Everyone, I hope you all got some food, got some time to stretch, and I'd like to introduce our next presenter. Do you have anything you wanna add? I think she'll introduce herself, Dr. Candy Stockton, you'll enjoy it. Hi, I'm Candy Stockton, I am a family medicine and board certified addiction specialist doctor working in rural Northern California, and I started doing buprenorphine therapy with pregnant patients by accident. About 18 years ago now. So I think like some of your providers here, I was working in a remote rural area in Northern California. Our closest methadone clinic was six hours, one way drive to the methadone clinic. And those of you familiar with methadone clinics, you have to go daily for dosing, which means a 12 hour round trip drive every day, which is essentially the same thing as saying impossible. And so that's kind of my background with this. About 18 months ago, after 25 years of treating patients directly, in the last 10 of them spent working primarily with pregnant and parenting individuals with substance use disorders, I jumped ship and moved upstream because I got tired of the barriers that my patients were facing to be able to stay on treatment. I'm gonna pull this off because that's just not working for me. So got tired of the barriers that my patients were facing. So if you're a physician and you know that the evidence-based treatment for something is that if you have an opioid use disorder, you should stay on treatment, but somebody besides your patient has custody of their children and that somebody is telling them that they can't get their kids back unless they get off their medicines. These are barriers that are above our level, our ability as providers to address, and they're above our patients' abilities to address. And so I kind of cautiously made the jump to public health where I get to work with our county, with our board of supervisors and our criminal justice system and our tribal courts to actually address some of these factors that are upstream determinants. So I will admit that right this minute, I don't see patients, but that's where I spent all of my time for the last 25 years and where all the experience for this talk is gonna come from. Also, please feel free to stop and ask me questions or holler anytime. I'm not a super formal presenter. And I think that the most boring thing anybody could be subjected to is listening to me talk for two hours straight. So feel free to jump in with questions anytime. Disclaimer slides, I and this talk are brought to you today by the Opioid Response Network come through SAMHSA's grant for technical assistance to regions. If you have further requests you'd like to make on other topics, talk to Jan there in the back. Trainings are free to the requesters. Here is their website for information. And you'll have a copy of these slides after the presentation. So just kind of flying by those. I have no financial disclosures. I will be talking just very briefly about off-label use of medications. And I do wanna recognize that most of our data around pregnancy and substance use disorders, most of the studies that we draw from come from an era where we identified all pregnant individuals as women. And we do recognize now that that's not the case with all of our pregnant individuals. They don't all identify as women, but where we're quoting research from that era, we will be using those gender specific terms. So I just wanna acknowledge that. So learning objectives for today. When we're done, you should be able to explain why the American College of Obstetrics and Gynecologists, the American Society of Addiction Medicine and the World Health Organization all oppose. Notice that's not don't support, it's oppose detoxification for opioid use disorder during pregnancy. Be able to explain the similarities between substance use disorders and other chronic diseases that complicate pregnancy and understand how to appropriately screen for substance use disorders during pregnancy. Because you all got to talk or listen to Sarah's great talks this morning, I get the benefit of not having to spend a lot of time talking about the technical aspects of treating pregnant individuals. The technical aspects of treating pregnant individuals are basically exactly the same as the technical aspects of non-pregnant individuals. So really not any medical differences. We'll talk about a couple of points that are specific to pregnant women, but I'm not gonna go into the details of medication because the details are exactly the same as what you've already heard. We're gonna talk more about the philosophy and approach to treating pregnant individuals. And a little bit about our stigma and biases. Can I just pull the room really quick? How many of you are prescribers? Okay, how many of you are family medicine docs? OB, internal medicine, ER, that doesn't seem to quite add up, so I'm missing some specialists probably, but that gives me an idea of who's in the room. Psych, oh, okay, oh, obviously, sorry. So I come from a region where there are essentially no psychiatrists, so it doesn't even occur to me that they exist most of the time. I do realize that across most of the country, addiction medicine is actually closeted within psychiatry. We just don't have any in Northern California, so sorry. So we'll be going over consensus statement from the White House and Oregon, oh, sorry, I forgot to change the slide, Alaska state law around pregnancy and substance use disorder. We're gonna do a case presentation, and because I believe it's wrong to manipulate people without telling them you're doing it first, it is a trick case. We're gonna talk just a little bit about alcohol use disorder, a little bit more about opioid use disorder, and a tiny bit about stimulant use disorder during pregnancy, and a little bit about neonatal abstinence syndrome or neonatal opioid withdrawal syndrome, depending on which acronym your organization is using, as well as eat, sleep, and consult treatment. Before I do that, another poll. How many of you believe or accept the statement that substance use disorders are a chronic disease? Okay. Do you practice eat, sleep, consult treatment for infant withdrawal at your hospital? Great, excellent. So like half of my talk is already done. You've got my first two points down cold. Always check, because depending on where you are, you may be unfamiliar with eat, sleep, consult. There are still hospitals that have not implemented that yet, and there's regions where nobody practices it. And there are still audiences that you have to convince that substance use disorder is a chronic disease, and this goes a lot smoother if everybody's already starting on the same page. So this is the consensus statement from White House Office of Drug Control Policy. It is the only slide I'm gonna read verbatim, because I think it is important that we really understand this as a foundation. So White House, not me, having substance use disorder in pregnancy is not by itself child abuse or neglect. Criminalizing substance use disorder in pregnancy is ineffective and harmful as it prevents pregnant women with substance use disorders from seeking and receiving the help they need. Everyone has the right to effective treatment, and denying such care on the basis of sex or disability is a violation of civil rights, in this case, disability being their pregnancy. Pregnant women using substances or having substance use disorders should be encouraged to access support and care systems, and barriers to access should be addressed, mitigated, and eliminated where possible. And improving coordination of public health, criminal justice systems, treatment, and early childhood systems can optimize outcomes and reduce disparities. Okay. Pregnancy and substance use disorder in Alaska. So Alaska is fortunate, is a state where having a substance use disorder during pregnancy and using substances during pregnancy are not classified as a crime in and of themselves. There are states in the US where actually just that is a prosecutable crime, which makes it a lot harder to treat patients in that setting. But there are women in Alaska who've been prosecuted for substance use during pregnancy. So even though it's not actually classified as a crime by definition, it can sometimes be prosecuted that way here. And there's no specific law defining substance use disorder during pregnancy as child abuse. Always stick the state statutes in there because you will invariably get stuck in a room with somebody who will insist you are wrong about that. And I'm not talking about me today, I'm talking about you when you're talking to other people. So now you have that reference if you need it and you don't have it memorized, it's in your slides. So our case study. Before I start on this, I wanna share a rather embarrassing story with you. When I was five or six years old, I was visiting my grandfather on his ranch and my grandfather had to take one of his dogs to the pound. I'm gonna now say what is probably the most controversial thing that I will say in my entire talk today, which is that I actually don't even really like dogs. Sorry. But I remember being really incredibly traumatized. I remember crying for several hours, I remember nobody could figure out why that was the case. I mean, I remember being really upset. About 10 years later, after spring break, I had a classmate, a friend come back from spring break and tell me that they had had to take their dog to the pound every spring break. And I said, that is so awful, how could you do that? And my friend's like, what? And I said, well, don't you know that when you take a dog to the pound, they, you know, they actually probably don't do that. My little five-year-old brain had envisioned two very large concrete blocks, one suspended over the other, and that the word pound was literal. And this is a belief that I absorbed when I was very young and it lived in the back of my brain and I didn't take it out and investigate it or think about it, I didn't question it until I got to be older and started to say it out loud and realized that that could not be a real thing, no matter what I actually thought. There was no way that that was actually happening. The truth is that most of us have grown up in a fairly homogenous culture, whether or not you believe that way, we're raised in a culture that's informed by Judeo-Christian values, we have historically viewed substance use disorder as a moral failing and a sin, if you come from a conservative Christian family like I do, it's a sin that you could very definitely be forgiven for as long as you repented and quit using, but it was still a sin, right, still a choice. I'm also a child of the 80s, just say no, this is your brain, this is your brain on drugs, if you are too young to remember those commercials, go home and check them out, they're great. Not helpful, but very entertaining. So in spite of the fact that we know substance use disorders are a chronic disease, that we know that their development occurs because of a number of factors that we're exposed to, genetic, epigenetic, environmental, social, economic, in spite of the fact that we know all of these things and we see, we believe substance use disorders are a chronic disease, we actually don't treat them that way. And what I'm gonna share with you over the next two hours is gonna actually challenge you to bring out what beliefs you have, what your pound story is, what you're holding on to that is not helping and informing our care of our patients because we all have them, and if you think you don't, I hope that you realize you do by the time we finish this. So this is the story of Amber. Amber was born, and I hate this term, but you will hear people use it, Amber was born addicted to drugs. Her mom injected drugs several times a day throughout her pregnancy. During her pregnancy, she had to be, she had three emergency interventions for overdose and one for medical complications, skin infections. When Amber was born, she alternated between being lethargic, she was irritable, she didn't eat well, she required placement in the ICU, she was there for four days, she required medication and management dosing every two hours for four days. Not fun. If you haven't already run across a patient like Amber and her mother, in your brain, pause for a minute and think about how you react to that. What do you think should happen? Should you be calling child welfare services? Do you need to be talking to social workers? How worried are you? Are you considering whether or not Amber should go home with her mom? Do you have hospital policies in place that say that you shouldn't even think about sending her home until you've done a safety evaluation? Don't have to answer that for me, but just think about it a little bit. So Amber's mom was lucky. Her hospital was one of those hospitals that could do transitions onto oral meds. So right after delivery, mom got switched onto oral meds for treatment and was pretty stable on those by four days later when it was time for Amber to go home. They'd met with the lactation consultant, had a little bit of coaching on breastfeeding, wasn't going very well, but nobody seemed particularly concerned. And we don't, as is often the case, know much about the health status of Amber's father. Does that change the way you feel about what's happening? Does that change your judgment? Are you happier now that mom is on pills instead of injecting? Does four days seem like long enough? Do you care that you don't know anything about dad? Does it matter? Again, just think about it for yourself. So as many patients do, mom is doing really well on therapy. She's