women that we see at this hospital have really suffered in their young lives long before we ever met them. Many of them have trauma histories, lots of them their parents had trouble with addiction, alcohol or heroin themselves, and we are really working hard to educate people about the fact that this is not their fault.
We don't treat them with scorn or derision, we treat them with respect and compassion, and we tell them like, "We're going to work hard with you to prevent this from happening to this adorable baby that's sitting here in my arms. We want to see how we can intervene with this cycle of trauma and substance abuse so that your child is not back here in fifteen years in exactly the same boat."
Melanie: Thank you so much, Dr. Costello, for being with us today and for the wonderful program that you're running there at Boston Medical Center. This is Boston Med Talks with Boston Medical Center. For more information on the SOFAR Clinic, you can go to www.BMC.org. That's www.BMC.org. This is Melanie Cole, thanks so much for listening.