Hello, everyone. I'm Kathy Carlson. I'm your host today from the American Society for Pain Management Nursing. And we're fortunate enough today to have Exploring Perinatal Prescription Opioid Use and Misuse in Primarily Rural Settings by Dr. Jamie Morton. Now, before we begin, I do want to say that the chat has been turned off, but the question and answer button is still active. So any questions that you have, you can put in there. And then we will, at the end of the presentation, address the questions. The second thing that I need to tell you is that in order for you to receive the continuing education credit for this, you must fill out the evaluation. The evaluation will be emailed to you in one or two days, and it's a short amount of time. And then once you fill out the evaluation, the certificate will be emailed to you. All right, so now I would like to introduce Dr. Jamie Morton. She holds a Ph.D. in nursing research. She is currently completing an interdisciplinary postdoctoral training fellowship in pain research at the University of Iowa. She has extensive bedside care experience across the lifespan, with a special interest in the maternal child population. Her research interests are focused on the intersection of women's health, emotional and physical pain, socio-environmental influences, and opioid substance dependency. So I'd like to welcome Dr. Jamie Morton. Thank you. Thank you very much. All right, well, that was a pretty awesome introduction. I appreciate that. The study that I'm going to be sharing with you today focuses on a qualitative bit of research that I completed while I was at the University of Missouri-Columbia. First, I've got a little bit of housekeeping things that I need to do. I have no conflicts of interest to disclose. Looking at the target audience, the overarching goal of PCSS is to train health care professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. I do have my educational background, and I do have my educational objectives listed here for you to read over before beginning my presentation. Before I begin, I would like to acknowledge my funding trajectory that has allowed me to pursue this line of research. And I would also like to acknowledge members of my research team for this study. So, to provide some context for why I did this specific research study, we are being inundated daily with news reports about the opioid epidemic in the United States. While the opioid epidemic impacts all populations, there's been an uptick in perinatal opioid overdoses and resultant overdose deaths. When looking specifically at pregnant women, a recent study reported that 21.2% of pregnant women indicated opioid misuse and or dependency, and were more likely to misuse prescription opioids than other forms of opioids or illicit substances. Another more recent study by Brasilius and Martins that I think just came out last year, found that pregnancy-associated overdose mortality increased from 6.56 to 11.85 per 100,000. This translates into an 81% increase between 2017 and 2020. While fentanyl has been largely credited for a bulk of these opioid overdose statistics, it's been previously noted that prescription opioids are a gateway drug to illicit substances such as heroin and fentanyl for perinatal women, so it makes this a very important healthcare focus. This population is unique because if pregnancy occurs to a woman struggling with misuse or dependency, it creates negative consequences for both the woman and her baby, such as increased maternal and neonatal morbidity and mortality, prolonged neonatal hospitalizations, and increased healthcare costs. So, digging through the literature, the most frequent contributors to prescription opioid use and misuse were physical and emotional pain and lack of support. Another pertinent finding that I feel is worthy of mentioning was that most of the studies that I reviewed were conducted in urban or undisclosed settings. Very few explored rural residencies' influence on prescription opioid use or misuse for this vulnerable population. So, to gain additional insight and context related to the experiences of women with perinatal prescription opioid misuse, I also completed a qualitative medicine synthesis study. What I found was an overwhelming presence of healthcare-related stigma that these women encountered throughout the entire perinatal period, and I actually defined that as a year prior to birth, all the way out to two years after birth. Their stigma experiences were compounded by little to no medical or medical-related changes to their lifestyle. This impacted the women's decisions regarding accessing recovery programs and healthcare for both their infants and themselves. But more importantly, it really highlighted the negative impact of stigma and lack of support on these women's emotional health and well-being. So, there were some gaps that I identified from the literature review and the qualitative medicine synthesis. While there was a plethora of studies that identified that women with perinatal prescription opioid misuse had a significant impact on their emotional health and well-being, while there was a plethora of studies that descriptively identified pain, whether it's emotional or physical, as a predictor of use, it really didn't explore the antecedents to the population's pain experience. It was also noted there was a gap regarding whether this population's pain sources were from past or present events, if one pain source preceded the other, or even if they co-occurred. And it was also unclear how the socio-environmental context of where this population lived impacted the initiation and perpetuation of their use and misuse. So, to address the gaps that I identified, the overall purpose of the study was to gain