Okay. All right. Are the slides showing up correctly, Sarah? Nope. No. I need to switch the view. Yep. Oh, we get, we see your next slide. Okay. We just learned how to do this in the previous meeting. If you would like assistance. Yeah. Display settings. Yeah. There's another way for me to. Do this, which I just have to. Maybe not. Okay. Let's just do it. Okay. So let's just do it this way. Yeah, that's what presenter view inside show should do it. Yeah. Sometimes I just share my other monitor and then it just fixes the problem for me. Not today. Let me share my other monitor. Okay. So I'm going to pause for a moment because I, I put in some Slido slides to hopefully. Make it a little bit more engaging and interactive today. If you are on your phone and can't participate in those, feel free to come off mute and just shout your answer out. So today we're going to talk more specifically about substance use in pregnancy. The goal last time was to kind of. Give the lay of the land of what are people using? What are substance use disorders? And then how to ask about substance use during pregnancy. So the background of our in. That you can glance through it and know Sarah talked through this last time we met. And so what we're going to do today is talk about the prevalence use of substance or the prevalence of substance use during pregnancy. The impact of substance use on maternal fetal and infant health. And then how to ask about substance use during pregnancy. And so that those are really the goals. Okay. So to talk about substance use during pregnancy, the first question I have for you is what are the most commonly used substances during pregnancy? You can either. Use the Slido and throw it in. By scanning the QR code, or you can just shout it out. I want to say meth, but that's going back to California. So I don't know. Methamphetamines? Correct. Fentanyl. Fentanyl. We think marijuana. Marijuana. Think broadly, what are the most used substances overall? Alcohol. There's one more very common substance. Nicotine, smoking, smoking. Exactly, nicotine. Yeah, exactly. It's like we got two more people typing in an answer. Nicotine wins the day. Okay. Caffeine. So when we talk about substance use during pregnancy, this is from the National Survey on Drug Use and Health. So this is an annual survey of housed people. So the one caveat to this survey is that it will not include people who are homeless. And it estimates substance use and mental health problems of people that are age 12 and older. It's not as accurate in the younger age range as like Monitoring the Future is when we talk about adolescent substance use, but this is a pretty good measure of adult substance use. So when we look at past month substance use in those age 15 to 44 from 2017 to 2020, and this data here is specifically from pregnant women, what you can see is in 2020, roughly 8.3% of pregnant women reported using any illicit drug. And that's gonna include marijuana. Actually, the bulk of that is gonna be marijuana. And you can see that kind of broken down in the bottom panel there where 8%, so well over 90% of those individuals, 95% of those individuals, what they're using is marijuana. A small portion of them are using opioids and an even smaller portion using cocaine. Those rates have remained relatively steady. Actually, fortunately for us, the rate of pregnant women using opioids has actually decreased over that time period during the fentanyl epidemic. So that's a positive that some messaging there may be working. Tobacco obviously is one of the most commonly substances used. We often talk about it, nicotine now, because vaping has become so prevalent, but about, and I would say that this estimate is probably low. I'd have to go back in and see if this includes vaping, but my guess is it does not based on how low these numbers are. But tobacco products, it's about the same, about 8.5%. And I would estimate the number, actually vaping is probably closer to 20% or maybe even slightly higher. And then alcohol use, the estimated prevalence in 2020 of alcohol use is about 10.6%. And you can see tobacco products messaging. We've had very aggressive messaging around tobacco products in the United States and rates there have declined, whereas rates for alcohol and marijuana in particular, the two other most common substances have remained relatively steady. And that's fairly true over the last decade. So when we talk about alcohol use during pregnancy, about 10% of pregnant women report current use of alcohol and half of them binge drink. So do you recall the definition of binge drinking? Have you guys heard the definition of it before? No, it's a lot less than we think. Yeah, I actually love asking this question to teenagers when I'm meeting with a teenager that drinks alcohol. I'll say, how much alcohol at any one time is too much? And I think my favorite answers so far have been 20 beers. I was like, yeah, that's a lot. And two bottles of vodka. And I was like, that is also a lot. And so teens give you some crazy number. So for women, too much is four drinks at a time. And what we mean by that is four drinks within two hours. Binge drinking, so the liver chews up alcohol at a set rate. So imagine that alcohol is a block and the liver can chew up 100 blocks every hour. It can pretty much do that at all times in anybody. So if you drink 100 blocks of alcohol in an hour, it chews it all up. If you drink 150 blocks of alcohol in an hour, it chews up 100 of them and 50 of them are too much. And so binge drinking is the amount of alcohol you drink in a two hour period that basically overruns the liver's ability to chew it up and get your alcohol level, your blood alcohol level to 0.08, which is the legal limit. So that's where that comes from. So for women, it's four drinks. For guys, it's five drinks. But that's important to know when you talk to people about binge drinking. Sometimes that's an easy harm reduction intervention is how much is too much and then educating them about what is actually too much if they're not ready to stop drinking. Alcohol use is highest during the first trimester. Why do you think that is? Because they don't know they're pregnant. Yeah, they don't know they're pregnant. And so we'll talk a little bit about how to ask women about whether or not they're using substances. But if you come right out and ask a woman, are you using alcohol during your pregnancy? They're gonna say no, probably whether or not they are because that's the right answer. But it doesn't mean that's what's actually happening. So we're gonna talk about strategies. 20% currently use and 10% binge drink. So fairly similar. 75% of people, I thought this was really interesting actually from the National Survey on Drug Use and Health. 75% of people who are trying to get pregnant, so they're actually trying to get pregnant, don't stop drinking at that time. And so there's a chance that they're going to be drinking when they find out that they're pregnant in the first trimester. 40% of pregnant women who currently drink report using other substances. And then chronic alcohol use leads to decreased intestinal absorption of folic acid. We all know about folic acid supplementation and how important that is in preventing birth defects, especially central nervous system and spinal cord defects in newborn babies. So marijuana use. When we talk about marijuana use in the past 12 months, and this is just looking at women. And on the left, you have pregnant. On the right, you have not pregnant. And what we see is there's actually a trend in this age range from 15 to 44 of increasing marijuana use. And so we often talk about, well, marijuana use wasn't associated with increased rates of prevalence. And that may be true in some age populations, but in 15 to 44, and especially in 18 to 25, when they're still undergoing brain development, that's not true. And so we are seeing these increases in substance use, specifically in marijuana use, that are also translating potentially over to pregnancy in terms of prevalence. When we talk about those who use daily or almost daily, so you can see that it's not an insignificant number. It's roughly a little over a third of those who are pregnant that use are using daily or more. And similarly, a good fraction of those, just under half of those who are using that are not pregnant or I guess about almost about a third as well, who are using, who are not pregnant are also using almost daily or more. The other thing that we talk about when we talk about marijuana or cannabis use during pregnancy is who's using. And so when we look at data from 2002 to 2014, this was a study that was done by Brown and published in 2017. What we can see is overall, the prevalence of marijuana use when we zoom out and look at over a 12 year period has actually increased among women. But that biggest increase has been among the 18 to 25 year old group. And the reason that that becomes really important is because when you're working with a young lady who's 18 to 25 and she's pregnant and she's using marijuana, you have two people being impacted by the marijuana use. You have both the unborn baby being impacted by the use and also the young woman whose brain development is ongoing. Part of the challenge that we have specifically when we talk about marijuana in pregnancy are these kind of perceptions that there's some harm or some benefit to it. So roughly 15 to 28% of young urban, low socioeconomic status women use marijuana during pregnancy. 