All right, good afternoon, everyone. It's 3 p.m. Eastern time, so thank you for your patience. So we're gonna go ahead and get started. So welcome to today's webinar titled Opioid Use Disorder in Pregnant and Postpartum People, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Wellbeing. Thank you so much for joining us. My name is Coyle Shropshire, Project Coordinator of Practice Improvement at the National Council for Mental Wellbeing, and I will be moderating today's event. Before we begin, I just wanna cover some quick housekeeping notes. So just so y'all know, today's webinar is being recorded and all participants are gonna be kept in listen mode only. The recording and the slides will be made available on the PCSS website within two weeks. We will share this website link with you, I believe, at the end, and my colleague can also drop it into the chat. There will be an opportunity to ask questions at the end of the webinar, so we encourage you to please, please, please submit your questions throughout the webinar in the Q&A box located at the bottom of your screen, and then we'll go through them during that Q&A section at the end. I am now pleased to introduce today's presenters. We have three guest speakers, including Dr. Manriquez, Tara Sundom, and Tawny Carson. So starting off, Dr. Maria Manriquez is an OB-GYN specialist in Phoenix, Arizona, and has been practicing for over 20 years. She graduated from the University of Arizona in 1998 and completed her residency in 2002 at Banner Good Samaritan, now known as Banner University Medical Center Phoenix. Dr. Manriquez is the physician lead for the pain and addiction medicine curriculum at the U of A College of Medicine, Phoenix. She has worked with the Department of Health Services in the development of a curriculum that educates the undergraduate medical education and graduate medical education learners on pain and addiction. Her service commitments include multiple leadership positions with the American College of Obstetricians and Gynecologists and as an oral examiner for the American Board of Obstetricians and Gynecologists. Next, Tara is a board certified neonatal nurse practitioner with more than 28 years experience in neonatal intensive care. She was a frontline worker in the growing opiate epidemic, caring for the most innocent of its victims, the newborn suffering through opiate withdrawal, which is neonatal abstinence syndrome. Her passion to transform the healthcare experience for them and their families led her to found Hushabye Nursery an Arizona nonprofit dedicated to caring for opiate exposed newborns in their first weeks of life. The 12 bed inpatient nursery opened its doors and its arms to these babies and their mothers and parents in November, 2020. Under Tara's leadership as executive director, Hushabye Nursery has grown from an idea to save the babies in 2016 to a unique model of care for this underserved population that focuses on the family unit, both prenatal and postnatal. She holds a master of science from Arizona State University and is a member of the National Association of Neonatal Nurses, the Academy of Neonatal Nurses and the Neonatal Nurse Practitioners of Arizona. Tara lives in Gilbert with her husband, two sons and their dog. Finally, Tani's story began as a pregnant individual addicted to opioids. She saw no hope and was always open to the fact that her life could change. Around seven months pregnant, after working with Dr. Henriquez and Hushabye Nursery, she decided to take a leap of faith. Today, Tani is two years sober and successfully parents her three children. Most importantly, Tani is giving back to other families who struggle with addiction and recently became a peer support specialist at Hushabye Nursery. So we are super thrilled to have all three of them with us today. Moving forward with logistics, the speakers today have nothing that they would like to disclose to the audience. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well for the prevention and treatment of substance use disorders. All right, at this time, I'm gonna turn it over to Dr. Henriquez who's gonna review our educational objectives and begin the presentation. So just give me one minute while I transfer control to her. Good afternoon, everyone. I am just thrilled to be here with you and Tara and Tani. It's fantastic to be able to share our journeys and how we're approaching substance use disorder with patients who are pregnant. The educational objectives for today will be to review the current landscapes of opioid use disorder for pregnant and postpartum patients in the United States, describe the neurobiology of opioid use disorder among pregnant and postpartum patients, examine legal challenges related to pregnant people and parents with substance use disorder, and then finally discuss recent policy changes that impact how opioid use disorder treatment is provided. I wanna just take a second just to explain or talk about that last bullet point and appreciate kind of how far we've come and how much more we need to go. How far we've come is at the turn of the century, the last century, we basically were made as physicians not to be able to treat people with addiction. So there were big heavy duty laws in place that disallowed a physician to treat patients with any medication if they had addiction. So it was limited in what could be done. After the Data 2000 Act passed, we had a little bit more liberty and it's continuing to improve substantially, which is great, but I almost like, and as I was sitting here thinking about it, it's almost like Hurricane Katrina. We knew that the levees were probably not the best and we knew there was a risk every year with hurricanes. And so we kind of knew that what we had in place was potentially gonna be ineffective. And indeed, we're still with very, very many patients that need access to care. And that's a big problem that we have in the United States today. And I will, let me do that. Yay, all right. I wasn't sure if it would work off my keyboard, but it did. So let's talk a little bit about the epidemiology of substance use in pregnancy. So during pregnancy, alcohol exists in about 3.6% of pregnant patients using the diagnostic