insight into the unique pain-related and geographic socio-environmental factors that contributed to the decision for these women to initiate prescription opioid use and misuse. And I specifically wanted to look at rural women. The three specific aims were developed to address the study purpose, and we aim to explore the pain-related experiences, the socio-environmental factors and experiences, and the healthcare-related experiences of women who used or misused prescription opioids during the perinatal period. So, the study was guided by the theory of symptom management, which is based on three interrelated dimensions of symptom experience, symptom management strategies, and outcomes that influence one another. I specifically focused on the dimension encompassing the symptom experience of pain. So, this dimension is also influenced by the underlying contextual variables that also are the domains of nursing science, and they're person, environment, and health and illness. And these were explored to see how they interacted and influenced pain that led to perinatal prescription opioid use, misuse, and on to dependency. The concepts from the framework were used to develop the study's semi-structured interview guide. So, in order to capture the experiences of this population and to keep the findings close to their words, we chose to use a qualitative descriptive method. We got IRB approval from University of Missouri-Columbia prior to starting, and also from all of the sites that had agreed to let me recruit. We did do convenient sampling for study recruitment, and I do have my inclusion and exclusion criteria for potential participants listed on the screen. So, like many other researchers that were actively recruiting during the COVID pandemic, I ran into some recruitment difficulties with accessing this already very, very hard to access population. As a result, I did have to expand my geographic recruitment parameters to include all of the United States. As a result, I did have to expand my geographic recruitment parameters to include all of the United States. So, this resulted in the initial recruitment of three urban participants, and then we kind of had crickets in the recruitment department. Once the social distancing protocols were relaxed, I was able to get back in and recruit onsite at a rural Midwestern community resource center, and that's where the remaining participants were recruited, which gave me a total sample size of 12. The participants were asked to participate in private individual interviews, excuse me, interviews, during which they answered a demographic questionnaire and the adverse childhood events questionnaire in order for me to kind of characterize the sample. They were then asked the open-ended questions from that semi-structured interview guide that I mentioned earlier, and all participants received a $40 gift card for their participation. For the analysis, we used descriptive statistics for the demographic and ACEs data, and then I followed the six steps of the thematic analysis with that stepwise coding process to analyze the replies in the semi-structured interviews. So, next are the results. Excuse me. The sample consisted of 12 women who provided 14 interviews. Demographically, they were primarily white, rural, single or separated, and had either some college education or had graduated college. The mean age of the participants was 27 years, and they reported experiencing a mean of 4.92 childhood adverse events. And just for context, that's kind of high. The majority self-identified as living at or below the poverty level and received some form of financial assistance. And the predominant prescription opioid use or misuse was hibercodone. Now, poly drug use was also reported by seven of the participants. And from that poly drug use, other substances identified were methamphetamines. And this was exclusively identified by, the meth was exclusive to the rural participants. Synthetic illicit opioids, benzodiazepines, cocaine and cannabis, which the last two were only identified by the urban participants. So, from the 14 interviews, three main themes were identified that coincidentally reflected the three specific aims of the study. The first theme was, it's kind of hell on earth, it's all consuming, pain experiences. And the second theme was the long and winding drug dependency journey. And the third theme was, we just want to know someone cares about us, system level insights. And within each of these major themes or sub themes that I'm going to present next. So, the first major theme, it's kind of hell on earth, it's all consuming. Pain experiences focused on the women's sources of pain. The impact of their pain experiences and their experiences with managing their pain. The first sub theme contained women's pain sources. Some reported physical conditions stemming from chronic health alterations, such as migraines, polycystic ovarian syndrome and fibromyalgia. Others listed injuries from work or motor vehicle accidents as physical pain sources. However, the prominent source of identified pain stemmed from emotional or psychological sources. Depression and anxiety were frequently identified by the participants as causing emotional distress and suffering. Feelings of being abandoned, as well as not having or losing a source of support, exacerbated the participants depression and anxiety, which ultimately increased their emotional pain. And some exemplars here, my participant one said, I was diagnosed with PCOS as a child and I have a severe back injury from work. That will require surgery in the near future. My participant eight said, I mean, I've always suffered with depression. I believe that's because it's kind of hell on earth. Past and present trauma experiences were