34 to 60% of users continue to use and many even believe it's safe. And that can be in part because there's some messaging that we have medical providers in the communities who even though every professional organization has released statements about the harms of using marijuana during pregnancy, we have medical professionals who will actually recommend it to women as a way to control their nausea or morning sickness and disregard the harms in the professional standards that are in place. It's further complicated. So it's further complicated by that. We also have about 18% of pregnant women who then meet criteria for cannabis use disorder. So they have problems regarding their use but they continue to use during that time. So that's a little bit of a background about what are the most prevalent substances that are used and how often are they used in pregnancy. But as we talk about substance use disorders, sometimes we think about, okay, well, substance use disorder. So there's a problem, you're pregnant, you gotta stop using substances. And so we gotta get you to just stop. And I think it's important to remember that substance use disorders are a chronic disease, whereas pregnancy is a temporary condition. And so it can be really hard for someone who has a chronic disease to just all of a sudden not have a chronic disease just because they're pregnant. And that obviously, there are a lot of reasons that we want them to cut back or stop their use, but we can't discount the challenge of what we're asking them to do. So women who are between the ages of 18 and 44, they're actually at the highest risk of developing a substance use disorder. And so that gives you kind of an idea that this is your highest risk group for developing a substance use disorder, also the group that's most likely to become pregnant. Roughly over the decade from 2007 to 2016, about 7% of mothers who gave birth in hospitals were estimated to have a substance use disorder. So how does that compare to other chronic diseases that affect pregnancy? Just to give you an idea, diabetes affects about 7% to 11% of pregnant women, hypertension about 1% to 5%, and depression and other mood disorders affect about 10% to 20%. So substance use disorders would fit within the range of what we consider common chronic diseases that can affect pregnancy, but we don't treat it like it's a chronic disease that can affect pregnancy. We treat it a little bit differently. And does that potentially cause harm to the way that we talk about it and the way that we interact? Part of the reason that we interact differently is because of the impact that substance use can have, not only on the mom, but on the fetus and the infant as well. So again, use your phone or shout it out, but what are some of the effects of substance use during pregnancy? birth retardation that type of thing is that what you mean yeah so effects on either effects on the pregnancy itself or effects on the on the baby dependence for the baby the withdrawal yeah so withdrawal after birth dependence under development so there are a number of a number of effects that substance use can have on pregnancy so there are complications of the pregnancy itself premature birth eclampsia eclampsia if you're not familiar with it is a life-threatening condition where the woman gets uncontrollable hypertension it is an increased risk of seizures and so the only way to treat eclampsia is to deliver the baby whether that's by c-section or inducing labor the baby has to come out there's pre-eclampsia which is treatable but by the time we get to eclampsia the baby has to come out that's the only treatment that there is and then there are also placental problems that can develop unexplained death of a baby during sleep which is also known as sudden infant death syndrome is also more common if they were exposed to substances in utero children taking longer to reach milestones such as speaking or walking withdrawal was mentioned so infant drug withdrawal after birth we often called this neonatal abstinence syndrome but that terminology is kind of going away because it doesn't make a lot of sense to say the baby's now abstinent from drugs when they weren't really using it by choice in the womb and so that's part of where we like well what language is stigmatizing and not helpful so we now often talk about it as a withdrawal syndrome rather than an abstinence syndrome and then birth defects and so there are some congenital and anomalies that are more common in babies that are exposed to substances so we're going to dive a little bit more specifically into cannabis use and talk about some of that there's a couple of reasons we're going to do that one is oftentimes people misunderstand or don't understand the impacts of cannabis use during pregnancy whereas alcohol we generally have a better understanding of and people are generally aware that you're not supposed to drink while you're pregnant cannabis also gets a little bit complicated in several states because it's considered medical and so people think well it's it's you know it's medical I can use medicine while I'm pregnant so they're less likely to perceive harms than with other substances but it also illustrates nicely the impact of perinatal substance use during the pregnancy on the fetus and the postnatal impact on child development and so we'll go through some of this together the reason that substances can have an impact early in development is you know obviously when the egg is fertilized you start as a one cell than a two cell then slowly expand out to a multi-cell organism we have multiple major structures that start developing very early in development so by week 3 the central nervous system has started as well as the heart and you can see that that progresses all the way up so in the first trimester when you have the fewest number of cells and you have the foundation of these major organs that's when substances can have their most detrimental effect so that's why substance use during the first trimester can be really really impactful when we talk about the endocannabinoid system which is the system that cannabis specifically THC works on it's expressed in an embryo as early as 16 to 22 days gestation so by 16 to 22 days an embryo or a fetus exposed to THC that THC will have an effect on how the embryo is developing cannabinoids are lipid soluble that means that they can go anywhere they want there's really not a cell in the body that can keep them out the placenta can't keep them out they can cross all the barriers that the body has and they just kind of go where they want so approximately one-third of the THC that is absorbed into the plasma of a woman will cross the placenta into the baby so that's not an insignificant amount and so if someone's using quite a bit of marijuana that's a fair amount of THC that's actually going to make it across the placenta into the baby well we talked specifically about well what is the endocannabinoid system do why does substance use matter there's a couple of components so the endocannabinoids themselves you can see here anandamide which is represented by AEA and then Delta 9 THC which is one of the psychoactive cannabinoids