in recovery still, but we never asked the question and dad is actually injecting multiple times a day, was throughout the entire pregnancy and still is three years later. When Amber's about two and a half years old, she finds an injection in the house that still has some product left in it and injects herself. Now, how do you feel? If you haven't called Child Welfare Services already, are you on the phone? Do you have concerns about this? Mom gets pregnant again and literally within days of getting pregnant, the stress is too much and she's injecting again. On at least two different occasions, neighbors find Amber running around the street in nothing but her rain boots and her panties because mom is impaired and passed out on the couch. Now, how do you feel? Does anybody feel good about this? Is there anybody in the room right now that's not thinking about calling Child Welfare Services? For those of you who have not guessed it, that mom is me, the drug I was injecting is insulin. My husband is a type one diabetic. He will inject for the rest of his life. Makes a difference, right? Because at no point during that process did anybody ever consider calling Child Welfare Services on us. Right? They did what was probably appropriate in that situation, which was sit down and talk to us about how we could deal with that better. We installed some child safety locks on the top of the door that my daughter couldn't reach. My husband got transitioned into insulin pins. That was right about the time that they became available and so we didn't have syringes lying around anymore. Right, like we looked at all the things, like what can we do? You have a disease, there are complications. No one told me while I was pregnant with my daughter that if you eat tortilla chips and your blood sugar goes high, you are a bad person. I know because I tested that on more than one occasion. Right? No one was actually surprised when my daughter ended up in the ICU. By the end of my pregnancy with my daughter, I was on more than 500 units of insulin a day. By the end of my second pregnancy, I was on more than 700 units of insulin a day. I like to affectionately say that's like enough to kill like three elephants. I don't know that the studies have been done on that so I can't back that up with evidence or research papers, but that's a, pardon my language, that's a shit ton of insulin, right? So you can imagine how difficult it was to control my sugar levels. On at least one occasion, my three-year-old daughter was home by herself with me when I started seizing from low blood sugars because this was 25 years ago before we had effective glucose monitor, or you know, like continuous glucose monitors that people could use. So I have to ask, if none of you would have called Child Welfare Services in that situation knowing you had diabetes, what is different about the disease of addiction that makes you feel like we should start the process questioning whether or not that family should even be able to keep their children? What is your pound belief that's driving you that makes you even walk into a room with somebody and actually start the process by thinking, you know what, I question whether or not you should even be allowed to keep your child? I think it's because it's not an extremely intermittent inability to care for the child, but this is a mind altering substance from the get-go and somebody who's using enough heroin to be passed out on the street and the kid wandering the streets is probably impaired a great deal of the time, unless they're under some kind of treatment. Have you ever taken these on injections? So because you asked, I will share personal information that my husband would probably rather I didn't. So I was in medical school when my daughter was born. I was in residency when my son was born. I was working a billion hours a week during most of their childhood. My husband's a software engineer, he worked from home. My husband did most of the day-to-day parenting of our children. It has only been in the last 10 years since my husband got onto a continuous glucose monitor and we were able to monitor how often he was low and adjust to that, that his mood swings that his mood swings, anger, lashing out, and other issues have actually resolved and I wasn't aware of them and didn't know about them because I wasn't there. There is no question that my kids have emotional trauma from being raised in a household with a type one diabetic who had poorly controlled blood sugars, right? And he was getting the best treatment that was available. So again, I say that not to call you out because I appreciate you being willing to share that and also if you have somebody who has seizure disorder, if you have somebody who has mental health disorders, if you have somebody who has labile diabetes, if you have somebody who's got dialysis for end-stage renal disease, like we have so many chronic medical diseases that actually do impair our ability to think, our ability to cope, our ability to safely, I mean, at least if you're injecting heroin, you know you're gonna inject heroin as opposed to a seizure, which could happen in the middle of a bath, right? So it is a valid question, and I'm not suggesting that every family who is using drugs is able to safely parent their children. I'm asking why we don't start the conversation with, of course you're going to be able to parent your children, what kind of support do we need to help you do that? And when that support fails, when it doesn't work, when all the resources that we throw at it are not enough, then yeah, sometimes you do have to get involved for the safety of the children when it can't, you know, when there isn't another way to manage it. But why do we walk into the situation assuming it's not okay and having to prove that it is, when with every other chronic disease that we treat, we walk into the situation assuming it's okay to parent and recognizing that in the rare occasion that will fail. But the assumption is it's actually okay because a rational and sane society does not believe it is okay to take people's children away from them, right? It might do it as a last resort, but it should never start out with the idea that I have more right to parent your children than you do. So, substance use disorders are a chronic disease. Pregnancy is a temporary condition. I don't think I'm surprising anybody with that. I kind of got both those things down. The other fallacy that we fall into, and I am guilty of this. I have been treating pregnant women for almost 18 years now, and I still remember saying in the beginning, of course we have to treat her. We have to do it for the baby, right? Which is good. I mean, it's good that somebody cares about the baby. That's great. But in fact, mom doesn't quit being an individual deserving of treatment and care and compassion when she becomes pregnant. She is not just a vessel for the infant that she's gestating. She is an individual who has a life-threatening chronic disease with a good evidence base for treatment that works, right? Bottom line, mom deserves treatment. Mom needs treatment. And for any individual with a chronic disease who becomes pregnant, there are predictable and expectable consequences for the pregnancy. If you have a mother who has gestational diabetes and is taking 700 units of insulin a day, not only are you going to have a big baby that's going to be relatively difficult to deliver, you are also going to have a baby that is more likely to have immature lungs and need respiratory support. And you are more likely to have a baby that will not be able to manage and maintain its own blood sugars after it's born for several days and low blood sugars after birth can cause the same kind of brain damage that low oxygen after birth could cause, right? And you know what? I knew all of that as a pregnant individual because my healthcare team sat down with me and said, hey, you're not a bad person, but you've got a chronic disease and your chronic disease results in these kinds of outcomes with pregnancy. And there's a good chance that your baby's going to end up in the ICU and need support. And it's okay because we know how to take care of it. We know how to control it. And as long as we take care of it well, it doesn't cause any long-term consequences for the baby. And it's all right. Don't feel bad if that happens. You are not a bad person, right? We know this. We don't do this with pregnant individuals who have substance use disorder. We say things like, don't you care about your baby? Why are you doing that? You know, your baby could be really sick after it's born if you don't stop that. The truth is, even if you're stable on optimal treatment, your baby could still have withdrawal. We don't really know why some babies have withdrawal and some don't. It doesn't seem to have anything to do with the dose of medication that mom is taking, right? So we understand that when you have hypertension, when you have diabetes, when you have asthma, when you have seizure disorder, when you have whatever the case may be, that there are going to be consequences for the pregnancy. And we educate mom about that. We prepare for that. We reinforce that she's not a bad person. And we assume that she has a right to parent her child and that she wants what's best for her child. And it's our job to figure out what kind of medical and social support she needs to be able to do that. Substance use disorders are the only disease that we, again, have this hang-up because we still see this moral part of it. We still have this background pound beliefs that are making us actually react to this emotionally differently than we do to other diseases. So we know that about 10% of pregnant women will have pregnancies affected by diabetes. About 15% of pregnancies will be affected by hypertension. Close to 20% of pregnancies will be affected by depression and mood disorders. And somewhere around 10% of pregnancies will be affected by substance use. And I lay that out like that because these top three, for those of you that are not OB providers, these are all standard parts of OB care of the prenatal visits and screening processes that we do. They are standard. It is malpractice not to provide these. And we screen for them with evidence-based tools or specific measurements. We don't ask you, do you feel like your blood pressure was high yesterday? Did you get lightheaded at all? Well, we might ask about the lightheaded, but not to screen for blood pressure. We use a very specific validated measurement. We measure your blood pressure. When we screen for diabetes, we don't just randomly check a blood sugar and hope for the best and leave it at that. We screen with a handful of different validated options that will tell us not only what their sugar is at the moment that we take the test, but also what their relationship with sugar is over time, how they manage it over time. And that's important. Oh, and then depression and mood disorders, we screen with validated tools, questionnaires that we've studied and we know are representative of what we're looking for. How do we most often screen for substance use disorder during pregnancy? Urine drug screen. So I would like to point out that the term urine drug screen does not refer to this being a screening test for substance use disorder. It is a screen because the test itself is not confirmatory for the presence of the drug. It screens for the drug. If you wanna be 100% sure the drug is actually there, you need a confirmatory test. That is what the screen in urine drug screen means. And just like checking me one time for my blood sugar level and making a decision about whether or not I have diabetes based on that one random blood sugar level, urine drug screens are useless for screening for substance use disorders. They will screen for the presence or absence of a substance at a given point in time, but that tells you nothing about the person's relationship with the drug, which is what a substance use disorder is. And because these tests are so misunderstood by healthcare providers, you can assume that they're not any better understood by the criminal justice system, the child welfare service system. So when you use this test as a screening test for a substance use disorder, you are placing the individual at risk for losing their child. What do you have to do before you order a procedure or a test on one of your patients? Informed consent. What does that mean? What you're testing for and why and what the potential benefit of the test is and what the potential harms of the test or the intervention are. If you are drug testing people as part of a normal policy without actually disclosing that this test result could ultimately end up in them losing their child, you are failing at your informed consent process. And in fact, there are several states and some federal regulations right now making their way through the system to make it illegal to drug test people. to make it illegal to drug test individuals without actually giving full informed consent. Now, why is that important? Here is why it's important. Because at the end of the day, we actually, in spite of the fact that we think we do, do not take children's people away because they use drugs. We take people's children away because they are poor and or in some other way disadvantaged and they use drugs, right? You need those combination of factors. And we can justify it all we want. We can say things like, well, you know, but if you are stable enough that you're not ending up in the hospital and not testing positive, then when you're here, is it really a problem? If you can afford to hire a