also reported as frequent sources of emotional pain. And that's the focus of the second sub theme. Childhood abuse occurring in forms of physical, psychological or sexual abuse was described by some of the women as sources of their emotional pain. Other childhood trauma experiences, such as emotional neglect and feelings of caregiver abandonment were identified as feeding into the development of emotional pain. Adult trauma experiences, such as intimate partner violence, human trafficking and coercion were also contributors, excuse me, contributors to emotional pain and distress and occasionally to physical pain for the participant. Participant eight's intimate partner violence experience really highlighted this connection. And she said, and I loved him. So I did anything and everything to show him, but he would deprive me like certain things and just argue and fight on purpose. So I put up with it for a long time, but it messed my head up and it got physical sometimes. The women provided insight into how their pain, whether stemming from physical or emotional sources, impacted their lives in the third sub theme. Participants shared their experiences of living with chronic physical pain, describing the difficulties with balancing daily functioning with their pain experiences. For example, participant one provided, but with this pain, it was all consuming. Who knows how long it's going to last? Is it going to last two hours, a day, a month, a year? Is it going to start and just never stop? Participants also described how crippling the emotional pain they experienced was. The women used words such as distress, devastation, turmoil, and even feeling emotionally broken to convey the impact emotional pain had on their lives. Some of the women indicated that their emotional pain experiences were so overwhelming, it led them to contemplate suicide. For example, participant seven, describing the depth of the emotional pain she felt from difficulties with child custody loss, indicated, if I can't have my kids back, I don't know what I would do. Participant attempts at managing their pain was the focus of the fourth sub theme. Women shared complex and often ineffective pain management experiences within the healthcare system where they felt their pain reports were dismissed or not being taken seriously. Participants were given prescription opioids by physicians who did not further investigate the sources of their physical pain. And for context, this wasn't like from long time ago memories. This was like in the recent past. An example was provided by participant six who said, the pain was really bad for a while. I would have to go to the ER to get more refills because the surgeon didn't believe I should still be hurting from the accident and cut me off. They just looked at my chart, looked at my back and leg, and then wrote me a new prescription. One finally did do an x-ray and I had something pinched and swollen in my lower back. He gave me some kind of pill that wasn't a pill, but would make the swelling go down. It worked, but by that time I was hooked on the pain pills. While some participants shared that they sought counseling and treatment for their emotional pain, attempts at self-management were consistently recorded. The majority of participants discussed self-managing their emotional pain with prescription opioids or other substances such as methamphetamines. Participant 9 shared, and I wound up being in the hospital from delivering my first baby and when I got out, I just continued to use. It was just my depression, using Help Me Stay Numb. The next four slides present the four sub-themes of the second major theme, the long and winding drug dependency journey. And in this theme, it describes a woman's complex progress from prescription opioid use to misuse to dependency and on to recovery. The first sub-theme, the pathway, describes the women's prescription opioid journey experiences, which ranged from active usage, or I'm sorry, initial usage to active usage outside of prescription parameters to that of recovery and abstinence maintenance. The women provided insight into the first time they used and provided context as to what contributed to their decision to use. Besides attempting to manage physical and emotional pain, other reasons provided for their first time using was coercion, either by a partner or by individuals identified as human traffickers, and unfortunately, curiosity. While all participants used or misused prescription opioids, methamphetamines were the primary substance of abuse for many rural participants because of the ease of access and the cheap cost. For instance, the prescription opioids were misused when methamphetamines were not available. Most participants described how quickly they became dependent once use was initiated. The journey that these women described was laden with cycles of active usage that were followed by an awareness or a desire to stop. And then the women reported immense struggles encountered while trying to stop their use. Many described multiple cycles of withdrawal and relapse, heavily influenced by the need to avoid the pain related to physical withdrawal and the return of their emotional pain. Participant 10 described her struggle. She said, it was probably the worst feeling ever. There's no one that I couldn't like beat it. And no one I'm fixing to have a baby. And just no one what's going to happen if I didn't. And it was just a bad state of mind for me all of that. But every day it was a struggle, I'd wake up and I I knew better, but it was just hard to beat it. The second sub theme titled It Runs in the Family highlights how generational influences were heavily threaded within the shared stories about the participants pathway into opioid and