the one that gets you high in marijuana and what this diagram is meant to show you is that the endocannabinoid system plays a role in almost every stage of fetal development and pregnancy plays a role in fetalization and fertilization implementation plays a role in determining which embryonic stem cells become brain cells and then once they do all the roles of brain development it plays a role in so it plays a role in them migrating to where they're supposed to go turning into the type of brain cell they're supposed to become developing axons and forming the connections that they're supposed to make and so this is a system that's very that's very vulnerable to the effects of cannabis use and part of the reason that that is is because endocannabinoids like anandamide are made on demand so the cell makes it releases it the signal last seconds and then that signal terminates and it's turned off when someone uses marijuana that exogenous THC that thing goes into those brain cells that signaling last minutes to hours and rather than being in one specific location it's it's diffusely across the brain and so it can really interfere with the signaling of this system when we talk about what could that do what sort of effects could that have when you when you're born when a baby's born they basically have as many brain cells as they're ever going to get you're kind of dealt the full deck of brain cells and then after that over time you start pairing brain cells back and you start connecting connections between them and so that's why babies start to gain abilities like being able to walk being able to talk it's because those pathways in the brain are actively being selected for and reinforced during development well one of the systems that helps determine that is the endocannabinoid system so having been exposed to THC will affect how that system works it's also responsible for developing neurotransmitter systems in the brain serotonin is the one we often talk about with things like depression anxiety and trauma disorders dopamine and norepinephrine are the ones we often talk about when we talk about things like psychosis and ADHD or inattention and so we can see that there are multiple places where this can start to affect cognitive and executive functioning so talking specifically about pregnancy itself cannabis use during pregnancy is associated with lower birth weight more likely to be admitted to a needle a neonatal ICU higher stillbirth smaller head circumference and you can see there's kind of multiple things that can happen right at birth and then the rest of these are things that happen that we learn about as the child develops and so we'll talk a little bit more specifically about that but there were there were two very large longitudinal studies that were done one was done in Montreal the other was done in Philadelphia and they started in the 70s or early 80s and what they did is they followed women who were pregnant through their pregnancy and then they followed those babies up into young adulthood and one of the things that they wanted to look at in this study was what were the effects of marijuana use specifically on infants children and adolescents as they developed and this is a this is a figure that we published summarizing these two studies what you can see is in infancy the babies that were exposed to marijuana in utero they were more likely to have a higher startle response and be more irritable which is not everybody's favorite thing in a baby and and have changes in their sleep by the time they kind of aged in the childhood more likely to be impulsive or hyperactive experience depression lower cognitive functioning in terms of reasoning and sustained attention and then by adolescence more likely to use substances and be impulsive and so you can start to see that there are definitely some trends that develop over time that then continue to get reinforced as these youth age when we talk specifically about some of those cognitive effects and what's the impact that they have it honestly it doesn't actually take all that much to have an impact so for example if we look at three to four year olds and we look at short-term memory impairment you have a drop of about one to two IQ points for every joint that someone smokes per day and so if you have a woman that's smoking three joints a day that would be three to six seven IQ points that could be dropped for verbal reasoning similarly 1.5 IQ points per joint per day so they were really able to get down and finally measure this now the caveat to that is back then when this study was done a joint was about four to six percent THC now in Colorado and in Washington who supply a lot of the marijuana to Idaho those joints are routinely 20 to 25 percent THC so these numbers wouldn't even compare to today's marijuana but that gives you an idea of what they were able to see and similarly we looked we saw dose-dependent effects and five to six year olds with with use rates as low as six joints a week so not even an average of a joint today was able to have was able to have an impact increased hyperactivity was also less than a joint today by the time they were 10 and so definitely some significant impacts that marijuana use can have so as we think about how do we apply this so this is we'll call it we'll call this young lady Jessica she's 22 she's 10 weeks pregnant gestation or 10 weeks gestation with her first pregnancy which was unplanned before she found out she was pregnant she was drinking two to three alcoholic drinks every night and vaping THC most days since finding out she was pregnant she gave she's gave up one drink to once a drink once a week so she's cut back on drinking quite a bit and she now uses cannabis edibles every morning for nausea and vaping THC throughout the day to manage the stress of her pregnancy so as you think about Jessica what's something that you learned about cannabis use during pregnancy today that you might choose to share with her as you're working with her the effects on the baby, maybe potentially how there's more THC in a joint and kind of work toward cutting her back and trying to... To try to work with her around the long-term effects it could have on the baby. Long-term effects on the baby. It's not just going to be immediate, it's going to be long-term. Yeah. We have one person typing. Anything else that anyone wanted to throw out there? Well, there we go. Brain development of under 25. So, yeah. So talking to her not just about the effects it could have on the baby, but the effects that it could have on her as well. So all very good. Okay. So now we're going to switch over. That's the deep dive. We're not going to go as deep on the other substances, but that's one that I think is really useful because people don't know as much about it, and people often have the misconception of being told, oh, use it for morning sickness. And so I think it's a good illustration of some of the science that we talk about, but also really good to get some more information to know how to message around those things where maybe a little less is known. Okay. So I have a quick question. Are you finding that most recently since cannabis has been legalized in Oregon that we're seeing more of cannabis use in pregnancy since it's a lot easier to go to Oregon versus Colorado? Yeah. So Oregon, Washington, and Colorado all have fairly similar cannabis products. And so, you know, having lived in Colorado for years and Colorado and Washington being first to legalize, those are often the two that I use as an example, but pretty much most states that have legalized marijuana have similar products. And so rates, when you look at the United States as a whole, taking states that have legal marijuana and states that don't, use rates in young adults and middle-aged adults have gone up over the last decade. And so that's true in Idaho. It's true across the United States. When you look at states that have legal marijuana, so if you were living over in the Boise area, really close to Oregon, this might be more true than maybe somewhere in the middle of Idaho or somewhere that's a little bit more rural. But when you look at states that have legal marijuana, the rates of increase over the last decade are higher than they are for the general population, for the general United States. So that increase