nanny to sit with the kids and we know they're safe, is it really a problem? We can justify it all we want. But the truth is we take people's children away when they're poor or disadvantaged and they use drugs. And we ignore the fact that other people also use drugs when they're pregnant. We just don't care because our methodology doesn't catch them. And if you question that, pull your hospital statistics, pull any hospital statistics in the state and look at the rates of screening for substance or screening tests, drug screening tests on individuals who come in and deliver. If you don't have a hospital mandate that says you test everybody or you test nobody, then the data shows repeatedly that we test women of color and poor individuals at a higher rate than we test middle-class white individuals, which is really interesting because when we look at the actual statistics taken from other areas, we know that white women use drugs at a higher rate than most other groups as other female groups, right? So very definitely our testing practices are informed by our pre-existing beliefs, by who we think are drug users, by what we associate with that. And then it becomes a self-fulfilling prophecy because if we only test people that look a certain way or have a certain income level, then we only ever find the drug use in those individuals, right? And then the kids that get taken away are always from those homes. And then we look at the kids that are in foster care and we're like, well, because they come from poor minority families. Yes, because we're only looking at those people or they come from poor white families or they come from somebody else who's disadvantaged. So it's really important that we understand how to screen individuals for substance use and that we know why we're doing it. And I'm gonna flip back to that in a minute, but let's talk about some other ones. Some people are gonna say, well, yes, but other substance use or other chronic diseases don't cause the same level of harm that like heroin and fentanyl do. And we just couldn't, we know we're treating it different, but we just couldn't send babies home with somebody where stuff that dangerous is in the household. So let's talk about alcohol. We don't even screen for alcohol use during pregnancy, not really. And the only time child welfare services ever gets involved if somebody has an alcohol use problem during pregnancy is when they're falling down drunk in the hospital. Outside of that, we don't care. Smoking. Do I need to convince anybody that smoking is bad for pregnancy? Oh, good. Do I need to convince anybody that smoking in a household where children live is dangerous for the children? You all know it increases rates of asthma and other problems, ear infections, sudden infant death syndrome. So when you look me in the eye and you tell me, I can't send a baby home with a family who has something that dangerous at home. Yes, you can. You do it every day. You don't even question it. The last time you had the thought, maybe I should call Child Welfare Services because that mom smokes was never, right? So in, I think these are Alaska statistics from 2022 and 2019, which are the last years that were available a month ago when I prepped these slides. We know that nearly 20% of childbearing age women in Alaska report binge drinking at some time in the last month. And we know that 10% of women report smoking in the third trimester of pregnancy, right? Both of those are pretty common problems. And yet our foster care systems are not full of kids that come from families where mom smokes or drinks. Now, please don't leave here with the idea that what I said was we should now start reporting women who smoke or drink. It's not what I said. What I said is if we actually think we can't send babies home with families where people use substances that could kill them, you do. This is just the difference between flying and driving, right? Who gets a little anxious about flying? It's a little scary, feels dangerous. How many times a day do you get in the car and drive without even thinking about it being dangerous in spite of the fact that as statistically the thing that is far more likely to kill us? The most dangerous part of any plane trip is the drive to and from the airport. But because we're used to that risk, because we've been doing it every day, because we see it all the time, because we don't think about it, our brains play this trick on us and they tell us, oh, it's okay, that's not dangerous. And a new risk, something that's new to us that we haven't seen before, we don't deal with every day or we haven't settled in culturally within our society that always feels riskier even if statistically it's less of a risk. So I don't have the reference here. I'll pull it for you if anybody would like me to prove it later. But if you look at studies that were done around the risk of physical abuse to children, I would hazard a guess that most of you think probably meth use is the most dangerous for that situation. And we know that in fact, when mothers use meth, that those children are reported to child welfare services at higher rates than any other substance. And we know that they're removed from the home more often than any other substance. In spite of the fact that children in homes where dad drinks alcohol are statistically much more likely to experience physical abuse, right? But we accept that because A, we're not quite as judgy of dads as we are of moms, and B, meth is really fricking scary, right? And people look weird when they're using it, so of course they're dangerous. Okay. Just to drive home, again, looking at the rates of illicit drug use and other substances, I'm never quite sure where to put marijuana anymore on that table, but just as looking at those rates that we recognize that lots and lots and lots and lots of kids are growing up in households where there is substance use, right? We only get kind of moralistic and concerned about it when we know it's mom and we know it's illegal drugs and we know it's during pregnancy. That triggers all of our like hot, scary buttons. But in fact, a big chunk of kids in this country grow up in homes where there's substance use. Do I like that? No, in my perfect world, if I could snap my fingers and all substance use disorders would go away, would I do that? Yes. In a perfect world, would I make sure that everybody got all of the most effective birth control they needed so that no children were ever born before they were planned? Hell yes, I would. But in this world, at least I can know that even though it feels scary in that situation, the truth is many kids are growing up in homes with substance use. And in fact, when we find them later, when we try to take them out of their homes and put them someplace else, how often do they run away and try and get back to that home, right? So how do you screen for substance use during pregnancy? Just throwing some tools up there. NIDA quick screen, the four Ps or five Ps plus. The five Ps plus is my favorite. CRAFT for women in adolescence, 12 to 26 years. In case you didn't catch it earlier, urine toxicology is not screening for a substance use disorder. And understand why you're screening and what you're gonna do with it. If you can't offer treatment and support, help to somebody who has that chronic disease, you really have to question whether or not you should even be screening anyway. Is your screening doing more harm than good? If the only outcome from your screening is punitive interventions and you have nothing positive to add, you're probably not ready to start screening yet. So understand what your goal is in screening, right? And your goal should be to identify a common chronic disease that affects pregnancy and to connect them with the appropriate evidence-based treatment to help them treat their chronic disease because they deserve to be treated for themselves and also it results in better outcomes for the baby. It's like a win-win, right? That should be why you're screening. If you're screening for any other reason, you really have to ask yourself, am I, and what I'm doing, is it okay? And is it having a positive effect on patients or is it actually just causing more harm than good? And then if you want some more information about the different screening tools, there's a couple of different references below. The top one is through California's, the CMQCC California Maternal Quality Care Collaborative, which is the resource group that provides guidance and resources to hospitals for dealing with these problems. That's their toolkit and I mentioned that one specifically only because I am one of the credited offers on that kit but that is not a conflict of interest because it was all volunteer work so nobody got paid. But both of those resources will take you to sites that'll talk to you more about the different kinds of tools and the pros and cons of each tool so that you can help decide what might be best for you to use. I'm not gonna spend a lot of time talking about the differences. I will say that in my experience, the one that is best for you to use is the one that already integrates into your EMR system so you don't have to pay some developer like $80,000 to patch it in. But if that's not the consideration for you, the 5Ps Plus is a really great tool to go with it. Those of you who are not familiar with it, it starts with did your parents use drugs? What about your friends? What about your partner? In the past, have you ever used drugs? So it kind of normalizes those questions before you get up to the really vulnerable question of what about in the past month, while you were pregnant, did you use drugs? So it's a really gentle way to lead into it. It's my favorite tool to use because of that but I will admit that I use whichever tool the EMR supports at whatever group I'm working with because you're not gonna win that battle if you're fighting to get them to add a new tool. So again, we can't do this, it's too dangerous. Between two and 5% of the US population, projections say are affected by some level of fetal alcohol spectrum disorder. So again, we can and we do all the time ignore substance use in parents. We can and we do all the time send children home with families that use substances. We just don't like it when it triggers our moralistic alarms because it's heroin or fentanyl or methamphetamines. So there's some things that we know about opioid use disorder that help drive some of the stigma that we have. We know that 86% of pregnant opioid abusing women reported that their pregnancy was unintended as opposed to somewhere between a third and a half of you that were unintended. Unintended, however, does not mean unwanted. And we use this to say things like, why on earth did you come in so late for your pregnancy? Don't you care? So let's turn that around. If you are a woman who has an opioid use disorder, opioids mess up your endocrine system. Most women who are using opioids regularly and have been for years don't ovulate regularly and they don't have regular periods. Many of them may have been having unprotected sex for a decade or so without getting pregnant and may genuinely believe that they cannot get pregnant. All of you probably know a story about somebody in your friend group or contact group of some 45-year-old woman who was having stomach pain for months and nobody could figure out why because it just didn't occur to anybody that she'd be pregnant. This happens a lot for women who are using opioids and critically it happens when you start treatment and you start to stabilize a little bit and your hormone levels start to stabilize a little bit and you may get pregnant before that first period hits. And you may have had no idea it was even possible for you to get pregnant. So that is a very good reason why many people who show up late for care show up late for care because they genuinely didn't know they were pregnant. That's one. Two is if you told me that because I have diabetes and I know that and I know how much harm it's gonna cause to my pregnancies that if I get pregnant, I'm gonna have to go through a legal process where you can decide whether I get to keep my kid or you get to keep my kid, I'm gonna try not to show up for care. And I would argue that I am neither dumb nor poorly educated, right? And I would choose to try and hide my pregnancy and take care of it on my own rather than show up if there was a risk that you were gonna take my child away from me. So what you guys see as or can see as being ashamed, as not caring enough to show up is often a sign of the very opposite that they want that baby so badly that the threat of showing up someplace where people have the power to take their child away from them, they may be more than they can make themselves do. We know that overdose mortality has surpassed hemorrhage, preeclampsia and sepsis as a cause of pregnancy associated death. For those of you who are OBs or nurses on the labor and delivery floor, I'm gonna guess that you have actually very specific protocols for dealing with each one of these things, right? Hemorrhage, preeclampsia and sepsis. Makes sense, they're scary. We don't want those things to happen, right? But in fact, if I am in my office or you are in the hospital and a person walks in and they're pregnant, the thing that they are most likely to die from within the next year is actually overdose, which takes us back to that question of, are you screening with a validated tool? And are you making sure that if you screen that you're connecting people to treatment for their chronic life-threatening disease for which we have evidence-based treatment that is at