substance usage. Generational cycles encompassing parenting, coping mechanisms, behaviors and beliefs were identified as influencing the participants journey into use misuse and dependency. Those family members such as parents, uncles, grandparents and cousins were specifically called out as openly using around the participants from childhood to the present time. And what that did for these women was it normalized the use misuse and dependency. Participant 12 story reflected this. She shared for the first 11 and a half, 12 years, my biological mom and her boyfriend was both users and drinkers and her boyfriend would rape me. They would both he would beat me and my brothers and everything and she would let him they'd done drugs with me in the room. Any drug you can think of really. Many of the rural living participants described experiences of receiving tough love from their journey and the impact it had on their dependency journey. These women described how the family members withdrew their support and distance themselves as a mean of punishment for their usage or place conditions on receipt of their support. Many considered this a harmful expression of tough love that was guided by generational beliefs surrounding substance use and dependency. These women described that while tough love may be necessary at times, harmful tough loves consequences actually caused increased emotional pain and loss of support, which ultimately contributed to some of the cycles of relapse. For example, my participant 11 said, if I would have gotten less tough love, more acceptance and understanding, if I would have gotten the kind of love that doesn't make you afraid to speak up when you need help, it would it would have kept it from developing maybe. The third sub theme is I'm a survivor, not sure how I survived, and it tells the women's development of resiliency through their journeys with use misuse and dependency. Expressions of extreme emotional pain described as feelings of hopelessness and despair were used to describe different periods within their journey. Participant 10, just 15 years old, shared her experience that really captured this when her mother turned her away. She said she just let me move off by myself. Me and her ever since when I left, that was kind of a line to where now I'm on my own, you know, and I really couldn't come back. Someone in detail being placed in vulnerable positions such as homelessness that required difficult decisions for survival during their journey just to meet their basic human needs. Many of those difficult decisions involved participating in drug use for for shelter. Despite the dire circumstances that many faced as their dependency journeys unfolded, these women felt that their experiences ultimately made them stronger and wiser, and it helped them focus on their future and many of them identified that it actually helped them kind of develop that sense of self, excuse me, efficacy that made them want to pursue moving forward toward treatment programs. So central to the women's stories were their experiences as mothers during the opioid and substance use journeys. And that makes up the fourth sub theme, which is titled We Aren't All Bad Mothers, Motherhood and Drug Use. These experiences highlighted unplanned pregnancies, the intersection of dependency and motherhood, infant birth outcomes, experiences with child protective services, and the motivated excuse me motivation that the infants provided for the women. Pregnancy brought out a sense of responsibility and protectiveness in the women for their babies, culminating in the strong desire to mother their infants. It was noted that despite this desire to be a mother, there was a large prevalence of hesitant, excuse me, hesitancy to initiate and maintain prenatal care. This hesitancy was fueled from their struggles with physical and emotional pain management, physical withdrawal, and fear of punitive repercussions such as legal involvement and loss of child custody. Of the women that participated in prenatal care, many disclosed the desire to have a healthy baby, yet chose not to disclose their usage. A resultant pervasive fear of child custody, excuse me, custody loss was present in all of the women's shared experiences. The women described experiences that ranged from being threatened by various healthcare providers with child protective services or Department of Family Services involvement to actual child custody loss, and this caused significant emotional pain for the women. The women shared their stressful, often emotionally painful experiences of navigating conditions for reunification that consisted of multiple, multiple failed attempts fraught with frustration, lack of understanding the mandated requirements, and lack of help and guidance that for some triggered relapse. And participant seven kind of really highlighted this. She said, why did I go back to using? Because I wasn't getting any help through DFS. You have to do certain stuff. I did what they wanted me to do. I went to rehab. I went to all the classes they wanted me to, parenting classes and stuff. I got no help, no feedback until I was told I was still not good enough. So the third major theme contains five sub-themes that present the intersection of women and the family and community level systems in which they live. The first sub-theme is perspectives about living with the use and misuse, where participants shared their perspectives regarding how the areas in which they live influence their usage. It was shared how poverty experiences, housing instability, and even food insecurity influenced the presence of opioid and substance use where they lived, regardless of their geographic location. Drug manufacturing and selling became a means to income, which