has more of an effect if you live in a state where it's legal. But it's going up generally across the board. So that's definitely the impact. And the reason that legalization had such a big impact on marijuana products is because we commercialized them. We made it a multibillion-dollar industry. And so, you know, some of the scientists at the local companies, they actually used to work for pharmaceutical companies. So they're actually really good at making compounds that are addictive and that deliver very, very fast. Yeah. Yeah. Okay. Other questions? Okay. I just wish they had more information about it. I mean, we all know alcohol is bad for you, but, you know, when you're pregnant. But I just haven't seen that around pregnancy whatsoever. So hopefully we can bring that out there. Yeah, and that may be some where it may be worth looking at some resources that have been developed in states like Oregon, Washington, and Colorado, because they're very much in the trenches of having to combat these messages. Right. And so there may be other resources that are out there, particularly in those states that are geared towards specifically targeting messaging around this. Okay. Yeah, for sure. So for example, like in Colorado, a couple years ago I was part of a work group that we passed a law that a warning label had to be put on high concentrate cannabis products. And so this was part of the messaging that we put on that warning and on that information sheet. But by the time that somebody is getting their marijuana in Idaho, is their dispenser nicely bringing along that information sheet and saying, here you go, here are the warnings of what you're about to use? But the dispensaries are supposed to be giving that out in Colorado, for example. So there definitely is more messaging in those states because they're in the middle of addressing it. Interesting. Okay. So when we talk about alcohol and for the rest of the substances, we're going to kind of break it down and talk briefly about what are the effects on mom, what are the effects on the infant, so that you kind of have both of those in mind and thinking about what they can do. So with alcohol, the most common effects that we see in the mother are vomiting and dehydration, high blood pressure, nutritional deficiencies, and gestational diabetes. When we talk about high blood pressure, the risk of that is it can develop into preeclampsia, which can then develop into eclampsia. So it can become a life-threatening condition for the mom. When we talk about the infant, we have a lot of data around what happens with alcohol. So miscarriage rates are higher, preterm birth, higher congenital anomalies, we know a fair amount about, and developmental disabilities. And we'll talk about those two in combination here in a minute. But then this is also one of those populations where we definitely see higher prevalence rates of sudden infant death syndrome. Alcohol compared to other substances used during pregnancy is unique in that it has a developmental disorder associated with it, and it's called fetal alcohol spectrum disorders, or FASD, is what you'll sometimes see written for short. And what this is is this is a constellation of congenital anomalies and neurodevelopmental disorders that affect youth to varying degrees. So some of these youth, they look a little bit abnormal. When I worked at Children's Hospital, we used to say diagnostically that if the child was adequately funny-looking, you could tell that they had a congenital anomaly of something like fetal alcohol syndrome because their face just looked off. And that's often a place where we can see a lot of these features first. But some of these kids with fetal alcohol syndrome, they actually function at pretty normal levels cognitively, and then others of them have severe developmental delays and cannot maintain independent living. And so that's why it's a spectrum disorder. It's a very broad spectrum of disability from mild, almost no effect, to quite significantly impaired. So when we talk about this, and this is another young lady we'll talk about, Salisha, 34-year-old, started having abdominal pain and nausea and was seen in urgent care where she found out she was 18 weeks pregnant. She's been drinking wine coolers every night to unwind. When meeting with Leisha, she's scared about the impact of drinking may have had on her unborn child. So how would you support Leisha? You know, she didn't mean to drink while she was pregnant, but she did. I'd evaluate if she was willing to stop drinking now on I would try to give her resources potentially if she does have a dependence would communicate with the physician on you know they would be aware so would you know what good ultrasounds show and basically where she's at with development of the pregnancy and you know whatever resources I could provide her yeah absolutely I mean I think this is a good example of someone who didn't mean any ill will to an unborn child not that anyone really does but certainly had no idea and if she has a chronic you know disorder she has an alcohol use disorder getting pregnant and unexpectedly can make it really hard for her to then figure out how do I get sober I think sometimes coming in from a supportive angle can be really helpful because it's going to bring their defenses down obviously if you tell Alicia hey you're not supposed to be drinking she already knows that she already feels guilty about it and so I think taking that approach of how do I come in alongside you and help support you and offer these resources I think can be really helpful so let's take a slightly different angle so this is Emma she's 28 20 weeks pregnant with her third child she's continued to drink one bottled cocktail most nights and have a few drinks on the weekend so she's still actively drinking during her pregnancy she's cut back when asked about her drinking she gets very defensive and states that she drank all the way through her first two pregnancies and her kids turned out just fine so what would you say to Emma I think we could start with finding her other things to find her relaxing things to do at night, so maybe a warm bath, you know, maybe some kind of support group, even if it's just for single moms, if she doesn't want to talk about the alcohol thing, but somewhere that gets her mind off of the drinking in the evening that will help, maybe something like that. Yeah, so maybe even not taking on the drinking head-on right now because she's clearly resistant to that, finding other ways of supporting her, other ways of helping her cope with the stress that she's experiencing, and hopefully as we start to alleviate that stress through some of these other means, maybe she stops drinking or becomes more receptive to stopping. So I think that's a really good idea. Rather than fight you over this and getting into a power struggle, how do I support you in other ways that might create the conditions in which you'd be willing to stop or come back? I think it's really important that you come across to her as non-judgmental too because you won't make a difference unless you come across that way. Yeah, absolutely, absolutely. Smile when you're talking. Smile when you're talking. And we'll talk at some point about motivational interviewing and the skills that we use are broadly applicable, but they're certainly applicable to situations like this. One of the messages that we would certainly want to give both women and anyone who drinks is it's never too late in pregnancy to stop drinking. So we have data that if you stop drinking at any point, that's better than continuing to drink throughout the pregnancy. And so especially for our first friend who had not intended to drink during pregnancy, that might be a really supportive message for her. It's not too late to stop. It doesn't mean that something might have happened, but we can give that supportive message rather than fixating on what could have happened. We can really give a supportive forward-looking message of it's not too late to stop. Okay, so switching over to nicotine. Most of the data that we have about nicotine comes from cigarettes, not from vaping. So vaping nicotine is very different than cigarettes. And nicotine itself is a Category D substance. So the FDA rates every substance and says, what's the risk to use during pregnancy? And