least as successful and often more successful than our treatments for other chronic diseases. And just because somebody always says this, there are a lot of different ways that we assess death associated with pregnancy. So pregnancy associated death specifically refers to any death that occurs during pregnancy or within 12 months of the end of pregnancy, whether or not it is caused by the pregnancy. We know that pregnancy can be a powerful catalyst, which is why we encourage screening during that time period, right? Because that's a time where mom is super motivated for change. But we also know that the shame and stigma that surrounds this can actually be a real barrier to showing up for treatment and for change. And balancing that internal motivation to do good versus your internal shame and fear can be a really difficult thing. And so it's not, some women will really do well with treatment during pregnancy. It'll be like the ideal time to interact with them. And some women will fall heavier on the shame and guilt side. And it may be harder to work with them. Then it doesn't mean that we shouldn't work with them. It doesn't mean there's anything wrong. It's just recognizing that that, if it's harder to work with them, doesn't mean that they don't care about the pregnancy or they don't care about their baby. It may just be that their guilt and fear around that are so overwhelming that they're almost paralyzed when it comes to doing the other things. And then in 2020 in Anchorage, you had about 13 per 1,000 newborns that were diagnosed with neonatal abstinence syndrome. So this is not an insignificant problem for you. I will also point out just to muddy the water that there are a lot of things that cause withdrawal symptoms in infants. And if your hospital is not real experienced in kind of parsing those out in the timeframes, you may miscall this entirely. So obviously smoking can, antidepressants can, certain blood pressure medications can. I mean, there's any number of things that can cause withdrawal symptoms that look very similar. And that'll tie into kind of our eat, sleep, console conversation later and why the eat, sleep, console methodology is such a good methodology for managing withdrawal symptoms. But the fact that an infant is withdrawing after birth isn't proof that people are bad for using heroin and fentanyl because it makes them withdraw. We see the same types of symptoms in babies that are exposed to prescription medications that mom needs to control her other diseases as well. So why don't we detox? In a perfect world, wouldn't it be better if babies were never exposed to drugs of any kind during pregnancy? Yeah, of course, right? However, this isn't a perfect world and that baby does not exist in isolation. The pregnant individual has a chronic life-threatening disease that requires treatment. And if we're gonna treat something, we wanna use evidence-based treatment. We know that when mom gets pharmacotherapy for her opioid use disorder, that she's less likely to die from overdose. We know that she's more likely to actually show up for both her addiction treatment and her OB visits. And that's what I have to say with a little bit of a disclaimer. She's also more likely to deliver in the hospital, those of us who are medical professionals generally think of as a good thing. I am from Humboldt County in Northern California. Humboldt County is the queen of alternative birth methodologies, midwives, home deliveries, bathtubs in the field, you name it. I am not here to judge other people's decisions about how they deliver their infants. Having had two babies that ended up in the ICU, I would never even consider delivering a baby any place other than a hospital that had a tertiary ICU. But if you choose to do that, I think you have the right to choose it. It should, however, be a choice based on your beliefs and not something you do in terror because showing up could result in having your child taken away from you. Again, I just said I would never even consider delivering my baby any place other than the ICU. There is an exception to that. If you told me there was a risk you could take my baby away and there was nothing I could do about it if I delivered in the hospital, mind you, 28 and a half hours of labor with my first child, I still would have attempted that at home rather than going into the hospital. And I suggest that that is actually the only rational course of action to take in that situation and to put people at risk of having to be afraid and hurting and doing this at home on their own because it is literally too dangerous for them to come to the hospital because they could have their child taken away is inhumane to a degree that it's hard for me to even imagine somebody voluntarily accepting if they thought that through and what that meant. So you read these stories, these horror stories in the newspaper about these terrible drug addicted young women who choose to have their babies in hotel rooms and then something goes wrong, baby doesn't make it and they end up putting the baby in a trash can. You've heard these stories and these women being prosecuted for crimes. And we all sit around and we go, those are really bad people. Man, drugs really screw you up. I don't know that I wouldn't have tried that. I don't know that you wouldn't have tried that. I mean, having our children taken away from us for those of her parents that is the most viscerally terrifying thing that I can imagine. And for us to sit out here and be like, she was clearly a bad person, the drugs messed her up, that's why she did that. I'm gonna argue that we don't know anything about what kind of person she was but it's more likely that our system is a bad system and she did the only thing that she thought she could to try and keep her child. And rather than criminalizing her and jumping to conclusions about her being a bad person, we should be asking ourselves, what do we do that contributes to somebody making those decisions? So why don't we detox? You guys are all familiar with X and Y axis. X axis, the number of days since the detox process happened. Y axis, the percentage of patients maintaining abstinence at that time. So can I point out that on day one, day one at your highest rate, you are already at only 75% successful with making it through day one. And by day 30, you are down 17 maybe, 17%. And you are at an increased risk of overdose death because you've lost your tolerance or at least some degree of tolerance. So you're at a higher risk of dying when you relapse and use. Is it ever okay to recommend a treatment for a life or death condition that has a less than 15% success rate at 30 days out when you have a treatment that is between 60 and 70% successful for treating that disease? And that's why this is actually considered malpractice at this point. Because there is no rational justification for recommending a treatment that fails at least 75% of the time within 30 days when we have treatments that are 60 to 70% successful at keeping people alive and controlling their disease. This is malpractice. This is criminal. And if you walk out of here today still thinking, I don't know, you need to ask yourself, what are your concrete blocks? What are your pound story that are making you hold on to the idea that this is actually okay when we know it results in deaths and it doesn't improve outcomes for the infant at all? So what does pharmacotherapy do? What does appropriate therapy do? Well, first of all, nobody calls insulin medication-assisted therapy for diabetes that you can have if you go to seven sessions of nutritional counseling first and hit the gym with the free pass that I'm giving you twice a week, right? Insulin or other meds for diabetes are fundamentally the treatment for diabetes. And if you add on the nutrition education, the exercise, the other things, you get even better outcomes. Yay, medical care, right? But nobody says, Mrs. Smith, I'm sorry you were admitted to the hospital for a hyperglycemic coma. We see that you have a new diagnosis of diabetes and we know that your chances of surviving with this diagnosis of type one diabetes without insulin are not very good. However, people die from injecting insulin. They do, by the way. People die from injecting insulin and insulin is kind of expensive, only because we make it that way, but don't get me started on our pharmaceutical industry. And therefore, if you want this insulin prescription, you need to go home and go to these once a day, two hours diabetes education courses for at least a month and keep your sugars under control during that time without any med. And if you can do that to prove to me that you're serious about getting your diabetes treatment, I will prescribe insulin for you. Could never be okay. You'd lose your license that day. It's not okay. And yet we do this to people with substance use disorders in spite of the fact that the evidence shows us overwhelmingly that that doesn't work. So when you do put people on medication for their chronic disease, their opioid use disorder, what do we get out of it? In this case, we're talking specifically about buprenorphine and methadone. Why? Because those are the only FDA approved treatments during pregnancy. There's some conversation about naltrexone, which we can discuss afterwards if you want, but these are the two that are FDA approved. They reduce opioid use. They do that by reducing cravings, they reduce withdrawal symptoms, and they minimize the euphoria that happens when you do lapse and use your drug of choice. Notice I said they reduce opioid use in much the same way that insulin reduces sugar levels, but it doesn't make you not diabetic anymore. And if you eat those tortilla chips at the Mexican restaurant when you go, because you only want to, and you're sure that two won't be a problem, you will still sometimes have high blood sugar. And when you go in for your visit, nobody says, oh man, your blood sugar is high today. We're cutting off your insulin. You don't deserve it if you're not gonna do better than that. I know you ate those tortillas, right? We say, huh, can we adjust your eating any? If not, how much more insulin do I need to give you to cover those tortilla chips? I'm gonna skip that one for a minute. They help prevent overdose deaths and they prevent HIV transmission. I think those are things we can both agree are good. Skip the top one for just a second because I think that deserves some qualification. For those of you who are OB or family medicine providers who work with pregnant individuals, just a cautionary tale. I think that we all internally recognize that low birth weight and low head size are associated with a plethora of medical complications that we would prefer to avoid. So when we say you have increased birth weights and increased head circumference, that sounds like a good thing to us. When you say that to a first time 17 year old mother who's going to be delivering, it does not sound like a good thing. So make sure when you're quoting the research that you actually pay attention to what the research means. We're talking about increased births at term, increased birth weights and increased head circumference as a good thing because we understand that with uncontrolled substance use disorder, babies are typically born smaller than normal and with treatment they get back up into the normal range which is good, but make sure that doesn't come across as big heads and big birth weights because that does not sound good to a delivering mom. And then here's the most important thing. We get really hung up on what treatment is best for mom or what treatment is best for baby, right? Well, is methadone better for baby or is bupe better for baby? Because bupe babies don't tend to need quite as much treatment in the ICU and so we really think mom should be doing bupe. 15 years ago this was, well, mom should really only do methadone because that's the one that we have the data on. The truth is I don't care because just like nobody really cared that my baby was going to end up in the NICU in the sense that it was just an expected part of my illness that was going to happen and as long as they treated that appropriately it wasn't going to affect her long-term outcomes. What was important is that her mom was alive and healthy enough to be able to take care of her. The same is true for substance use disorders, opioid use disorders specifically. We don't really care. We would like to minimize the time, the number of medical interventions the baby needs, the time the baby is in the NICU, the cost of those interventions because that's good for the healthcare system as a whole and having babies in the NICU is very stressful as a parent who's sat through that twice, I can personally affirm that, right? So we'd like to be able to minimize those things just as a matter of course, but in fact if we're going to talk about what's best for the baby long-term, the best thing for the baby long-term is to have a stable family of origin that can raise it. So the best treatment for baby is whatever the best treatment for mom is. When you meet an adult and you're getting to know each other and that adult says to you, I was raised in foster care, are there any of you who think to yourselves, wow, I hear that's really great, tell me more about that? So again, we look at these babies in the moment that we're born and we look at the mother who has a substance use disorder and we get scared about sending that baby home in that situation because this is a helpless and generally adorable slash ugly life that we feel very responsible for in that moment and good for you that you do, you shouldn't