at times led to use, misuse and dependency. And I really found this interesting because this was very unique to the rural participant stories. For example, when talking about her cousin, participant 12 provided, they do it and they sell it. I know my cousin, that was how she made money to pay for groceries at first. Her habit's so bad now, it's just to get more drugs. The second sub-theme presents the women's perspectives about available resources and support in the context of where they lived. An overall lack of mental health support services were commonly mentioned by all participants regardless of the location where they lived. And while substance recovery treatment services were not considered lacking by all participants, for the rural ones, it was generally perceived that there was a significant lack of awareness as to what services are present, as well as how to even access them. Participant 10 recounted her experience. She said, I've lived here for a while now and never knew there was a treatment program up and down, you know, and I've been here for years. I didn't even, it's just not advertised that much. Contained within the sub-theme three were suggestions based on the women's perspectives regarding what is needed to improve outcomes and how nurses can help. The desire for open, honest, and nonjudgmental communication from nurses was commonly discussed. It was emphasized that nurses and other members of the healthcare team need more education regarding perinatal substance use and misuse care needs, with trauma-informed care and recognition of red flags related to abuse and coercion. Additionally, participants provided that nurses need to be aware of this pervasive sense of distrust and fear of authority figures held by women like them. And to be clear here, we in healthcare are considered authority figures. The women provided insight for nurses regarding how to overcome this distrust. Open and honest communication was again mentioned, as well as being patient and being a source of support. And most importantly, these women needed nurses to focus on helping them as much as their infants. They felt left behind and forgotten. For example, participant 12 shared, like, if I would have been using with my youngest and I would have failed, I would have wanted them to talk to me about it before they called state or whatever to see if maybe they could get me to go into treatment or see what they could do to help me stop using or get me out of the situation I was in. They just automatically let me fail. Descriptions of stigma experiences were prominent in the stories shared by all participants and made up subtheme four. The women described pervasive feelings of being looked down upon, shamed, subjected to judgment based on their history of misuse during their pregnancies from family and friends, from their community members, and also from nurses and physicians providing not just obstetrical care, but their primary care. The women reported feeling fearful and unsafe within the healthcare system as a result of their past stigma experiences, and that ultimately led to distrust. My participant six kind of highlights this. She says, too many people I know had babies taken away. I was scared I would too. I didn't tell anyone unless I had to because I was too afraid and didn't want to be treated like dirt. That happened with my OB and I felt judged. He made me feel like I was this worthless person, like I wasn't worthy of being a mom. Women wanted to be extended the same level of compassion and professionalism perceived to be extended to other women who did not have opioid or substance misuse. Subtheme five consisted of the women's perspectives on support. Participants described little to no support from their obstetricians, nurses, law enforcement officials, DFS and child protective services caseworkers, community and even community members in general. Examples of not being listened to, perceptions of being dismissed and viewed as an addict or a bad mother instead of a person in need of support and help were frequently noted in these women's stories, and it was across the board. For example, participant 11 shared her experience of reaching out to her obstetrician's nurse for help. The lady turned and looked at me and told me, well, you better get your bad word starts with an S together, or you're going to get in trouble for substance abuse. There was zero help, zero help from the nurse, and to provide context, this woman was trying to escape a drug house where she was being coerced and forced into drug use. All participants identified that a source of support was important for the women struggling with substance misuse or dependency. However, participants shared the common belief that women with opioid use and substance use struggles are often left behind in the system. It was perceived from their experiences that children were prioritized over mothers. There was a strong desire consistently expressed to focus on helping women with opioid and substance use problems too. The women expressed the need to focus not on the drug use or misuse, but on the root cause, while recognizing the difficulties they faced with the recovery process. Through their experiences with perinatal opioid and substance use misuse and dependency, a desire to be acknowledged and cured for as a human being was fitted through the women's stories. As participant six said, just because I may be an addict now or was an addict, doesn't mean I'll always be. I deserve a second chance too. We all deserve second chances. So from the women's stories, there were some pain related insights noted. Detailed experiences of both childhood and adult trauma were prominent. Raising questions about the relationship between the two, overwhelming, this