that's where the category comes from. So if something is a Category D, what it means is there's positive evidence of human fetal risk based on adverse reaction data from studies that have been done in humans, but potential benefits may warrant the use of the drug in pregnant women despite the potential risks. So that's D. So C is we don't know. A and B are various levels. It really doesn't do any harm, probably doesn't do any harm. And then E is don't do that. And so this is in between and says, well, it does cause harm, but we don't always tell people not to use nicotine during pregnancy. So do we recommend that women continue smoking nicotine during pregnancy? No. No. No. No. Okay, lots of people are saying no. That's good. I'm glad no one is saying yes or maybe. There you go. Hey, I mean, there was a time, right? Healthcare. When I worked at the VA back in the day, we had a birthday cake and we realized that no one actually had a lighter or matches in the physician and the physician workroom. And so we walked out to the nurse's station and the nurses at the VA, they would wheel the patients outside and they would smoke with the patients. And that was very common in the culture at the VA. And when they banned cigarette smoking at all hospitals and medical facilities in Iowa, which is where I was living at the time, the state lawmakers actually lobbied for the VA to be excluded from that so that the staff could still smoke with the veterans on the property. And so they did. That's where we went to get a lighter. We went to the nurse's station and asked for a lighter because we knew they were usually the respiratory therapists that have the lighters for the smoking. I'm just going to say that. There you go. There you go. So when we talk about the fact that it's category D, we're going to talk about why that is here in a minute. But smoking cigarettes in pregnancy. So again, when we look at the effects on mom, effects on the infant, so ectopic pregnancy. So that's a pregnancy that the egg gets fertilized, but not in the uterus. And so it's in the fallopian tube and makes it somewhere outside of the reproductive tract altogether. That is a life-threatening condition over time. And so that pregnancy has to be aborted. They have to give you a medication to abort that pregnancy. So when you talk about states that have absolute abortion bans, can't do it for any reason whatsoever, some of those bans actually include ectopic pregnancies. And that can put the mom's life in immediate jeopardy if we're not able to do something to treat that. And so when people talk about, wow, this is really, you're putting mom's life in pregnancy or in harm's way, that's one of the conditions that they're talking about. If it's an absolute ban with no exceptions whatsoever, not all pregnancies are actually within the uterus where it can be safely carried and developed. Placenta previa is basically where you have the placenta kind of blocking where the baby needs to pass through. So that's not going to be able to make it out safely. Placental abruption is where the placenta prematurely disconnects from the uterine wall. So that's baby's lifeline. So if that disconnects, obviously the baby's not going to get nutrition anymore, but it can also cause a significant amount or even a life-threatening amount of bleeding within the mom, within the uterus. And then premature rupture of membranes, which can obviously lead to infections within the uterus, which can threaten the life of the baby and the mom, as well as lead to premature delivery or early delivery. These are some of the effects that it has on the baby. So you can see fairly similar effects to what we've seen with other substances. That's where there's some common themes that run through as to what the types of effects are in terms of what substances can do. And so we certainly do encourage women to quit using nicotine. And there's kind of a hierarchy of interventions. And so when we talk about quitting, when we talk about nicotine use, the safest thing to do is quit altogether. And the reason that it's Category D is because there are pharmaceutical forms of nicotine. So not cigarettes, not vaping cartridges, but things like nicotine gum, nicotine lozenges, and then patches that we can put on the skin. And patches have the most controlled release of nicotine. They release it over the day. So that gives you the most controlled release. And so if they can't quit altogether because of the withdrawal and the cravings, the next safest thing to do is to quit using those types of products. So that's why it's Category D. We might encourage them to use a nicotine product, but not a cigarette or not a vape. The next safest thing to do is to change from cigarettes to e-cigarettes. That might be because we don't have a lot of data on e-cigarettes. So come back in 20 years and this slide might be different than what it currently is because e-cigarettes have become wildly popular. So we'll see if that stays true. But the least safe thing to do right now based on what we know is to continue smoking cigarettes. So hopefully that helps them thinking through the hierarchy of how do you help someone cut back their risk if they're using nicotine in pregnancy. All right, so now opioids. So opioids, this was something that came up, fentanyl came up as something that was mentioned. Not one of the most common substances, but definitely something that gets used. And when people are involved with CPS or they're on Medicaid or involved in other state agencies, they're more likely to misuse opioids than the general population is. So you'll see a higher proportion of individuals within these populations than you might see in the general public. Within the mom, the major health effects of opioids are primarily life-threatening. So eclampsia, sepsis. Sepsis is an infection that spreads through the blood. So the infection, unlike being like an infection in your lungs like pneumonia or an infection in your skin, this is something where the actual infection has gone into the bloodstream and now diffusely goes across the body and can cause shock to the entire body. And then heart attack or heart failure are other things that we can see with opioid use in pregnancy. In terms of the infant, very similar type effects as we've seen before. But now we start to talk about this neonatal abstinence syndrome or neonatal opioid withdrawal syndrome or NOWs is what it would now most commonly be called. Opioids perhaps are a little bit more concerning study or concerning thing. So the national prevalence more than quadrupled when we talk about the prevalence of opioid use disorder in pregnancy. So from 1999 to 2014, we saw that rate of opioid use disorder quadruple. 86% of pregnant opioid abusing women report that their pregnancy was unintended. Pregnancy can be a powerful catalyst though to get them to engage in treatment. During pregnancy, we know that adolescents have the highest rates of illicit substance use in the prior month and that we know that there tends to be a downward trend in use over gestational age. And so as mom's age goes up, the likelihood that they're using substances goes down. But as gestation age goes up, we know that substance use also goes down. So what this shows us is that women who are pregnant who misuse opioids, they're often willing to engage in treatment or even treatment seeking because we know the risks that it can have to them and to the baby. So here's a clinical vignette for you. So this is Sophia. She's 25, 28 weeks pregnant with her second child. She's misused street pills including oxycodone and fentanyl since she was 16. Since finding out she was pregnant 12 weeks ago, she has struggled with being sober for more than two to three days at a time. And so this is actually very common, especially with fentanyl, that people get really bad withdrawal from it. And so they can often space their use out to every other day or maybe every two to three days. But a lot of people with an opioid use disorder, at the end of it, they're not actually using to get high. They're using it because they go into withdrawal. And so they're using it to prevent themselves from getting sick. And so that's the pattern that Sophia is currently in. So if we're like, hey, just give up that last one. She's going to be really sick and really miserable and feel