be here taking care of people if you didn't feel a sense of responsibility. But then we tend to separate that moment from the trajectory of the baby's life. I got into substance use disorder and working with pregnant women in particular because of the long-term consequences I was seeing in my 50 and 60 year old patients who weren't doing a good job controlling their diabetes and congestive heart failure and other chronic diseases and trying to understand why that was and listening to their stories of their very traumatic childhoods, right? That baby is only a baby for just a blink in time. And so when we're making these decisions about how we're gonna react to that baby, whether children should be taken away from their families, we need to think about those in the spectrum of their entire life and with what we now know about adverse childhood experiences and the disruption from being removed from your family of origin, it's becoming really clear that many of the long-term consequences that we have attributed to being exposed to drugs in utero are actually caused by the chaotic environment that the child's growing up in and not by the drug exposure itself. And so again, if we directed our time and energy and money into stabilizing those families of origin instead of pulling those kids out because we think we're saving them and then they go into our foster care system or some other less than ideal option, right? It's not a given that that's better for the child. You don't have to be a good parent, a great parent to raise an okay child, you just have to be a not that bad of a parent. If any of you think you were great parents, I don't wanna hear, I will just feel worse about myself. I think all of us kind of accept that there are things we wish we'd done differently and yes, having a substance use disorder is gonna make being a not that bad parent a lot harder because it is a very disruptive chronic disease but it doesn't mean it can't be done and if we tailored our interventions towards supporting that instead of assuming that they couldn't, we would be operating a very different system. So what is appropriate treatment for opioid use disorder during pregnancy? Is pharmacotherapy only acceptable treatment? Absolutely, all the way, 100%. If you can also provide or if they are also willing to participate in behavioral therapy components and support systems, that is even better but it is okay to just treat with pharmacotherapy if the other ones don't work, can't work, they won't do them, whatever the case may be. Is detox ever okay? I wanna hear you say it. Is detox ever okay for you to recommend? Thank you. Behavioral therapy only? No, for exactly the same reason, right? That the evidence tells us those treatments do not work to keep people with this chronic disease alive. And for us to recommend a treatment with a 10 or 15% success rate, it has to be the best treatment out there. There has to be nothing better. And there are diseases and times where we do that, where the very best treatment that we have to offer is only 10 or 15%, and we feel terrible about it, we're sick to our stomachs the whole time we're doing it, and we don't expect a good outcome, but it's still the best that we have. So we offer it when that's all we have. We never offer a treatment that has a 15% success rate when we have a treatment that has a 65% success rate. It's not okay. I throw this slide up, this study up, because this is actually from the MOTHER study. So remember I said there was a time, and I think many of you are old enough to remember it with me, when methadone was the only approved pharmacotherapy for use during pregnancy. That has not been true for quite a while. The MOTHER study was done to actually compare efficacy and to try and establish that buprenorphine was at least close to as effective and at least close to as safe so that it could be used. Yes. Is it buprenorphine by itself, or is it with naltrexone okay in pregnancy? I remember at one point it was like 70 tex so you don't have the naltrexone and I'm not sure. Yeah, no, so that's a great question. And the answer is the combo product is fine. And I'd actually argue that the combo product is probably better as long as the combo product remains the mainstream product. So for those of just kind of a two-minute diversion, so because we have all these weird hang-ups about addiction treatment in this country, when we approved methadone, we made it happen in secret places that couldn't communicate with the rest of the healthcare system and we put all these ridiculous requirements on it. And then buprenorphine came out and we attempted to modernize that system and make it more accessible, but we couldn't quite let go of our stigma and hang-ups, so we insisted that they do things to make it less abusable. So the naloxone in the combo product is not designed to prevent overdose, it doesn't help offset symptoms, and in fact, it causes side effects in many people who use it, but it's called an anti-diversion measure. So it's intended to make it so that if you dissolve it and inject it, that it blocks some of the effect of doing that so that you can't redirect it that way. I will say that not that many people enjoy injecting buprenorphine, number one, and number two, it's a complete failure as a diversion treatment because it's not a high enough dose to fully block the effect of the buprenorphine. If you do inject it, but nonetheless, from a regulatory standpoint, we believe it's less divertible, and therefore, that is what we mandate they use in non-pregnant individuals. And for those of us who started doing this treatment early on before bup was FDA approved for use during pregnancy, we use nothing but combo therapy in patients who are pregnant. So the entire first five years of my career, I use nothing but combo therapy in patients. Briefly, when they started switching over to the monotherapy product, I tried that, but there were two problems with it. One, if you make a big deal out of seeming like it's more divertible, then you make it more attractive for diversion, even if it's not really physiologically more divertible, which means that your pregnant patient who has this drug is at more risk of having it taken away from her, which is a concern. And then the other piece is, you come to me when you're pregnant, you're the most vulnerable that you've ever been, and I start you on this medication, and it helps you. And you develop a trust relationship with that medication, and a sense of confidence in it, because it is the medicine and the team that saved you when you were at your most vulnerable. And then you deliver your baby. For me, that was a very chaotic process. And you take that baby home, also a very chaotic process for me. And in the middle of that, you say, well, you're not pregnant anymore, you can't have this med anymore, you have to change to the other one. Because now you're not pregnant, you can't have the monotherapy product anymore. Many people will have some level of side effects when they switch, because they will absorb a little bit of the naloxone sublingually by swallowing their saliva. So you've not only taken away the drug that they trust and feel safe with, and forced them to change to something else, but you're also giving them one that is likely to cause a little bit of side effects that they won't have had a chance to get used to, and learn how to deal with. And so you're taking them at the most vulnerable time in their life, when Child Welfare Services is talking to them about whether or not they can keep their baby, when their baby might be sick in the hospital, and you're making them change to another medication, and you're just adding another level of potential for failure. So most of the programs I'm aware of that have been doing this long-term do not use monotherapy product with pregnant women anymore as a standard, just because the risk isn't worth it. There are still a few that do, and there are programs that are starting to actually push towards using the monotherapy product for any patient that wants it, not just pregnant patients, which I actually think is ultimately the right way to go, and that ultimately we'll end up with just a monotherapy product. But for right now, at least, that's why I don't use monotherapy product in pregnant patients. I'm pretty sure Sarah does the same thing. Yeah, well, I think ASAP guidelines should be a patient-directed conversation about, so I talk to them, I say, hey, we use a combo product all the time in pregnancy. It's bad to say, I know you might read a lot of different things online about the monotoxins, the one you have to take in pregnancy, which really isn't true, but if they feel really strongly that that's the one they want to take and they feel safe, they're like, okay, if you feel really strongly, that's it. You just need to know that the insurance is gonna require you to change the combo product after pregnancy, because I have this patient-centered conversation about that. Yeah, and there are, unfortunately, a number of times in addiction treatment currently, as it stands, where you have to get hung up on insurance regulations or state regulations or policies within your own practice, but in general, no, we don't encourage that. So anyway, these are just some differences between the two, and I throw them up, not because I think any of you are gonna prescribe buprenorphine, and I realize that most of you may not end up prescribing buprenorphine, but if you work with pregnant individuals, you should be at least passingly familiar with how this chronic disease affects them and information that they might face. So with methadone, as you get further along in your pregnancy, you metabolize the medication faster, and so most of the time with methadone, as you move through pregnancy, once-a-day dosing won't work anymore, which can cause a lot of difficulty for some people, so you'll need to go to split-day dosing for almost everybody, and you'll need to increase the dose for most patients as they move into the third trimester, somewhere between the second and third trimester. So just things that you need to be aware of. It's not that the patient's drug-seeking or their disease is getting less well-controlled, it's that their body is breaking down the medication faster. That does not happen with buprenorphine. By and large, every once in a while, you run into somebody who feels like it does, but as a whole, that's not something you see. Old guidelines, you had to monitor everybody on methadone with EKGs. That's changing now, but there is still some concern for people with some underlying cardiac arrhythmias that this could be a little bit riskier, whereas that's not true with buprenorphine. And then depending on which study and which design of treatment program you look at, in many studies, it showed that it was a little bit easier for women to stay with buprenorphine therapy than it was with methadone therapy. As you can imagine, if you've got to drive in daily for dosing and stuff. This should not be used to say that one treatment is better than the other. It's to help you understand some of the pros and cons of the treatments better, because the best treatment for baby is whatever the best treatment for mom's chronic disease is. And so she really needs to make that decision in conjunction with you, and you can't really support that decision if you don't understand some of the differences between the meds. So again, just a reference to the study itself so that you can check it, but not intended to prove one med is better than the other. This was done to show that it was okay to use buprenorphine during pregnancy. And when you do in those studies, you do tend to see a lower dose of morphine needed to treat neonatal abstinence syndrome. You do tend to see a shorter period in the hospital and a shorter number of days needed for treatment. And no one's entirely sure how relevant this is anymore, because this was performed during a time period where the standard treatment for neonatal abstinence syndrome was a Finnegan scoring scale and opioid taper for all babies, right? That scored above. And given that we don't manage it that way anymore most of the time, it's not really clear how super relevant this is, but I do mention it because other people will and you should know. How do you take care of women during delivery? How do you manage their pain? So what I would say with this is for both intrapartum pain management and post-delivery pain management, particularly if you've had a large laceration or you've had to have a C-section, that this, like all treatments for chronic diseases, should be managed at an individualized level after a discussion with the patient about the risks and benefits and their concerns and desires. Some patients are terrified of having uncontrolled pain because they've been left in pain before. And that is the most important thing to them, managing their pain. Some patients are terrified that using a pain medication during the delivery process will trigger them to return to use again. So this isn't really a yes or no type of answer or here's your protocol, use this for pain. Do know that your baseline dose of pharmacotherapy is adequate to control your withdrawal symptoms and most of your cravings and desires. If you activate a whole bunch of pain receptors on top of that, you cannot just then say, well, it doesn't matter, they're already on methadone or buprenorphine, it's treating their pain. It's not, it's the level needed to maintain their opioid deficit, to maintain their withdrawal symptoms so that they're not sick or at increased suffering from that. But if it would have