overwhelming presence of emotional pain, as well as the sources of emotional pain in the study was also an important finding that really needs further follow-up. And lastly, the women's stories brought to light healthcare experiences that failed to meet their physical pain related needs. So when I looked back at my coding trail, this specifically came from the rural participant stories. Because this was such a small sample, it's really unclear if their experiences stemmed from gender bias that minimizes women's pain reports, or is it influenced by the prescribers punitive fears regarding the current opioid prescribing guidelines? I really can't extrapolate. Regardless, the women's stories exposed how their physical pain was under-managed, and it suggests that it's still a pertinent women's health issue, specifically at least for where these women live that need further attention. There were also important socio-environmental insights worth mentioning. Poverty and housing instability, both considered social determinants of health, were embedded within the women's shared stories as impacting their journeys. Both contributed to the decision to use and perpetuated the progression of use to misuse to dependency for this sample of women. Another interesting finding from this study is the impact of poverty on the women's drug of choice. In this study, the women that lived in rural areas conveyed that their primary drug for self-medication was methamphetamines due to the ease of access and the lower cost, and prescription opioids were secondary drug of choice. Also, a general lack of mental health services was described, and while efforts have been made at the state and national level to increase access to mental health services, the findings hint that there's still an ongoing gap in access and availability for perinatal women's mental health care, at least in the communities in which these women live. There was a striking presence of multigenerational drug dependency that impacted all of the participants. Normalized multigenerational influences were reflected by the women as having influence on their pain experiences and subsequent use and misuse of drugs, and it really, really emphasized the complexity of the influences that these women were under that created painful experiences from childhood to present time. Regarding healthcare-related insights, the overwhelming lack of support and presence of stigma experienced by the study's participants from members of the healthcare team are frankly concerning. Healthcare providers were particularly called out as many times showing explicit biases towards the women, as well as implying that the women were bad or are not worth their time. So there were some limitations of this study. First, the small sample size and the qualitative nature of the study limited the generalizability of the findings beyond this group of women, even though saturation of themes were achieved and the data was just incredibly rich. Next, social desirability bias related to participant fear and distrust could have impacted the details shared in the interviews. And a third one that I identified is related to the preferred method of interviewing. Because we were still traversing kind of the tail end of COVID, many of the participants chose to do telephone interviews. And because we performed the telephone interviews, it really limited the ability for me to interpret any nonverbal communication. So this study provided some important insight pertaining the pain-related experiences contributing to perinatal opioid use misuse, as well as perinatal opioid use-related stigma. Findings from the study also highlighted the presence of generational influences on perinatal opioid and substance misuse, influences of social determinants of health, as well as the overwhelming presence of emotional pain experienced by these women who self-managed their pain with prescription opioids and other substances. The findings, if explored on a larger scale, may hold policy implications. Again, there's a need for further examination regarding the current policies in place that promote stigma, as well as the under-management of women's emotional and physical pain. Based on my findings, there are many avenues to pursue that this study could inform. However, the next step for me is that I am going to conduct a larger-scale quantitative research study that's going to examine the various associations between the social determinants of health, the cumulative impacts of childhood and adult trauma, pain development and management, and I'm going to expand from opioid use and misuse to include other illicit substances as well. And I truly believe that this is going to add to addiction and pain management science. So that ends the presentation portion. I want to end this by stating I am not an advanced practice nurse or a clinical expert in addiction or pain medicine. I identify as a maternal child nurse who went into nursing education and identified this complex issue from a bedside and an educational perspective. And I'm actively in the process of expanding my level of expertise. This was very much a foundational study to build my research program on. I also think that the women's voices that I've captured in this study opens up the opportunity for some really rich discussion. So I'd love to hear your thoughts and any questions that you may have. And I also have provided my contact information here for anyone that may have questions. And I was asked before we open things up for questioning, I have a couple more slides that I need to go through. So these are my references, and I can send those to you if you email me. And then I'd like to talk about the PCSS Mentoring Program. I'd like to make you aware of the two