pretty terrible. But there's more to the story. We don't want to encourage people to just quit using opioids during the pregnancy. We have long-term opioid agonist therapies. So we talk about methadone. We talk about buprenorphine or suboxone. They're the gold standard of care during pregnancy. We don't want mom to just cold turkey quit like we would with alcohol or even cigarettes or marijuana. And the reason is because once they detox, there are increased risks of relapse and overdose deaths. So actually just getting off it entirely during their pregnancy increases their risk of death if they were to relapse. In addition, if we can treat it with the long-term opioid agonist, we actually decrease the risk of loss of the pregnancy and of opioid withdrawal syndrome in the baby. So we know that the medications that we use to treat opioid use disorder are not associated with congenital anomalies at any sort of significant rate. Methadone is the one that most people have heard of. This is the one that when you look at the data would be considered to use this first in pregnancy because it has the most data around it. But the challenge is that it's very difficult to use. And in lots of regions of Idaho, this isn't even going to be available. Methadone requires clinic visits multiple times a week. So typically when I start someone on methadone, they have to go to the methadone clinic Monday through Saturday between the hours of five and noon to get their dose of methadone. And then once they've done that for several weeks and they show that they're consistent with it and they're doing what they're supposed to, they get to start taking home take home doses so they don't have to come in on the weekend. And then they only have to come in four days a week and so on and so forth. And it takes weeks to months to get to the point where you're coming in weekly or less to get your methadone. And it's very tightly federally regulated so that there are lots of rules around how that process works. Suboxone or buprenorphine, it's a little bit different. It's a partial agonist, meaning it hits the opioid receptor, but it's part gas, part break. And what that means is it's really good at treating withdrawal and really good at treating cravings, but you can't overdose on it alone. Methadone you could overdose on. This one you cannot overdose on it alone because it has that part break system. And so this is one that we can prescribe to people from the clinic and they can take it home the first day. And so they don't ever have to come into the clinic just to get their doses. They come in for management like they would any other medication, but we don't have to administer it to them in our clinics. So much easier to use, especially in a lot of the young women or women that you might work with clinically. Also more widely available because of that. So turning just briefly to stimulants then, cocaine, amphetamines, things like that, obviously increased risk of blood pressure, heart attack or impaired heart function, and placental abruption. And then again, very commonly the same types of things we've seen with other substances in pregnancy. Stimulants also are associated with a neonatal withdrawal syndrome. And so opioids and stimulants are the two that we typically will see withdrawal syndromes in the baby that might result in ICU care at the time of birth. Okay. So how do we talk about substance use during pregnancy? So this is where we're going to go into as we finish up our time together. So substance use may be hidden from health professionals and caseworkers due to fear of discrimination, shame, and the threat of the child being away or facing legal charges. So these are real fears that women have around their substance use, and they might be coming in and even getting prenatal care, but they're not telling us about their substance use or hiding it in general when they're interacting with people to avoid those sorts of consequences. And that's in large part because as a society, a lot of our reactions over the years to substances have been punitive in nature. We punish people who struggle with substances. And so this is a fear that a lot of them will have. So one of the ways that we can really help is by avoiding stigmatizing language. So if women hear us talking about pregnancy and the effects of substances on pregnancy in a way that's different from what they're used to hearing, that can help disarm them and help bring those walls down. So instead of saying this is an addicted baby, it's a born baby was born to a mom who used substances while pregnant, or is born with signs of withdrawal from prenatal drug exposure. Similarly, so it's kind of getting away from a lot of those stigmatized terms that we might have heard in the past and talking about it with person first language that kind of sounds a lot less judgy, to be honest, and reduces the stigma around substance use. There are some tools that have been designed specifically to screen for substance use in pregnancy. And so if this is part of what you do, it's good to be familiar with these different tools and we'll go through some of them. There's the NIDA quick screen, there's the 4Ps or the 5Ps, and then there's the TACE for alcohol specifically. One thing that's important is urine toxicology is not a screening tool for substance use or substance use disorder. They're actually not that great. This is something where I could soapbox for hours, but I'll just tell you very briefly. I wasn't planning on doing this, but see, I got derailed. So I'll just tell you very briefly. Urine drug screens were actually designed by the Department of Labor. And they were designed because we had a lot of people in the workforce who had a lot of trouble with substances, and they were designed to catch the worst offenders so that we could kind of weed them out of the workforce and get them help or not give them jobs where they could hurt other people. But you don't want to get rid of everybody who uses substances because in the 70s, you might not have a workforce if you do that. So they were actually designed to only be so good. In other words, they miss a lot of drugs. They miss a lot of substances. So they're not an effective screening tool. And then knowing why you screen and being aware of potential unintended consequences can be really important. So this is the NIDA quick screen. So this is regardless of if you're pregnant or not. In the past year, how often have you used alcohol? And then the definitions have been shrinking, five or more, four or more. Tobacco products, prescription drugs for non-medical reasons, and other illicit substances. In this day and age, I would list out marijuana and vaping specifically because a lot of people do that. But they may not think of a nicotine vape as a tobacco product, and they may not think of marijuana as an illegal drug. And so it's good to keep in mind to list those things out specifically. If they do use any of those, or if they say they use illicit drugs, then you follow up with what's called the NIDA modified assist. And that gets more specifically into these types of questions. So this is a screening tool that some people will use. This is probably what I would recommend because I think this is much more conversational in terms of talking to a woman about potential substance use. And so it's really this idea of start peripheral to her. Don't start right with, hey, do you drink alcohol during your pregnancy? But you kind of back it out to topics that are less threatening. Did your parents have any problems with alcohol or drug use? Do you have any friends that have problems with drug or alcohol use? Does your partner have problems? And so you can see you're starting to move this network in closer and closer and closer, but now you already have them talking. So you're approaching this in a much less threatening way. Before you were pregnant, did you have any problems with alcohol or drug use? In the past month, have you used any? So now you've already got them talking. You've kind of worked through their history. You have a better understanding of who they are before you ever get to, have you been using during pregnancy? And so this is an evidence-based way to get people talking about their substance use that is a lot more non-judgmental and less threatening in terms of approach. When