criteria. Nicotine is a substantially higher at 15.9% and then illicit drugs at 1.6%. Of course, that depends on where you are geographically. From 20,000 to 2019, antepartum maternal opioid use increased from 1.6, excuse me, 1.19% to 6.6%. So that was out of the CDC weekly, just a substantial increase, something that I think we were quite concerned about once we were seeing opioids prescribed a little bit more liberally to pregnant patients. And indeed, that became more and more of an issue. Of those that reported one in five misused opioids. So what we have as a product of that is 4.7% of pregnant women's report using illicit substances in the past month. So screening is a big thing that we should discuss and we will, but it's important to know you can't help people if you don't identify them. So some of our screening tools probably that are used in the medical arena are less than optimal. One in 300 women who are patients who become pregnant or have a cesarean, I apologize, will become dependent after using opioids. And as a matter of fact, is as short as a two week duration of chronic opioids can lead to a dependency. Dependency is a little bit different than opioid use disorders, I'm sure many of you know, but it's important to appreciate how short that timing from it can be. So we know that neonatal abstinence syndrome, but specifically neonatal opioid syndrome, when we're talking about opioids, cost on the order of 1.5 billion or more. This was a stat from 2015. And then finally, the most tragic of tragics is that substance use pregnancy is associated with death. And these statistics or percentages are from Texas, Maryland and Arkansas respectively. So 17%, 15 and 22%. So I'm sure no one here is surprised to hear that we have a problem out there and it is affecting our pregnant persons. In Colorado, it's the number one reason for maternal morbidity and it's coming close here in Arizona as well. And I'm sure in other states across the country have a high maternal mortality morbidity if you include that year after delivery. So something we all need to be well aware of and taking care of. The current landscape for treatment in opioid use disorder is medication for opioid use disorder. That is the current landscape and should be the standard. So for pregnancy, methadone and buprenorphine, either mono or dual product is acceptable. Some insurances get to be a sticker on the dual product. And for some reason, patients that have been on suboxone wanna continue to stay on suboxone and that's perfectly fine. There's been enough studies done to reassure us that that naloxone in the suboxone is not gonna be affecting the baby much. So it was historically thought that because of the naloxone that that could create withdrawals in the baby but it's not been found to be true. And then postpartum, of course, again, still methadone, buprenorphine, sublocate, which is a longer acting buprenorphine method and then Vivitrol. We don't use sublocate or Vivitrol much in pregnancy. There is some studies out there and some mostly case reports where we are looking at the outcomes, nothing very negative or untoward. Of course, it's hard to balance the changes in pregnancy with what has been evaluated in a non-pregnant patient. So most people are sticking with methadone and buprenorphine and then medically supervised withdrawal is an option for patients who are opioid dependent, not necessarily have a use disorder. However, if they do have a use disorder and the impulsiveness, compulsiveness associated, this is not a good option because it's an increase to relapse. So highly discouraged in those situations but it would not be a true statement any longer after at least a 1400 review of patients that did do medical supervised withdrawal to say that it puts the baby at increased risk for spontaneous loss and or fetal demise. The issue is relapse to use. So this is describing the neurobiology of opioid use disorder. So it is the binge is in blue. So what happens is there's a big release of dopamine and it affects the basal ganglia. So typically our natural dopamine release will either be with sex or great chocolate cake. This is significantly higher in the release and then depending on the drug itself, for example, many of the stimulants work directly on the dopamine receptor and that is just significantly higher. And it not only prevents the reuptake of dopamine into the cell, but also stimulates more release. So some of the graphs out there will demonstrate a hundred in the scale for great chocolate cake, or even 150 for a climax with intercourse, but methamphetamines can be up to a thousand. So a big variance, big difference. After the binge intoxication, you'll experience the negative effect. And some of those are highlighted here. This is typically when you're dealing with somebody with a use disorder, this is typically what is motivating them to seek drugs. They no longer want to feel the negative effects and then they become very preoccupied with the anxiety associated of feeling those negative effects. It's not so much the intoxication that they're seeking as much as they're trying to avoid the discomfort of withdrawals. This is just a little pictorial to kind of show you where some of these receptors are and the drugs that interact with the receptors. They're not all in the same place, but you can see here, if I can make this highlight, I don't want to mess anything up, so I'll try not to do that. But you can see the amphetamine, there's also release here, as well as the reuptake that is prevented. And so lots of different pathways, the CCAMP pathway, the calcium pathways, but there are multiple ways that the dopamine is stimulated to be released. And that is by and large what any of the substances of addiction are associated with. And then I like to tell patients frequently to help them understand all this or why they're feeling bad. I point out that it's a little bit like a teeter-totter, you push down on one side and it's going to go down and the other side goes up. Well, the body doesn't like to stay in that down place and that down place for the body is stop breathing, heart stop beating. So our body releases other substances or neurochemicals