required pain management of some sort in a patient who's not on opioid use disorder, if it doesn't have an opioid use disorder, it will almost certainly require some level of pain management for patients who are, and they likely will need higher doses than you are used to in other patients because they do have tolerance and you are having to overcome a partial blockade by buprenorphine if that's the case. So epidural, epidurals, spinal anesthesia, those are both good options if you have them. If you do operations, IV Tylenol can be great. Yes. Just thinking about, for a post-op patient who's not pregnant, like, okay, 16 milligrams of hydromorphone, this makes me a little nervous, but I'm okay, but I think, especially like labor and delivery nurses are gonna be pretty concerned about- Yeah, about, I'm sorry, about causing respiratory suppression in the infant. So somebody asked me this at the last conference and there were like four of us in the room who do this regularly and we've actually never seen a baby have respiratory suppression, a chronic opioid exposed baby. Sorry. We've never seen a baby who's chronically exposed to high doses of opioid throughout pregnancy, whether it's mom using heroin or fentanyl or whether it's the pharmacotherapy that we're giving them that actually ends up with respiratory suppression. From that, I'm not saying it's impossible. It's certainly possible, but those babies are exposed to high doses every day in much the same way that my baby was exposed to really high doses of insulin every day and so it didn't, you know, my babies didn't make any insulin when they were born because they just weren't used to needing it, right? So these babies are very opioid tolerant, but again, even if there was a respiratory suppression, they're in the right place. It's what we monitor for, it's what we treat for. It is a projected potential outcome from mom's chronic disease. Now, absolutely, if you load an opioid naive mom up with opioids during the delivery process, you need to be prepared to resuscitate the baby. That's just gonna be a thing, but not generally for these opioid exposed babies. Yeah, so we avoid the opioid dosing during pregnancy, not because we're concerned about the impact on, or during delivery, not because we're concerned about the impact on the infant, but because it's just trying to effectively control mom's pain during the process. I wanna continue mom's pharmacotherapy dose postpartum. I mentioned that because with moms who are on methadone, remember they may have had a dose increase during the end of their pregnancy. You don't wanna immediately drop them back down the morning after delivery, you just wanna monitor symptoms. Recognize that you might need to decrease the dose if mom is over sedated, but I would also just suggest that an overly high dose of methadone is not the only reason that a woman who just gave birth might be tired and not waking up easily. So don't jump to the conclusion that it's methadone and decrease your dose immediately, that will not be effective. Then you will just have a very tired, cranky mom who is also in withdrawal, which is not fun for anybody. NSAIDs and non-opioid pain medications, scheduled orders, not PRN. I think Sarah already talked about that, so I won't beat that horse too much. And you can use full opioids. Again, Sarah covered that, so I'm just gonna skip past this. Next most important thing. We follow women really closely during pregnancy. We follow them really closely for about three to six months after pregnancy. At about six months after pregnancy, if mom or baby are doing well, we start patting ourselves on the back and telling each other we did a good job. The highest risk of overdose death for women who have gone through pregnancy is six to 12 months postpartum. And so it's something that you need to be aware of at the time that you're pulling back the more intensive support, because under other circumstances they wouldn't need it. If you have women with substance use disorders, that six to 12 month period is the highest risk period for death. So it is really important. And if you keep those women on their pharmacotherapy, oh, I forgot I have a pointer. If you keep them on their pharmacotherapy, right, they have lower risk of death, that's the orange line, but not zero risk of death. So it is better to be on pharmacotherapy than not, and all of those women on pharmacotherapy or not need to be monitored because they still have an increased risk of death at that six to 12 months postpartum stage. Can you breastfeed? Yes. There has been an argument made that the small concentrations of methadone and or buprenorphine that pass through the breast milk actually help to offset withdrawal symptoms in the infant. I think it might be more reasonable to actually, now that we recognize eat, sleep, control methodology, that it might actually be the skin to skin contact of breastfeeding that's actually reducing withdrawal symptoms and not the medication itself. But at any rate, it is safe to do. It's not going to cause problems. It increases oxytocin levels in the mom, which leads to lower stress, better bonding, and decreased risk of relapse. And for infants, they tend to need less pharmacotherapy. And again, that probably has to do with the skin to skin contact, that part of the whole eat, sleep, console methodology as opposed to transfer of opioids. But either way, it's better for both of them. Birth control. Yes, right? But birth control in the way that you would offer it to any of your other patients, which is we know that you and your baby, no matter who you are, will do better and have better outcomes if you space your pregnancies by at least 12 months. We don't tell you that because we think you're a bad person who doesn't deserve to have children. We don't tell you that because we think you have no business getting pregnant with your chronic disease. We tell you that because we know for everybody, that is the way that you get the best outcome. So when you're working with individuals who are pregnant who have substance use disorders, they should be getting the same advice, not in a judgmental way, but in a supportive, this is education we do for everybody way. And if they agree that they do not wanna get pregnant for the next 12 months, we should also recognize that these women are going to have a lot more barriers to regular medical followup, right? They're gonna have probably some, there's a high likelihood that they'll have some level of criminal justice or child welfare involvement. They have the chaos of managing their chronic disease on top of the chaos of raising a new baby. They've got external family pressures that are telling them they need to get off their medications and we've got all kinds of things going on. So if we can offer those women long acting or reversible contraceptives before they leave the hospital or at least have a plan to get it in at that first week followup, that is by far the best outcome for everybody. And I would suggest that that is true for all women who have chronic diseases, not just a substance use disorder, that getting that done is important. So my son, when he was born, his lungs were immature, he spent 10 days in the ICU on respiratory support and they were not sure he was going to make it. And my OB was crying and begging me to get my tubes tied because it was not a good pregnancy. 700 units of insulin a day, multiple hospital admissions, like not a good thing. And the truth is I didn't want more children, but I was not capable of making that kind of a permanent decision when my child was lying in the ICU and I wasn't sure he was going to live. It's not like I thought having another baby afterwards would make that okay. It was just, I wasn't emotionally capable of making that decision. If somebody had offered me, however, the option of putting in an IUD for me, at that point I would absolutely have taken it because I didn't want to be pregnant again in the next 12 months. Like I didn't really ever want to be pregnant again, but I just couldn't do that in that moment. And so I would argue that this is actually not specific to women with substance use disorder. This is just good practice. A little bit about stimulant use disorder. You know how I told you that you should never offer a treatment that's 10 to 15% successful when you have a treatment that's 70% successful? Stimulant use disorder is really difficult. I'm not going to lie. I'm not going to pretend we have great treatments for it. We have a few treatments that have between a 10 and 12% success rate. That's not great, but we have other diseases for which we have really abysmal success rates. So I'll give you the worst possible scenario. I have a friend right now who has a six month old infant. She has a terminal inoperable ocular cancer that has spread to her brain. It had spread to her brain before she decided to get pregnant. She actually decided to get pregnant after that fact. I personally think she is crazy and would never have made that decision. Having said that, none of us ever thought, I wonder if we should be calling Child Welfare Services because this woman has a disease that is going to kill her within the first couple of years of her child's life. Instead, we sat down and we thought about how can we support this parenting process for whatever time is available? How can we help build memory boxes and leave messages? Sorry, I'm not doing real well with this. She is not doing real well. But it never occurred to us that because you made such a crappy decision and you have a disease that cannot be treated and you are going to die that we had the right to even consider taking your child away from you. Instead, we invested everything we had in trying to support that parenting process for however long it's possible because we believe it's important for mom and we believe it's important for the baby. And so to say that, you know, if the disease is less treatable, if we don't know how to do this, that, you know, that that changes things, it doesn't really because in any other chronic disease, we wouldn't react that way. We would be looking at supporting parenting for as long as possible. And we have a lot of anxiety and fear around methamphetamine use disorder, stimulant use disorder during pregnancy. So we talk about really small babies and preterm deliveries and all of the placental abruption and all of this risk. Again, personal story, my son, one of his testicles did not descend like it was supposed to and they did not catch it in time in spite of me asking if there were problems multiple times and he ended up being well past the cutoff age by the time he had surgery for it. My urologist told me very helpfully that I had just quadrupled my son's chances of getting testicular cancer, which was horrifying as a parent. And I said, well, what does that actually mean after I got over crying? And he said, well, it's quadrupled. I said, okay, but what is that? Well, it's like four times as high. And I'm like, yeah, I can do math, what is that? So I went home and I looked it up. I'm like, oh, it went from one in 60,000 to one in 15,000. Yeah, that is four times as high. And also I am going to let my son get a driver's license and date someday and if I can handle those things, I can handle a one in 16,000 chance of testicular cancer, right? How we present those numbers are important. So when we talk about small birth weight babies because of stimulant exposure during pregnancy, we're talking about a baby who comes at 37 and three days on average, as opposed to 39 and one. When is the last time you were concerned because a baby was born at 37 weeks and three days gestation? Right, lower birth weight. Instead of 3,300 grams, you're coming in about 3,100 grams. If I remember correctly, that's like five and three quarters versus 6.2 or something like that. So yes, it is smaller, but we're not talking about a two pound infant that's in a special isolation bassinet in the NICU, right? It's a little smaller. It's statistically significant, but it's probably not really clinically significant. Placental abruption, baseline rate is a risk of 0.4 to 1%. Odds ratio for increase is 5.6%, which puts you at somewhere between two and 5% risk, which means somewhere between 95 and 98% of stimulant-affected pregnancies will not have a placental abruption. Is it fair to talk about these risks? Is this important for us at a population level to understand them? Absolutely. Should we be saying your son is now four times more likely to get testicular cancer because this didn't get done? I mean, it's true, but it's misleading. And the same thing for when we talk about really small babies, really early babies being born after stimulant use exposure. It's true, but it's misleading and not helpful. What are treatments for stimulant use disorder that work? Contingency management, maybe a combination of bupropion and naltrexone, both of which are actually approved for other uses during pregnancy. So there's a handful of things that have a 10, 12% success rate, and we should offer those things where they're available, and also some diseases we just don't have very good treatments for yet. And harm reduction, always harm reduction. Harm reduction is the cornerstone of chronic disease management, right? When we screen for retinopathy in diabetics, when we use inhalers, when we talk about the allergen proof covers on mattresses and pillows, like all of these things are harm reduction to minimize the long-term consequences of chronic diseases that cannot be cured. Harm reduction in the setting of substance use disorders are exactly the same techniques that we practice