we talk about the TAs for alcohol use, this is specifically, we've heard about the CAGE questions. So CAGE questions are these screening questions that can be used, cut back, annoyed, guilty, eye opener. They've been adapted to pregnancy. So how many drinks does it take for you to feel high, which is tolerance? Have people annoyed you by criticizing your drinking? Have you ever felt you ought to cut back on your drinking? Have you ever had a drink first thing in the morning to study your nerves or get rid of a hangover? And so based on how people answer these questions, a positive response to any of these questions is predictive of an alcohol use problem such as alcohol use disorder. So when we're screening, the goal of screening is to identify individuals who need additional support or treatment. Are your screening practices equitable? In other words, are you screening individuals based on demographic characteristics like race or income or are you screening generally across the board? And with something like this, you want to be in the habit of screening generally across the board. Are your staff supportive and non-judgmental or do they get treated differently? Do women who use get treated differently once they're identified? And are individuals with identified substance use treated differently at labor and delivery or by child welfare? And so these are often questions that we have to ask when we're screening because there can be unintended consequences of detecting substance use that in some areas and in some systems of care or other systems might then become putative or at least judgmental for the individual that's receiving care. Okay, so Dakota, she's 20. She's 13 weeks gestation. Just found out she was pregnant with her second child. So based on the information that we talked about, how would you bring up screening for substance use with Dakota? I think I lost everybody in the silence. So are you asking like in the sense of how do we bring this up without offending her or? Yeah, so how would you bring it up? Like if you had that information, how would you bring it up with her? I would just bring it up with her like it's a normal thing because I believe it is. Okay. Especially when you don't find out that you're pregnant till you're 13 weeks. And I think, I don't know, I feel like that's easily explainable. Yeah, yeah. To prevent and to benefit both you and the baby, this is something that we discuss. It can be hard. It can make you feel like you're being interrogated, but truly our concern is just for safety of you and for baby and that can help us provide the best care. Yeah, so sometimes the more we caveat what we do, the more awkward it becomes because if I start giving all these caveats around something it might make it seem like I'm not comfortable discussing this with you or I think it's bad. And so treating it like it's normal and having a normal conversation around it, using kind of that five Ps model is a really good way to go. Okay. So I just want to address a couple of things about the putative nature of substance use and why substance use in pregnancy becomes a difficult topic. So one of the things that's important is to understand the war on drugs and specifically the impact of systemic racism. So the war on drugs actually was initiated as a political initiative by Richard Nixon and his chief of staff, his former chief of staff has written very extensively about this since Nixon left the White House. It was actually initially started because Nixon was afraid of losing the South. And so the quickest way to get voters off the rolls was to give them a felony charge. And the quickest way to give them a felony charge in large numbers within the cities was to make the substances that they were most likely to use felonies. So crack became a felony, whereas cocaine was not. And so this initially started as a political movement really to help Nixon win reelection. But after the war on drugs, every president picked it up because now it's like a straw man thing. Oh, drugs are bad. So we're definitely gonna continue the war on drugs. So it is continued for 50 years but it started really as a punitive thing. And so oftentimes, especially if we're white we may not perceive the war on drugs the same way that someone from a black community does because it was designed to target them more than it was designed to target white people. That's the nature of how it was rolled out. And it's the nature of the impact that it's had on people. So what have been some of the impacts of the war on drugs? What have you guys seen or heard about? I think we're going through it right now, aren't we? Yeah, to a degree. Well, I remember back in the day they had marijuana classified in the hard drug classification. It was just kind of strange. Yeah. Yeah, they did for a while. A lot of people have felony charges that they were serving time for from marijuana even after it became legal in some of those states. So definitely something that we're living through and something that we're seeing. And so when we talk just about the numbers of getting to the bottom of some of it it really is a good example of understanding systemic racism and why people of color may be less trusting of law enforcement, of the medical community in general because of the effects that the war of drugs has had specifically on them and on their families. So black and Hispanic women with opioid use disorder are much less likely to consistently receive any medication to treat their disorder during pregnancy. So they don't get the same access to care that white women receive, for example. Lawmakers often respond to substance use problems by enacting putative policies such as the policies around the war on drugs. We took a punitive approach and it's really recently that we've been working on taking more of a restorative approach to these issues. But putative drug policies have been disproportionately enforced against people of color. So black mothers are more likely than mothers to be reported to child welfare by pediatricians or obstetricians suspecting prenatal drug use. So even when they come into an educated healthcare professional community our own colleagues are more likely to report black mothers to child welfare for substance use than any other mother. So that tells you something about the impact it's had even in the places where they should feel comfortable getting treatment and receiving support. Women of color are less likely to be connected or have access to mental health or substance use disorder treatment in general. And in 2018, only 23% of substance use treatment centers offered programs designed for pregnant and parenting women. So not only are they less likely to receive treatment but even if they weren't a woman of color there aren't that many services readily available to them during their pregnancy. So you take a very underserved population and then you stigmatize and minoritize a group within that population. It makes it even harder for them to get care. So this was a quote from the National Partnership that I thought was just really interesting and made me think a little bit. My third child, I had no prenatal care because I was taking drugs. Well, not drugs, drugs. I was down there smoking on marijuana and drinking liquor. And they told me if they see THC or something like that in my system then protective services would get involved. So I didn't go to no care for her, none. And so this really speaks to the punitive nature that our policies around substance use have had. And it's really sad that in some cases we have pushed women away from being willing to get care because they're afraid that they're gonna get in trouble. They're afraid that their kid's gonna be taken away or that something else is gonna happen. And so whenever you walk into a room that's part of the history of what you're walking into. That's part of the stigma, part of the stories and culture that people have grown up with. And it's just very important to be mindful of that and be receptive to that, especially if you look different from the person that you're sitting across from. So what about substance use during nursing or breastfeeding? I feel like this is a trick question. I wouldn't think B was right, but it isn't. Okay. So I think we could all agree that A is probably true. Yeah. So the question