that prevent you from dying. And those are the ones that don't immediately go back to normal. And those are the ones associated with the withdrawal effects. So the pathophysiology of opioid use disorder, it's a chronic relapsing disease influenced by factors of genetics, stress system responses and prior opioid exposure. So particularly genetics, it was just about a month and a half ago, I think, maybe two months ago, they identified a loci in the gene that is the same for all addiction. So all substance addiction, which is really interesting. Then it gets into the kind of interesting and or scary stuff, which is CRISPR, which is actually cutting out that piece of the gene. How all that will work is to be seen, at least it's something that we understand that is truly identified as a genetic and likely an increased metabolism of the substance. Stress system responses, we talk a lot about ACEs and trauma. And so appreciating that those are going to affect individuals differently, but it has a high, high influence on use. It's unusual for me to have a patient, particularly a female patient that presents. And if you're asked the question as to the pros of use, it's often because it numbs me. So they've had experiences that are difficult to reconcile. And this is one way to help them in that space. So a lot of behavioral health is important while we're helping people get to a place of not using substances illicitly. And then prior opioid exposure, prior not managing pain can be an issue. So those are important factors that we'll have to be doing a lot of teaching on, given that the data waiver has gone away and people are just like, what do I do? How much do I give? So it's wonderful that PCSS is doing these talks and helping people understand just some of the, not just the basics, but a lot of the basics and then what to do and how to manage your patients. Pharmacokinetics and pharmacodynamics of pregnancy, just appreciate that there is a huge change in the volume. It increases by two thirds almost. And then of course, in a change in metabolism, there's a lot of protein binding. So a lot of the medications that are being used for use disorder are being bound by the increased protein binding that happens because of the big bulk of estrogen, making it viewed to the patient as less medicine. So it's not infrequent that they'll need more medication and or need split dosing. I prefer split dosing just so that I don't need to increase the methadone or even the buprenorphine. And it just seems to help them a little bit. These are also some of the changes associated with pregnancy. So of course we are all probably appreciated that opioids cause constipation, so does pregnancy. And so that's really important to evaluate. Your patients may not come directly to you saying I'm constipated, please help. But you want to evaluate that frequently. And if they need different types of medications to help with that, and I certainly want to provide that. If you don't need to prescribe extra iron, don't. Most of our prenatal vitamins have iron but you want to keep an eye on that. And they may need it. But again, all that bowel habits is really important because you have two big factors affecting their motility. Increased cardiac output. And I spoke to that a little bit about why some of the medications pharma dynamics may change. Increased fat compliment. That's important that they understand that especially with any of the lipid soluble drugs that they may be taking, particularly cannabis if that's happening in pregnancy. And then some of these others are just to appreciate that there's a lot of changes in pregnancy and answers the question why a lot of docs are like, no, I may have taken care of you all these years but now you're pregnant, you need to see somebody else. Not necessarily true, but I think some of these changes in some of the physiodynamic just circumstances of pregnancy make people a little bit leery. Not to mention the history of high liability associated with obstetrics. These are the medications that we commonly see and how they're affected in pregnancy associated with which enzyme is metabolizing. So just know that you're going to, for example, codeine, you're going to have an increased metabolism, whereas you may have a decreased metabolism with some of the other meds like your asthma medications. Methadone has an increased metabolism. I don't need to tell most of you that because if you're prescribing or working in OTP, you know that they're going to need a higher dose of methadone. And that's, again, because of the protein binding, but the increased metabolism as well. So treatment, the recommendations are not to provide detoxification, well, both by ACOG and ASAM. And the biggest reason is, again, is because you put your patient at risk for relapse. Both methadone and buprenorphine are, that suppress and reduce cravings are recommended. And well, that jumped really quick. Sorry for that. So these are some of the studies that exist for medication-assisted treatment. And really it's, I tend to write medication for opioid use disorder. It's not an assisted treatment. It is the treatment along with behavioral health. So these are just some of the findings that methadone and buprenorphine have similar effectiveness. If folks are having difficulty finding effectiveness with buprenorphine, it may be that the dose is too low, particularly with some of the fentanyl that we've been experiencing now. Fentanyl today is not the fentanyl from the streets even five years ago. So it's quite different and we may need to look at higher dosing. The reason people keep dosing and particularly insurance companies keep dosing at the 24 milligrams per day is related to studies that demonstrated that the ceiling for buprenorphine was about 32 milligrams daily. And after that, you didn't get much of an effect. But I think that's as different as anything in patients. They think all patients are different and how they metabolize we know is different. And so that probably needs to be looked at again. There's a nice meta-analysis comparison between the two medications and demonstrated that buprenorphine had higher birth weights and were less likely to be treated by or