with all of the other chronic diseases that we treat. So what's harm reduction look like for stimulant use disorder because we don't have a lot of effective treatments for it? Information, real information, not scare tactic information, because when you tell me my baby's gonna be two pounds and be in the ICU for seven months, I'm too guilty every time I've slipped up and used to come back and get the other care that might help me have a better outcome. When you tell me quitting any time can make outcomes better, reducing use can make outcomes better, and even if you're not able to, there's other prenatal care we can give you that will help you and your baby do better, and it's okay because not everyone can quit. We open the door for them to keep coming back for the other treatments we can still do to help them. Overdose education, I think everybody knows this, but at this point, it's really hard to find a completely clean supply of methamphetamines that doesn't have any fentanyl involved. So even if you think your patient just has a stimulant use disorder, you still wanna be giving them Narcan. Syringe exchanges, or just syringe services. Condoms and safer sex education. Remember that if you have patients who have a substance use disorder, the chaos that that causes in their life leaves them open to be involved with abusive partners where they may be forced into coercive sex. They may have transactional sex just to get the food, shelter, and other things they need to survive, and so they may have less control over their own bodies than your other patients do. And so supplying them with condoms and education around that to the extent that they're able to use them can be very helpful. Topical antibiotic creams and ointments for injection sites. Oh, and acknowledging that issue around sex for them so that they can come in and ask for SDI testing every month if that's what they wanna do so that you can get them screened. Recognizing that can happen to them and not making them feel shamed so they can walk in and say, hey, this happened, I need to be tested. Water, getting dehydrated is very common. Hydration's really important for all kinds of reasons in pregnant individuals. Oral hygiene care, so providing toothpaste and toothbrushes. If you have the ability, quiet rooms where people can wash up and shower if they don't have access to those resources on their own. So those are all things that you can recommend. And this level of harm reduction is the same thing that you do for all other chronic diseases. So when somebody looks at this and says harm reduction is a dirty word, just please point out to them that this is how you manage chronic diseases. All of them, all of the ones we care for. So I'm not gonna spend a lot of time talking about Eat Sleep Control Console because A, you already do it and B, I'm not very good at timing myself and I've got like two minutes left. But if people have questions, there is lots of documented work now that shows actually that the outcomes are just as good for infants so they spend less time in the hospital, they require less medication treatment and they are not more likely to end up readmitted than infants who are managed with traditional opioid tapering schedules. Would also say that the scoring for Eat Sleep Console because it's based purely on symptoms and managing those symptoms is less inherently biased than the older Finnegan scale was. So if you had scored my insulin withdrawing baby on a Finnegan scoring scale, you would have scored them fairly high for opioid withdrawal so we do know that where it's been studied that the scorer's perception of the parent if they know the parent used drugs or not actually changes the way the infant scored. Essentially, it's more open to bias that can disadvantage certain groups of people so this is good for a lot of reasons, good for baby, cheaper for the healthcare system, less biased, good thing. Oh, and it also helps mom learn the skills she's gonna need to manage baby when they go home as opposed to keeping baby locked up in an ICU for a month and then sending them home suddenly. So what do we do if we treat this like a chronic disease? We inform ourselves, our colleagues and our patients about what they can expect during pregnancy that's affected by this chronic disease. We educate the patients about what to expect during the pregnancy, during and after the delivery and that includes getting familiar with both medical outcomes and legal outcomes in your area. If you are postpartum and somebody walks into your room and says, hi, I'm Jo, I'm here to evaluate you and see if I'm gonna take your baby or not, the normal reaction to that is to lose your temper and lash out, that is the only appropriate reaction from a parent who just had somebody threaten to take their child away from them. Unfortunately, that is often viewed as lack of emotional regulation on the parent's part and additional evidence that they are not qualified to take their child home with them so while it's not fair, one of the best things we can do for our patients if we know they face that is to coach them about that up front. So early on in my career when not many people understood this, I would actually write all of my patients letters, I'd seal them with my personal cell phone inside, I'd say, it's possible that somebody will call Child Welfare Services and somebody will show up to talk to you and if they do, I know it's hard, it's almost impossible but I need you to take a deep breath and remember that we talked about the possibility of this happening and give them this letter and tell them that you want them to call your doctor. Give them something so that they have some other way they can fight back because it is not natural to have somebody threaten your child and not try to fight back so you need to give them a safe way to respond to that situation and then prepare, make sure that you've got a plan in place, make sure that whoever's covering for you when you're on call or on vacation or whatever the case is, understands that they might get these calls and they may need to advocate for their patients and that's it. I made it like right on the dot if that clock is right. I think, I'm pretty sure I cut into like the edge of the next presentation so I will be around till afterwards but I'm not sure that we actually have time for questions. Oh, we do. Okay, nevermind, we do. Yes. I wanted a little bit more about Eat, Sleep, Consult with you. Sure. So, Eat, Sleep, Consult. So when we manage a chronic disease, we're really looking at the impact on your basic quality of life, basic life skills functioning, right? Can you do the things you need to do? For an infant to survive and thrive, you need to be able to eat, you need to be able to sleep and you need to be consolable because an infant that's not consolable is it unfortunately increased risk for physical abuse because there's only so long anybody can listen to an infant screaming before they lose it. So instead of assuming that a child's going to need pharmacotherapy, you work on soft parenting skills basically so every hour you do an assessment, is the infant able to eat at least one ounce per feed or breastfeed well? If they are, they are meeting that goal, no concern. If they're not, then you move to the next category which is non-pharmacologic interventions and I'm gonna skip that till we get through each of the first three steps. If the infant is eating, can they sleep for an hour at a time, right? The answer is yes, you're good, move on. If the answer is no, we go to our non-pharmacologic interventions and the next one is, can your infant be consoled within 10 minutes? Yes, we're good, repeat every hour, no, move to non-pharmacologic interventions. How many of you have babies or had babies at some point? If you wanted to make your baby cry, what would you do? Undress them, set them down, put them in a brightly lit environment, maybe throw some random beeps into the background, have people walk by in a hurry. Like if you wanted to agitate a baby, that is what you would do. If you want to console a baby, turn the lights down, limit the visitors, decrease the noise in the environment, swaddle them, skin-to-skin contact, breastfeeding on demand or feeding on demand. If you want to console your baby, that's what you do, right? That is standard practice for all babies. That's like not magic, we know this. Well, it turns out that you can manage the physical symptoms that most babies are experiencing with withdrawal by doing this. And if you think about that, that makes sense. If you've ever had, your baby's ever gotten a cold or the stomach flu or whatever, what do they wanna do? They wanna curl up against you and snuggle and then they vomit to the side or write down your shirt or whatever the case may be, and then tuck their heads back down again and feel better. Because that is how infants are consoled. They don't have this sense of suffering, of like the fear of what's gonna happen in the future. Oh, I felt like this before, I know what's coming. Like adults do, they have just this very visceral, in the moment, this is how I feel and nothing makes me feel better than being snuggled up against my person, right? So it turns out that you can control most of the physical manifestations of withdrawal from most babies using this system. Not always, not everyone, but most of the time that we can. And that makes a lot of sense if you realize that, again, going back to adult patients, if you've got an adult patient who's on the post-op floor, med surge floor, recovering after surgery, and it's the middle of the night and they're cranky and they don't feel good and they're annoying the nursing shift, and you've got an order from morphine and you give them morphine, they're suddenly a lot less agitated and irritating, right? Because if you not load somebody up with morphine, it mellows us out, regardless of what the cause of the symptoms are. Same thing is true for babies, right? You load a baby up who's in nicotine withdrawal with morphine, they're gonna quit showing physical signs of withdrawal. Did you treat the problem? No, you just snowed them so that they're not expressing the problem in a way that bothers you. But you're not actually treating the underlying problem. There are a lot of things that cause withdrawal-like symptoms in infants, and the vast majority of them can be managed with this Eat, Sleep, Console methodology, and when that fails, with feeding on demand, swaddling, and or skin-to-skin contact, low stimulation environment, parental or substitute parental presence. And so that will actually work. And so you institute those things and you keep monitoring, and if that controls the symptoms, then you're good and you keep doing those things. And if you're not, then you give a single dose of morphine as a trial and you continue to monitor. And if they need a second dose, then you typically move them into the ICU and you kind of do your more standard opioid taper type of process, because that baby is not responding well, is not managing, has a higher level of physical withdrawal symptoms than you can manage with this. But most of the time, you can actually manage with these first initial measures. And then you don't actually just load every irritable baby up with morphine, right? Oftentimes, the withdrawal from mom's antidepressants is actually more physically agitating than the withdrawal from her opioid pharmacotherapy is. And we really want to treat infants with opioids only when it's absolutely necessary. And this methodology does what we were trained to do. This helps us support new parents in how to take care of that baby when they go home and increases the odds that that baby's gonna have a better life, that mom is gonna be better able to parent, that there's gonna be less frustration and less poor coping skills, because we've taught them in a controlled supportive environment how to do these things for their baby. And we've psychologically reinforced that the way we cope with trauma is with coping skills and not drugs, because we've spent the last nine months of their pregnancy trying to teach them that the way you cope with distress in your life is to actually learn coping skills and not take drugs, right? So this helps us reinforce that. Yes. Is there any physiologic difference with doing an induction of buprenorphine during pregnancy in terms of like timing or like the dose that you start at, or is it all just what Sarah talked about this morning? You know, honestly, it's all pretty much just what Sarah talked about this morning. I will throw one thing out there because I didn't catch her whole talk this morning. So I don't know, she may have mentioned that she may not. There has been historically a lot of concern that withdrawal causes miscarriages or pregnancy loss. And so there's a lot of fear in some people around implementing buprenorphine and the potential for precipitated withdrawal. So there is more recent data has come out that says that actually withdrawal doesn't really increase your risk of pregnancy loss. And that makes sense if you think about it, because if you use heroin, you're injecting heroin, you're going to withdraw like four times a day. It's not like a withdrawal is something you never experienced. Withdrawal is something that you happen the entire time. As somebody who has spent time in the ED while I lost a pregnancy myself, I can tell you that you were there for many hours. And if you are somebody who is using substances, you are going to go into withdrawal during that time. So there are going to be a lot of anecdotal ER stories where you had a woman who was in withdrawal