is, is B true? And B and C are kind of in conflict with each other, right? So one of them is saying you should continue breastfeeding. The benefits of the breast milk typically outweigh the risk of exposure. And the other one is saying you should not breastfeed. And so generally, when we talk about nursing, this is kind of a summary from the American College of Obstetrics and Gynecology by substance. So hopefully this will give you a little bit of useful information. So in general, across the board, we recommend no substance use while nursing. For alcohol, if you want to get down to more specifics, we recommend waiting three to four hours to allow the alcohol to be metabolized because we know how alcohol metabolism works pretty well. So we can get it down to the time and say, wait three to four hours after a single drink before you pump or before you breastfeed. Matter of fact, we know so much about alcohol metabolism that patients also know a lot about it. So if I put someone on Anabuse, which blocks the enzyme that digests alcohol and makes them sick whenever they drink, all of my patients that have ever been on it know to the minute when they have to quit to be able to drink. I had one patient that I remember coming into clinic one day and I asked about his compliance with it. And he said, yeah, I do pretty good. I skip it every now and then, but I know I want to drink. And I said, how long do you have to be off of it before you can drink? And he said, I have to be off at 23 hours and 42 minutes. He had figured it out down to the minute. I was like, well, that's impressive. You really know your body. Nicotine, the benefits of breast milk outweigh the risk of nicotine exposure. So if a mom is continuing to smoke or vape, we do not discourage her from breastfeeding. For cannabis, the benefits of breast milk outweigh the risk of cannabis exposure. So we talked about how a bunch of cannabis causes the placenta. The milk glands seem better at filtering it out. So between how much ends up in the milk and how much the baby's GI tract can absorb, they get exposed to about one one thousandth of mom's exposure. So much less than they get exposed to when they're in utero or when they're in the placenta. For opioids, for prescription opioids except codeine, it is not contraindicated to breastfeed. Absorption is about one to three percent of what mom uses. So again, fairly low exposure risk to the actual baby itself. Codeine is the one exception to that. And then the difference for all of it is methamphetamine. So this came up, someone mentioned this as a common substance of pregnancy. This is where breastfeeding recommendation are different. Women who are actively using methamphetamine should not breastfeed. And the reason is because it inhibits prolactin release. And so that's what releases milk. And so it's found in breast milk at concentrations that are three to seven times higher than mom's levels. So this is the one substance that really does concentrate within breast milk. And we discourage breastfeeding in those individuals. So hopefully that gives you an idea of if after pregnancy, women are continuing to use most of these substances, we want them breastfeeding their babies for the most part with a couple of exceptions. Because the benefit of the breast milk to the baby and to its overall health and development outweighs the risks of substance exposure. Okay, so in summary, alcohol, nicotine, and cannabis are the most commonly used substances during pregnancy. Many women do not stop using when trying to get pregnant, and pregnancy may be unintentional. Continued substance use poses risks both to the mom and the baby. Women with opioid use during pregnancy need to be referred for treatment. We don't ask them just to stop using opioids. The gold standard of care is to get them on a medication like Suboxone. Screening should be conducted in a sensitive way that acknowledges concerns about confidentiality and punitive consequences. And in general, no substance use while breastfeeding is recommended, although for most substances, breast milk benefits outweigh the risk of exposure to the baby. So for those who would like to learn more, these are just some websites that have some good resources about substance use in pregnancy, as well as harm reduction. I have not checked the CDC link in a while, so I hope it's still there, but links from their website have been disappearing. But overall, I hope that this presentation was helpful, and I'm happy to answer any questions that you guys have with the time we have remaining. I have a question. Yeah. Okay, when you were talking about the three medications for opioid use, do sometimes moms or anyone in general try to use another medication, or not a medication, but another substance withdrawal problems? Or maybe they use something else, so the withdrawals aren't so bad, just because they don't want to go to the office and get those types of medications. Yeah, they certainly, some do, and the argument against that would be we know the medications in pregnancy are safe, and so we know we can safely treat their opioid use disorder. But you'll see that where people think that one substance is safer than another, and I kind of consider it in some ways, and this is going to sound stigmatizing, and I realize that, but I don't have a better comparison. In substance use, there's this interesting concept of like honor among thieves, where the people who do not use IVs or don't inject drugs are like, they think that the people who do are like terrible, and they would never do that. And the people who use opioids look at people who smoke cocaine or crack, and like, I would never do that. And so it's really interesting where people draw lines, and what's good and what's bad and what's worse, and they're not necessarily founded in any sort of information, they're just the way that people approach it. I remember I had a, this is an opposite example, but I was treating a young lady at one point who had a benzodiazepine use disorder. She was using Xanax, and used quite a bit of it. She would use four to five tablets of Xanax a day, and when I was treating her, she came in one day, and I've been treating her for about four to five months, and we were doing our normal encounter, and I at some point said, so tell me how the Xanax use has been over the last month, and she said, I haven't used any, and I said, really, you haven't used any? That's phenomenal, and she said, yeah. I started smoking fentanyl, and I'm like, that's worse. That's not good, but she saw it as an improvement, because like, well, I'm not struggling with Xanax anymore. So that definitely happens. So. I got one more question. Yeah. Okay. Since we're talking about moms, and there may be a dad in the picture, would it be extra beneficial to understand how maybe the drugs affect dad, not just for the outward appearance, but does that have anything to do with the sperm, or the fact that maybe mom might be a little lighter on the drugs, but dad's a little heavier, so would that even matter? Yeah, so it definitely can matter, and I would say we're in kind of a more experimental realm with that. So as we have learned more, so the actual genetic sequence that you get comes from both mom and dad, but the substance use itself affects a lot of markers on the DNA. We call that epigenetics, and so that determines which genes get expressed and which ones don't, and there's a lot of research going on on this right now, so we don't have as many answers, but for example, paternal age is a risk factor for autism because of those epigenetic changes, and could substance use and the dad also be a risk factor for developmental disorders? That's quite likely, and they're working on trying to figure some of that stuff out. So we don't know as much, but certainly it's a risk factor. Obviously, for a woman who has a partner who's actively using, it's going to be hard for her to get sober if he's not on board with that, and they don't do it together. Their likelihood of getting her sober is much higher if we can bring in dad and have him be part of that and be willing to join her on that.

substance use

pregnancy

intervention strategies

maternal health

fetal health

fetal alcohol spectrum disorders

opioid treatment

stigma

racial disparities

screening methods

paternal substance use