be treated for neonatal opioid withdrawal symptoms or neonatal abstinence. And then a randomized control trial of 75 women assigned to either or demonstrated that buprenorphine required less neonatal abstinence treatment, shorter hospital days. Also that if neonatal opioid withdrawal symptoms was going to occur, it occurred sooner than the methadone cohort. So we'll examine some challenges associated with pregnant and mothers of substance use. So here in Arizona, we had a bill that was a little bit controversial, even among us that take care of patients with substance use disorder. And the bill required mandatory reporting of substance use during pregnancy. Some institutions do that just already as a normal. And I honestly didn't appreciate that. My institution is one of those, which I will be going to administration to have a chat with. I just, you know, our patients are still in that, how do I trust mode? And it's not helpful when they're getting sideswiped by somebody reporting them to DCS before they've even had the opportunity to get stable. And I know that Tara will talk a little bit about what she does and how she encourages patients to address DCS. And it's really been working really, really well for us. So this particular bill had me quite nervous, but the governor vetoed it. It passed not unanimously, but pretty darn close. And the governor vetoed it. But I think the initial thought process was we want to get patients taken care of. The reality is it just scares them and then they may not get any care at all. So I think whoever she sought out to get input from on this was fantastic because it needed a little more tweaking in my opinion. That's just one person's opinion. Discuss recent policy changes that have impacted how opioid use disorder treatment is provided. We all know that December 29th, maybe we don't all know, we should all know that December 29th this past year, the president signed to eliminate the X waiver requirement for buprenorphine. And then it went into effect about mid January. So all providers, MDDOs, and I believe nurse practitioners as well do not need to have extra training. The caveat is that the DEA now will require eight hours of training from all persons that have a DEA, whether they want to prescribe or not. And this is just important. I mean, I think many of the medical licensing boards have been requiring this for several years, but this is another way to get that training here on PCSS. And so now I'm going to turn it over to Tara. Thank you. Hello, everybody. I'm Tara Sundeman, I'm the executive director and founder of Hushabye Nursery. And really my portion of this is just how can it work? And what does that look like? Truly, I think, yes, it's our care model. So I think it's the absolute best, but I just want to stress that it's not just Hushabye that's doing this. It is truly the systems as good as your community partners. And so when we're working with families, we're not just working with the family with Hushabye, we're working them with Dr. Manriquez, with the HEAL program, with anyone that would have a touch point in a mom or dad's life while they're struggling with substance use. And so we created a prenatal program and a postpartum program that met the needs of families. And the reason that came about was what we were finding was that if we just educated the parents a little bit on what it was gonna look like when their baby was born, how could they make the withdrawal process just a little bit easier? And then what was gonna happen as far as child safety, child welfare? I found that when we just did one hour class once a month, out of 12 moms, we had eight of those moms taking their babies home and they were well. And really at that time, this was like five years ago, it wasn't hard work. It was like one hour of just connecting them and preparing them and teaching them. The big thing with child welfare was please tell the truth. Tell them that you need help. Tell them that you want to parent. And it ends up making that relationship not punitive, but more collaborative. And so we meet families prenatally and we're gonna kind of talk through Tani's journey about this. We meet them prenatally, help them with the social determinants of health, help them with parenting classes if they need them. We talk them through safe sleep. They get a brand new pack and play. We teach them car seat safety. They get a brand new car seat. We are able to do that because we work with community partners. Our health department supplies us with, and child welfare supply us with those resources because they know that families need to know these things. And I didn't have substance use disorder, but I sure wish someone would have taught me how to put a car seat in correctly. It is just all of those simple things, but meeting families where they're at and letting them know that we're not gonna judge them. You walk through the doors, you're scared to death. Well, how can we help? If you are struggling at that moment, how can I help? You need water, you need some food. I had a couple come in yesterday, very much struggling, living on the streets. We're helping them, we're giving them a tour, we're doing everything, and we're almost ready to let them out the door. And I walked by and I was like, can I get you some food? And the dad was like, yeah, that would be great. We're getting better, we're not great. But to just know that this family came to us and almost left hungry was something just very, very simple that we could meet their needs. And so it's just what helps them at that moment. Then we have the nursery. We have a 12 bed nursery here in Arizona that specializes with babies that are withdrawing. That is all we do. We meet the families, have them do nesting or rooming in, quiet, dark environment. Every caregiver that is at Hushabye chooses to work with this fragile population. It's not like in the hospital, and I was one of those nurses and nurse practitioners that working with a baby that was gonna cry 24 seven was not a good day. That was not what I chose. Somewhere in there, my love became these families, became these babies. I don't know where that's at, but it makes a huge impact on being able to heal