and miscarried. But it's not clear that, in fact, it's actually doesn't, it doesn't pan out that it's the withdrawal causing the miscarriage. It's more that being in a monitored setting for a prolonged period while you miscarry is triggering withdrawal in somebody who has a substance use disorder because they can't get access to their drug very easily while they're on the floor. And we're not very good about historically treating those things to prevent that, to prevent the withdrawal, not the miscarriage. Yes. Action for inpatients. I noticed that your harm reduction slide mostly addressed things that would be practical for an outpatient setting. Yeah, so actually the dental care, the monitoring hydration, quiet spaces, all of those things would still apply in an inpatient setting. Really, and I know, trust me, I understand this is difficult so no judgment that you're not always able to do this but to the best of the ability, limiting the number of times that disruptions come in and out, minimizing the amount of times that you wake somebody up so you don't add to the disruption and stress. Because if you have a substance use disorder, one of the things that you uniformly have that got you there is poor coping skills to deal with the traumas and stressors in your life, right? So that's just a baseline. The other thing I didn't actually reference in here and it's kind of harm reduction or decreasing trauma related is, and I usually mention, I don't know why I didn't today, is I tell you that it's okay to breastfeed after pregnancy and it is, absolutely. And when we first started doing these talks 15 years ago, you really had to convince people of that. There was like no way they wanted to let them breastfeed. In many places, the pendulum has swung the other direction and it's like, you must breastfeed, you must breastfeed. So if you are a woman who has a substance use disorder, there is about a seven out of 10% chance, seven out of 10 people will have had a history of sexual abuse or assault of some kind. And for some of those individuals, breastfeeding may be very re-traumatizing for them and they may not feel comfortable sharing that information with you. You may think there's nothing more shameful than a substance use disorder. There's a good chance they think their sexual abuse history is more shameful than that and may not be willing to share it. So you should support that it is okay to breastfeed. You should offer encouragement and assistance if they want it. And you also should kind of recognize that if you're getting just weird pushback of like weird reasons why they say it's not okay, that you really do wanna be sensitive to the fact that there may be another story there that they're not able or willing to share with you. And so again, what's best for baby is always what's best for mom. And if breastfeeding is massively traumatizing for mom, the medical benefits of breastfeeding are gonna be outweighed by the trauma to mom. And then just quick piggyback on that. Yeah so got it so so actually that is not harm reduction for the patient that is harm reduction for the hospital and I recognize why hospitals take that stance and also let's not pretend and I'm not saying that you are but let's not pretend that that is harm reduction for the patient that is medical risk harm reduction for the hospital and and so thank you for for calling that out because yeah that's not what we're talking about we're talking about harm reduction for the patient yes I don't know if you are familiar with if it's Alaska law or not but I was instructed when I started practicing here at this hospital that we are mandatory reporters and that one of the things that we must report to OCS is if a child is in the presence of a parent using drugs I don't know if that is just urban legend or if that is still law on the books but I think that is one of the legal like underpinnings that many people use to sort of like justify the social work OCS involvement with so not in pregnancy but in infancy the ones the babies on the outside do you sue I don't know the answer to that yours your state will have an advocacy group that should and it looks like somebody in the back might actually know the answer to that Or are you saying, you know, while you're trying to get the screening from the baby for the testing, diapers, stuff like that, like what? I think you're saying when baby is present at the time the parent is injecting or snorting or whatever. Yeah, like if their mom's injecting in the room with baby, it's more the sort of projecting forward that staff say, if this child goes home with his mother, the mother will continue using in front of them, and they're not... So got it. So I, because I don't live here and I get to leave tomorrow and I don't work anywhere here and so everyone can be mad at me and it won't matter, I'm going to say that that is a gross misrepresentation of legal standards. Now you'd have to do some research and I can follow up and try and find specifically what the wording is within your code. I come from California where it's specifically explicitly said it is not a crime to use substances during pregnancy and there are still people in hospitals that tell their staff, you're a mandated reporter, if mom uses drugs, you have to report, that's mandated. So there's a discrepancy between how hospital systems, particularly hospital systems that have presences in multiple states, what their internal policies look like versus what the actual state law says. And I would argue that there is no other criminal charge for which we say, I suspect that this person might do this thing in the future, for which we're allowed to impose legal sentence on them without actually having them commit the crime. You can threaten you're going to do something, you can be pretty sure you're going to do something but you're not actually guilty of doing something, assuming it's even a crime in the first place, until you've actually done it. So I'm going to say that that is ethically not in alignment with reacting to substance use disorder as any other chronic disease that we face and if that is your hospital's or your organization's policy, I would suggest that you start pushing back and ask them to show you where in law that says, it's not on you to prove it doesn't, it's on that organization to prove that it does because this is a innocent until proven guilty country and not a guilty until proven innocent country, it's one of our founding values. And so that's where I would start is kind of pushing back and say, please show me because I don't think that's what it says and if you're saying I have to do this, then you need to show me where that's actually in law. Yes. Well, if this is the current law and I'm assuming it is, it says if the practitioner determines the infant has been adversely affected or is withdrawing, there's the requirement. Yes. Okay. Future issues are not on there, nothing like that is on there. And in 40 years of practice, I've been told every time a new law comes out, the most ridiculous things you have to do to protect yourself or your organization that is not based in law. And if you ever talk to a lawyer, you'll find out that that's very true. But if you read the statutes yourself and you are in good faith following the statutes, that good faith alone is protective of you in a legal situation. It means having a good lawyer if somebody goes after you, but if you're acting in good faith, it's awful hard for the system to destroy you. And I will say that those of us who did this in the beginning, so I've been prescribing for pregnant women for, I forget exactly how many, but it's 17 or 18 years now. And it was terrifying in the beginning. There were no like, you know, academic programs that had guidelines that you get them. There was no warm consult line that you could call. And it wasn't FDA approved even. Like, I mean, it was terrifying. And I lived in fear for years of like, I'm going to lose my license, but this is so important. I'm just going to do this until I lose my license. Me and the other people that have been doing this for coming up on 20 years now, like it's just, suits don't come up over this. Charges don't come up over this. They just don't. Now, having said that, I think that there is a gap here, which is that you are correct. If you're the delivering party and that's your involvement, it explicitly says just if you're witnessing harm from it, and only if it's illicit drugs, not if they're on pharmacotherapy. And I would argue that if you have somebody who came in on pharmacotherapy, even if they use fentanyl that day, you can't prove to me that their symptoms are from fentanyl and not their pharmacotherapy, right? But there are multiple permutations of this. So maybe you're the doctor in the outpatient setting who's seeing them for pediatric follow-up and you're not the one who delivered them in the hospital. So anytime somebody comes at you with one of those kinds of, you must report this substance use thing, you always want to say, show me. Show me where that's written. I have to do that because I'm not going to do something that unethical and that harmful unless you show me it is required by law number one. And once you show me, I know what I'm going to go to my legislature to fight to change. But always start with show me because he's exactly right. The number of times we've been told over the years, oh, this law means this, this law means that, you have to do this, you have to do that. And then you go back and you read it and you're like, no, it doesn't. I don't even know what you're talking about. It doesn't say anything like that. Sarah's got an answer, I think. Yeah, just a comment. So I think if you look at like this particular statute that when we're in labor and delivery, this is where this comes up that. So I think this also really good. So say you have a woman who comes in who's on pharmacotherapy, whatever it is, you know, really asking yourself, if I drug test the baby, you know, if I take if I because you can, in theory, right, without mom's consent, you think it's got if you think it's going to be necessary to take care of the baby, you can send that cork water, that meconium up and that's going to go back 20 weeks of their drug. So a couple of times of using they could have been sober for the last month or so. But so it tells you nothing about whether that person is used under control. And it could, you know, so so and then you really don't think about the fact, is this actually going to change the man of this baby? Like, I already know that this baby, it might experience withdrawal symptoms. I already know how to treat that. Is this drug test result going to actually change the way that I am going to take care of this baby? And if so, don't order it. Don't order a test that's not going to help you better take care of that baby that could have horrible legal consequences for the mother. You don't need that to take care of the baby. You know, most of it's hard to treat all these other things. Babies like stimulants and the nicotine and the antidepressants. Right. We only have certain ways that we can entertain with helping that baby. And all that other information actually isn't helpful. And it probably is only harmful to that to that mom and baby. So so if we have a mom that's coming in and we know that they're on pharmacotherapy, we know that that's not reportable. We don't need to report them. We don't need to get any kind of drug testing because it's not going to help us take care of that baby. And we want to make sure they have the supports that they need. But we don't need to do a test just to see why a dramatic in the last 10 years, dramatic increase in reporting to child protective services by health care professionals, always afraid of what's going to happen to ourselves. And we never suffer the consequences of that. We it is like a one in a million thing that anyone is ever going to come after you for not reporting something. But it is a very good chance that your reporting is going to have an adverse effect on that mom and baby. So you really have to put that into consideration. But like it's CYA is not always the most important thing. You've got to think of really taking care of your patient there. And I am a family practice doctor and I will tell you with absolute convention. And and lots of conviction and lots of evidence to back it up. If you ask me what is more harmful for a baby, having a parent inject drugs while they're in the household or taking that baby out of that household when that parent and that parent is otherwise parenting. Right. They bring the kid in for their well child visits. The kid's gaining weight appropriately. It's developing appropriately. I will tell you with an absolute straight face and profound truth in my heart that they are not harming that child that would be harming that child is me instigating activity that would take the child away. And and again, I do want to acknowledge like there there are cases where children do need to be taken out of homes, not for substance use as often as we like to think it would, but there are absolutely cases where children do need to be taken out of homes. I'm not knocking the system itself, just how we how we implement it and our beliefs that drive what we do. Thank you.

Dr. Candy Stockton

addiction specialist

buprenorphine therapy

pregnant patients

rural Northern California

methadone clinics

substance use disorders

treatment challenges

stigmas surrounding addiction

evidence-based care

mothers and babies outcomes

biases in treatment

compassionate care

maternal substance use disorder

treatment strategies