resources offered through the PCSS that may be of interest to you. First, the PCSS's Mentor Program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our mentor directory, or we're happy to pair you with one. To find out more information, please visit our website using the web link noted on this slide. Second, PCSS offers a discussion forum, which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor on call each month, and this person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking on the image on the slide to access the registration page. And this slide simply notes the consortium of lead partner organizations that are part of the PCSS project. And finally, please reference the slide for our contact information, website, and Twitter and Facebook handles to find out more about our resources and educational offerings. All right, I do believe that ends that. Now, Kathy, should I stop sharing my slides now? Well, just one second before you stop sharing that slide, I want to point out down to the bottom right-hand corner, there's a website, www.pcssnow.org, people have asking where the slides will be shared. It's on that website. Then you go under education and training, and then under webinars, and you should find the title of this one. If it's not there yet, it'll be there within a day or so, and then the slides will be posted there. So now you can stop sharing if you'd like. All right, thank you so much. All right, a couple of business things. First is, again, if you came late, we will be sending you an evaluation form via email, and once you complete the form, you will be sent a CE certificate, but you have to complete the evaluation form. All right, so we have just a few questions here. Here's one that asks, how generalizable do you think this research is to rural populations with more diversity? That's a very good question. And I think that it's not, there's not a lot of diversity represented in the sample that I accessed. The area that I was able to sample from was predominantly reflected in actually the characteristics of the sample. That's one of the reasons why I feel very strongly that I need to do this on a larger scale and potentially do this either in a survey method that can reach more communities and then have the opportunity for some open-ended questions so that I can maybe get that context that I was able to get from these women. All right, have you considered collecting alcohol use in your study? So we talked about it, but we decided, the research team members decided that we needed to focus in specifically on the opioids, the drug component of it. One thing that we are interested in is potentially re-examining tobacco and even caffeine. I can't pull it out. I would have to email it later, but there have been some literature in the last five years that have shown kind of a upswing in the prevalence of tobacco use in this population as well as the prevalence of caffeine. And they have looked at that as predictors and they have seen that, I don't know if predictors is the right, they have seen that there is an increased amount in women that are identifying as having opioid misuse. Okay, and basically that's the last question. Another person just said, great presentation. Thank you. Are there any other questions before we go? I think I might've found one here. Where, they're asking, where are these questions? They're not showing in this Q&A or the chat section. Yeah, the chat section's closed and I don't know if they might just be, the questions might just appear to me. I'm not quite sure how it's set up. So you can click on the Q&A and you can type a question in. And then I see it and I give it to Dr. Morton. Anything else? I'm not finding them. Okay, well, Jamie, thank you. Oh, I might've gotten, I got one. How are you recommending working with CPS to provide support versus removal of custody? I have not gone into that area yet. I think that that is, that is definitely an area that needs attention. And I believe that, I believe that it's an important one. I feel like that I need to gather, I'm still early enough into establishing my program. I need to gather more information and get a bigger picture rather than just basing it on here. I do know that it is, it sounds to me like it is more than just related to where the area was that these women were that I recruited. It sounds like there are some systemic problems, but I'm very hesitant to reply to that because I don't have enough information to answer you intelligently and probably accurately. Okay. But it's worthwhile that now I'm probably, when we get done with this, I'm going to start looking into it and digging in it. So thank you for stimulating the thought. Okay, so I'm not sure what this one means. She says she wants to see an interactive discussion of the resources to make this work. And I don't know what she's referring to there. So that's not quite a question. Okay, to make this work. E.g., what's happening and showing in the data for rural areas. So that's what she'd like to see in the future. Okay, I think that's it then. All right, everyone. Thank you so much for joining us today. And Dr. Morton, thank you so much for this presentation. You're an excellent presenter. You have a very soothing, almost not entertaining, but a captivating voice, I guess maybe I should say, because these stories are so very, very sad. And you would hope that there could be something more to help. Well, I appreciate you giving me the opportunity to share these women's voices. So they need to be heard. Okay, thank you very much then. All right, bye-bye everyone.

perinatal opioid use

misuse

rural settings

pain experiences

socio-environmental factors

healthcare experiences

women

qualitative interviews

system-level insights