the baby, but truly heal the family, helping them understand that look at what you did. If I can teach them all the things that I've learned to care for a baby and to soothe the baby, mom and dad can do so much more than I can. And to tell mom and dad that, oh my gosh, look at you. Look at how you were able to calm your little one. That's not hard. And what it does is it gives families that have had no hope at all a little bit, like maybe I can do it this time. I didn't think I could, but maybe they're not judging me. Maybe we can do this. And then after baby's here, I'll show you next slide, show you our green binders. We have these binders that we give every family when they engage with us. I have one here that came about when I worked with a family just starting out before our facility was even created. And I was working with the families at medication-assisted treatment programs. And I had one mom, my very first, okay, maybe not first mom, but one of the first mommies that I met and she was well. She had been stable on her medication-assisted treatment under her methadone for six months. She actually had 67 pages of negative drug screens. Went to the hospital, I'd prepared her. I said, you're not gonna have an issue. We're great. She had an issue. She did not have a green binder. She went in, her other babies, her other kids were out of home. They were going to be reunified that next month. The worker that she got did not know about the worker of the other kids, had no idea that the plan was reunification. And back then, they didn't talk. They didn't know. They went, okay, this mom's new to recovery. She's on methadone. Baby was removed. Seven months later, mom, baby, and the other two kids were reunified. It was communication. There was nothing. Had mom had this green binder, put all of her drug screens in there, put her caseworker in there, had them all be able to talk, we are getting better. But that is where the ugly green binder came from. And moms will tell us it's like their Bible. And what we have in there is all of the resources that they did, everybody's business card that they're working with. So Dr. Manrique has this big business card. Tawny had everyone that she worked with at Hushabye, everyone that she worked with at all of the other facilities in there. And what it happens is when you're in the hospital and families are scared to death and child welfare comes in, scared. They can't even talk. We talk with them and we do a three-way call and actually have parents tattle on themselves is what they call it, but they call in self-report. And Tawny will kind of tell you about that. But what we found is it makes DCS, Department of Child Safety, very surprised that the mom or dad called on themselves that they have a baby that's born substance exposed. It starts building the trust between the two organs, between the mom and DCS. And what we found is when they come in and they look at the green binder, they look at the green binder. They open it up and go, oh my gosh, who are all these people? And they realize that they've been connected to all these different supports. Next slide. I just have let you guys peruse what we're doing here, but our outcomes, I think my favorite outcome is in the bottom right. 79% of our families that are engaged with Hushabye prenatally take their babies home safely. And does that mean every mom and dad are completely well? No. Moms and dads can still be struggling, but what we've been able to do is help them have the resources, have responsible adults or safety monitors in place so that we can keep the family system together while mom and dad work to get well. The best motivator for someone that is pregnant and parenting is that baby. And if we can keep them together, the mom and dad are like, okay, I gotta do it. I have to do it. This is my motivator. It has just changed the world. It really, really has. And I'm not just saying Hushabye's care model, but really what we're all doing here in Arizona. We're making magic happen. And Tawny, I'm gonna let you share your story. I met Tawny, I was looking back, Tawny, trying to figure out when we were connected and it was 2018, I believe, is when we were initially connected. And we at first were connected with your mom and your sister trying to get you support. And they were kind of our first connections, but I'll let you start with what was your first, what is your first memory of even hearing anything about Hushabye? So I remember my mother and sister really trying, they were so concerned about me. I couldn't make a phone call. I couldn't get anything done. I was just not mentally stable enough to. And I remember them really telling me that there was somewhere to help. And they would send me like these little messages, like, hey, you need to call Clarissa at Hushabye. I talked to Tara at Hushabye. They have an OBGYN, Dr. Manriquez, that would be really great for you to work with. And I really fought the process in the beginning. I was not, I just, I didn't see that it was possible. And you touched on so many important subjects about it's scary. We think, one, we're gonna be so judged. Two, our babies are gonna be taken and nobody's gonna understand. And there's probably no other woman out there who uses pregnant because we're judging ourselves enough. So it's just such a scary process to get started. And I just remember talking to Clarissa, who's one of the peers here at Hushabye, for the first time and her telling me, I get it. I take methadone. I had my baby, my first daughter taken because I used while I was pregnant. And that like completely blew my mind away. It wasn't what I was expecting to have on my first encounter. So I was, it really planted a seed. I wouldn't say I got it right away, but I started taking little strides of, okay, I'll go into Hushabye and do the tour. Okay, I'll go meet Dr. Manriquez. And that really just like started that journey. Yeah, Chani, I'm just gonna tell everyone just a few of the resources that you were connected with. I was going through and I'm like, holy cow. And this truly is a collaborative approach. And if I can tell anyone, you never know when the time is right. And you never know what you say might be that one time that they go, I remember when Dr. Manriquez said this and I knew I could do it. And who doesn't wanna be that person that changed their lives in that time? I mean, Clarissa, I think if she heard that, she'd be like, oh my gosh, really? I just had to share my story and that was it. I mean, you guys did tons of work after that, but just a few places. You had Desert Springs LifeWell, ACOS Urgent Care, the HEAL program, Sally's Place. You did a car seat program, safe sleep program. You did your Greenbinder. I have it that you actually completed it. You had it all ready. You ended up getting your GED at Sally's Place. Can you just tell everyone a little bit about, initially you went to LifeWell, which was, I'll let you talk about that. Yeah, LifeWell was a 30, 60, 90 day program that accepted single women, pregnant women, women with children. They were just open to all of that. And I went there with great intentions. I really did. And when I left LifeWell after 30 days, I really thought I was never gonna use again. And that just wasn't true. I was still seeing Dr. Manriquez and I wasn't prepared to go back home to the same community, the same people, and just the same situation. I just wasn't ready for that. But I really thought, oh, I'm not going any more than 30 days because I also didn't want that either. And so, yeah, I left LifeWell and I did get high one more time. But there was something in that that I would say was that moment for me of like, wait a minute, maybe I don't wanna get high anymore. So LifeWell was a great starting point for me, but I also think I needed to leave and see that it wasn't enough. So, and that's how I ended up going to the HEAL program. You know, it takes a lot of steps. Yeah. That's exactly it. I think it, one of the biggest things that I see as families reach out to us, and I'm absolutely sure Tawny and Dr. Manriquez, you see it, is families have their guards up. And they don't trust us. And it's like, are you gonna judge me? Are you gonna say something? What is it? Because there's no way that you're going to just take me as I am and not judge. And I think that we see that every single day when they come in and they're like, okay, we were able to get through this. Maybe I actually can do it. With Sally's Place, tell me about that journey and what that program is. Because I believe that was your next place you went. Yeah. So I did try outpatient for a little while first, but it still wasn't really enough for me. And mind you, Hushabye worked with me through that whole process of like, so let's try this, which was really important to my journey. Sally's Place is through Arizona Women's Recovery Center. And it's actually a program specifically for pregnant women. And now women who have given birth recently, they take them as well. But it's, you have a crib, you have a swing, you have all the wipes and diapers. You don't have to stress over providing for baby while also trying to get sober. It is a much longer term program than a lot of them out there, which when I first started was really scary to me. I remember hearing one year and I was like, whoa, what do you mean? I'm gonna go there for a year. And that actually ended up being more like 19 months before I left, because I just wasn't ready yet. And the really awesome thing about Sally's Place is they taught me to be a mom again. I had a 10 and eight year old who I lost custody of for three years, and I didn't see them almost any of those three years. So they taught me how to be a mom again until I could fight to get those two children back in my life, and taught me how to then be a mom of three again. They supported me through so I didn't have to worry about financially how I was gonna provide. They helped me get an education. When I went there, I lost my driver's license. I had no GED or high school diploma. I'd never even thought of college being a possibility. And they helped me get my peer support license. I mean, they really built me up in those 19 months to where I could be self-sufficient and show up to a job on time. Because in my addiction, I forgot everything. I forgot how to pay a bill, how to pay a traffic fine, how to go to school. I just forgot it all. And so through that 19 months, I was able to give birth to my daughter and keep her, gain my kids back, gain a GED, gain a peer support license. And next I'm going to college. So it's like, I couldn't have done any of those things without them in the journey, yeah. Tony, when you talk about, can you tell me a little bit about when you went to deliver, what you were feeling? I mean, and going into the hospital and then a little bit about DCS and making that call. Yeah, that was definitely an emotional part of the journey. I only had, I think I only had two and a half months sober when I gave birth and I'd hoped for more. And so I was really scared going to the hospital and it all went very quickly. I think she was just born very fast. And so when it came time that I finally gave birth, I had to call DCS. And I remember Hushabye calling and saying, did you self-report? And I needed them to do that because I was scared of that. I'm like, what do you mean I have to self-report? That sounded crazy to me, but it worked. As a matter of fact, my peer mentor had me on hold and three-wayed the phone call into DCS. While I'm crying, I'm telling them, utilizing the green binder, because in that binder is a DCS kind of script that tells you how to communicate to them your journey and what you're calling for. And I needed that because I wouldn't have remembered what to say otherwise. And in the end, they came to see me here at Hushabye and my case was closed because I was able to show them how long my journey went with Hushabye and Dr. Manriquez and just the whole process. And that worker told me she was proud of me for self-reporting, you know? And I never thought I would hear those words. So it was scary, but in the end it ended up great because I did do everything that I was kind of, all the suggestions that I was given. Yeah. Yeah. You like make me tear up every time. And so when you're talking about Sally's place, let's go back to that. You end up having your sweet baby and we'll show you in a little bit, everyone, so you can see her beautiful little girl. How was it here at Hushabye? What did her withdrawal look like? Yeah, so the hospital, I had planned to give birth at Banner University, but my labor kind of started in the middle of the night and I went by ambulance. So I had to go somewhere else, which was not a part of the plan. And at that hospital, they actually told me she wasn't withdrawing. And I didn't feel like that was true. Her hands would shake a little bit. And they were like really telling me that it was normal. And just something in my gut told me no. And I really pushed to go to Hushabye. And as soon as I got there, I believe you were here and you looked at her and you said, no, you were right. And I felt so much better just knowing that I was somewhere that like, that they just knew how to handle what was going on. And that made me feel better as a mom. And it was very comfortable. I was supported, I was clean. So I was able to breastfeed and I was just supported through that whole process. I never left her side, which was also very important to me. And Sally's place, I was on buprenorphine. So I was able to take my medication here because I was a part of Sally's place and they could bring it to me. And so I never had to leave her. And everybody was so comforting. I remember being very tired at one point and I wasn't sure about letting the volunteers hold her until one day I was like, you know what? I need a shower, I need a nap. And they held her for me. And one night nurses fed her because I was so, I wanted to breastfeed her so badly that I didn't really want anyone else to feed her. And when I was ready and I needed the help, they were there for me. And I was able to get that rest until the day that I finally did leave. So it was just a really great experience and there was never judgment, anything like that. So it was great. So where are you now? What are you doing now? So I- What is your goal in the future? Yeah, so I did graduate Sally's place and I did get my high school diploma and I'm working on getting certified in lactation because I want to help moms specifically who are on MAT services. And I'm also looking into possibly being a substance abuse counselor. But now I am working at Hushabuya as a peer support specialist, helping other moms and getting to tell them, my baby came here, you know, I understand how you feel and I want to help you. And that's just like the most amazing just thing that I could ask for. I still live in supportive housing through Arizona Women's Recovery Center, rent-free for a year while I save up and get some schooling in and I'm ready to move on. And I'm buying my first vehicle in recovery this weekend and just things are awesome. I didn't know that one. Yeah. I'm so excited. Yes. Okay. Thank you so much, Tawny. If you want to grab your sweet little one and we'll go to the Q and A, but I know everybody wants to see her. And I know just so everyone knows, she may last just a little bit with us because she's a walking and chattering, but thank you for the opportunity. And Tawny is amazing. She worked really, really hard to get where she's at and we're just lucky to have been just a little part in her journey. Oh, she almost closed it. My gosh. Thank you. Thank you. Thank you, Tawny. I hope you're seeing all the love going on in the webinar right now. Yeah, I'm kind of speechless. So thank you. And Tara, thank you for facilitating like incredible conversation right there. That was so naturally well done. And thank you, Dr. Manriquez for a very comprehensive and informative presentation. I think it was the perfect mix. So we do have about, let's see, nine minutes left and we have gotten a flow of incredible questions come into our Q and A box that we unfortunately won't be able to get to all of them. But I'm going to start off with one question that we got. So I think this goes for any of you from any different perspective that you have, but do you talk to the parents about different protective factors at any point in their journey? So, yeah, we definitely acknowledge that use disorder is a chronic relapsing medical condition. So just like diabetes or hypertension, if you don't continue to use the healthy habits, you're going to be faced with conflict that can lead to relapse. And so the healthy habits, particularly with use disorder is the counseling. And counseling takes a lot out of you, takes a lot of emotional energy, it takes time. And so people, when they get feeling good, that's one of the first things that they want to let go of. And we really, really, really encourage them to stay with it. And often they've developed a good relationship so that they're able to continue that. But it's also one of those things too, if they do have relapse, the moms will be very reticent to stay in that relationship. And I think they just have to get comfortable with knowing that there's no judgment. We just, we want to continue to keep you healthy. I would say, yes, we do all of the above. I think it's a matter of figuring out what's right for the clients. And if that's group therapy, if that's just meeting with their peer support, if they're ready to take like a formal triple P parenting class, if they're able to do that, we all need to realize that everyone's in a different stage of recovery. And it may be as Dr. Manriquez said, a relapse, but I had a mom the other day say, it's a lapse. It's a lapse in my recovery. And I was like, that is amazing. It is just a little lapse. It was like an oopsie. And if we can help families know that they're going to be oopsies, and if we can make it dumbed down enough, like I go on diets and I always have a lapse, always, no matter what. And if we can just go, okay, you did, let's pick you up. Let's pick you up from where you're at and make it so it's not that you spiral out of control. And hopefully one of the community partners will have developed that trust with this family. When they need it, they'll show up on our doorstep. And we see that all the time. Awesome. Thank you both. Another more technical question we got is, is there any advice on treating methamphetamine addiction differently now that much less most of the tests test positive for fentanyl? I'm not sure exactly I understand the question. Is it treating both because there's contaminants in the methamphetamine or? Yeah, I think that was the direction of the question. We definitely will send out, and I just recently was able to identify a cup that has fentanyl in it. I mean, screens for fentanyl. You can get fentanyl strips or you can get new cups that have fentanyl that is identifiable. But we would send out all our urines for fentanyl, even if it didn't have opioids or any of the opiates on the cup, because you do need to know what you're dealing with. It's going to make a difference in what medications you're using. So first we try to be as transparent and ask patients to be as transparent as possible with no judgment. And then if we do identify fentanyl, we address that. Similarly, as you know, there's not a whole lot out there or may not know, there's not a whole lot out there for methamphetamines in particular, some studies on bupropion and some of the other medications. That said, I found it interesting and purely anecdotal that many patients have far less trouble ceasing using methamphetamines than they do opioids. And so interesting given the fact that, you know, the level of dopamine that gets released with methamphetamine is significantly higher than opioids, but that brings us back to that comment I made earlier that patients are really trying to avoid the withdrawal symptoms. And the withdrawal symptoms for opioids is very different than the withdrawal symptoms from methamphetamines. And so that may be part of why they're able to stop use. But yeah, we do check for the fentanyl. Okay, thank you. We have time for one more question. So this is, what is the safest way to start a pregnant person on buprenorphine? Sorry, my pronunciation is terrible, but I assume a micro-induction to avoid withdrawal. If this is not possible, is it safe to start bup at home or is it a medically supervised induction? There is a medically supervised induction advised. Oh, so we have to come back to part two. Yeah, I was gonna say, can I just start, like when we've had, just a scenario. We have families that come to us that are not well, and they've had babies, they're with us at Hushabye, and we have been lucky enough to work very closely with Dr. Manriquez and a couple other community partners that sometimes we can do it, the induction telehealth. Otherwise we're able to do that really quick warm handoff of Dr. Manriquez, do you have an opening tomorrow or which hospital should I send them to? And then Dr. Manriquez, I'll let you go from there. But what we found is to be most successful is you gotta be quick. When they're ready, it is an hour time, and you have to make it be able to follow through. So you need to get them transportation, you need to get them there. If we had peer supports to actually go with them there, we're not there yet, but that would be ideal to sit with them. And then Dr. Manriquez, I'll let you talk how you do it, because it's amazing, it works. I was just responding to Anna Greer's question in how to, I specifically will reach out to medical directors if I need to get higher doses of buprenorphine or more frequent dosing. So that's what the typing was about, but the effect of which is the best and safest way, it's the way that works. At the end of the day, it's the way that works. And so I have been more and more microdosing patients, outpatient, and if that works, we're done. And we just continue with their regular dose. If that doesn't work, then we'll likely go inpatient. I try to get them as early as possible started so that they can be on stable by 20 weeks, because that is reflective for DCS as well as for the health of mom and baby. But we will be talking about that at the next webinar on how specifically we dose, and then the challenges of other substances that may be not uncommon for the patient to be on benzodiazepines or Xanibars from the street. So a lot of different options to use. But yes, I tend to trial patients first on a microdosing outpatient, particularly if they're less than 20 weeks, and then if they are unsuccessful or feel like they just couldn't do it, then we can trial a rapid induction inpatient. And then there's the traditional induction, which takes about seven days, and that's inpatient. But we've been using a rapid induction inpatient. And I'll explain that next time. Well, that's all the time we have for questions. And we have a quick few logistical slides to run through if anyone has time to stick around for one minute. But again, I'd like to thank Dr. Manriquez, Tara, and Tawny for presenting today. We're just so appreciative of your willingness to share your knowledge and expertise with everyone. As a reminder, the recording and slides will be posted on the PCSS website within two weeks from today. This is regarding our PCSS mentoring program, which is designed to offer general information to clinicians about evidence-based practices. You can learn more about this mentoring program at the website on the screen. And then if you have a clinical question, you can just ask a colleague through the link below. This is also provided by PCSS, and it's a way to directly receive an answer to medications for opioid use disorder. Well, I have a question. Will we get these questions, so hopefully that we can address some of them with the next presentation? Yes, I can pull the questions on my back end. Just unfortunately, they will not be made public, but I can share it with you all internally, yeah. Great, thank you. Yeah, no problem. And then just a shout out to our collaborative partners here at PCSS. So here are all of the partners that we work with at PCSS. And yeah, just thank you all so much for joining today. That is the end of our presentation. And here's all of the ways that you can access PCSS resources. So thank you all so much for joining, and I hope you have a wonderful rest of your day. Thank you, guys. Have a good day.

Opioid Use Disorder

Pregnant and Postpartum People

Providers Clinical Support System

National Council for Mental Wellbeing

Coyle Shropshire

Dr. Maria Manriquez

Tara Sundom

Tawny Carson

Neonatal Nurse Practitioner

Peer Support Specialist