All right, do we want to go ahead and get started? Yeah, you can go ahead. It's still morning for me, but for you guys, I know it's early afternoon, and you've got things to do today. Hi, I'm Candy Stockton. I am a family medicine and addiction medicine specialist in Northern California, rural Northern California, and the health officer for my county. And happy to be with you guys today. We're going to be covering some information on trauma-informed care for women with substance use disorders. And I understand that you guys are a substance use treatment program. So I know that you guys know all about working with people who have substance use disorders, and I imagine you're probably very, very competent and comfortable working with women, and that not a small number of those women you've worked with over the years have actually been pregnant. So I do want to acknowledge that you guys have probably a lot of internal experience and expertise on this already, and today we're going to focus on kind of bringing a trauma-informed lens to that care, and so kind of different ways of looking at and understanding some of the things that we see in our patients. Let's see if I can figure out how to get my slides advancing. There we go. So the funding for today's training is through SAMHSA's STRATA and SORTA grants, which helped establish the opioid response network, which basically means that all of you anywhere across the country who are working in addiction or interested in working in addiction or need more education for your communities can reach out and make requests. Every state and territory has its own regional transfer specialist who can help connect you with people to fill those needs. And the training is free to you guys. So we do always point that out and let you know how to get in touch with your local opioid response network consultants or transfer specialists for any requests that you do have or future requests that you need. I would encourage you to do that. I've been working with them as a consultant now for I feel like six or seven, maybe eight years. I'm not sure. And I've seen them cover trainings on a variety of things all over the country. So I know that they are a great resource if you have needs. And I believe that you'll get a copy of this slide deck. So all that contact information will be in there for you if you want it or needed it some future date. So I have no financial disclosures. I will be talking or in passing at least mentioning some things that are off label treatments. And I'll make sure that I point that out when and if I do. The biggest kind of qualifying statement I'm going to make, though, is that the studies and resources that we're quoting generally refer to all pregnant individuals as women, mothers. And we do understand that in this day and age, not everybody who identifies as or not everybody who is pregnant identifies as female or as mother or mom. But because this is the way that the papers and research studies were performed, we do use that terminology when we're quoting those specific studies. I myself am like really working hard to transition from 20 years now of teaching about pregnancy and substance use disorder and the attempts to destigmatize and humanize those individuals by referring to them as mom or future mom in my presentations. And so you'll see me catching myself and flipping back and forth because I'm still trying to relearn that process. Okay. Hold on just a second. I've frozen up. Okay, there we go. So our learning objectives for today. We are going to be talking about trauma-informed care and be able to define what trauma-informed care is. We're going to identify or list common trauma factors among women with substance use disorders. We're going to talk about or learn how to understand some of the problematic behaviors we see in those individuals in light of the fight, flight, or freeze responses to danger. I talk a little bit about pregnancy-specific barriers to care and explain the parallels between substance use disorders and other chronic diseases that can complicate pregnancy. And this one is really important because we do tend to moralize more about substance use disorder in pregnancy than we do about say diabetes or hypertension or other chronic diseases that can impact pregnancy. And then we'll talk a little bit about how to create a safe environment for screening and assessment for trauma in our settings. Please feel free to pop in at any time with questions or comments or share examples or places where it's relevant in your practice. I will try my best to monitor the chat if something pops up in chat, but you can also unmute yourself and just speak up. This is intended to be really informal and shared learning experience and not me lecturing you for an hour straight while you progressively get more bored. And I think Katie and Emily can kind of help me keep an eye on the chat. If I'm missing something, please interrupt me. I try to switch back and forth, but sometimes I get distracted. Okay, so what is trauma-informed care, first of all? And any of you who came from hospital-based settings, the most common thing that medical providers revert to when we talk about trauma-informed care is assuming that it was a medical trauma, car accident, gunshot wound, something like that. And so when you are interacting with other medical professionals and we talk about trauma-informed care, we always want to kind of reframe ourselves that we're talking about trauma-informed care. We're talking about how the exposures to traumatic events that individuals have had over the course of their life impact our response to things, how we react to the things around us, how we deal with or cope with diseases or other challenges in our life, and that if we understand why people react the way they do, we can start to see some of these behaviors not as them deliberately making our lives difficult or making dumb choices, but actually as a reasonably normal response that somebody in their same shared sort of circumstances would have. And that's part of how we reframe dealing with people, working with people who have substance use disorders. Our society has really kind of focused in on if you use substances in a problematic way, that's a choice, it's a sign of weakness on your part, it's a moral failing, you need to choose differently, without understanding really that there are predisposing factors that change the way we psychologically and physically react to substances that we're exposed to. And if we're going to talk about substance use disorder as a chronic disease, which we all now understand that it is, we need to work to reframe how we've interpreted these things in the past as evidence of a moral failing, lack of character, lack of willpower on somebody's part, and start understanding how they're actually fairly normal, adaptive and reactive processes that happen in the brain. We need to recognize the effects on our health and our behaviors of previous trauma that we've experienced. So if you're somebody who has been exposed to a war zone as a child, and you heard a lot of gunfire on a repeated basis, you're normally going to have an increased stress response when you're in a situation where a car backfires, or there's a loud sound, because your brain has been trained to recognize those things as a risk to you, and rightly so. And so it's going to use that pattern of learning to respond to things that you're exposed to later in life, even if that car backfiring is not the same thing, you know, it's not the same level of risk to you as a gunshot in your community was. If you've been trained to react to the sound that way, that is how your body is going to react. If you have been in high stress situations that caused high levels of cortisol and high levels of trauma response throughout your life, you're going to have higher risk for a number of different chronic diseases and a number of different what we call behavioral health issues, whether that's substance use disorder or psychiatric problems and other things. We want to train our team members. Part of trauma-informed care is helping our team members understand that those responses are normal and adaptive and not signs of misbehavior on the part of the patient. And then we want to actually make sure that we build our policies and procedures and our treatment plans with that understanding of how trauma affects people who've experienced it. And we also, and this is really important, want to avoid re-traumatizing individuals. Can you imagine how hard it is? I mean, many of you have probably been in this situation where you've had to seek health care at some point in your life where you or a loved one has been sick, have been sick and needed help. And it's bad enough to be in that situation, but to have to go into someplace that represents all of the ways that you've been mistreated in the past or abused in the past can really make that even harder to access care. And I give a really simple example of this, which is a little bit, it's not so easy to model over the camera, but for those of you who can use your imaginations and visualize this a little bit, as a primary care provider, one of the things that I was trained to do as part of my initial exam with somebody is to palpate the thyroid, right? The gland on the front of the neck right here. And so I, you know, you do that by kind of touching the neck. Well, if you're a provider and you walk into the room and the patient is sitting on the exam table or in the table, you start your exam and you walk up to the patient and, you know, I often will, you know, kind of put my hand on the patient's shoulder so that they're aware they're there and I'm not sneaking up on them. And so I'm standing on one side, I've got my hand on their shoulder and I, you know, put my hand on their neck to start palpating. For somebody who's experienced assault or violence in the past, this feels an awful lot like somebody looming over you, reaching down and starting to choke you, right? To me, in my absence of exposure to violence in the past, it never occurred to me that that could feel like a life-threatening action to somebody who'd been on the receiving end of choking or physical violence in the past. And there's so many ways where simple things that we do in our offices or that we do in our regular protocols with patients may actually trigger a callback to previous abuse or trauma that they've suffered and we're just sort of oblivious to the whole thing and don't realize that right at that point in the exam, that patient stopped listening to anything I'm saying, right? They may be sitting there still, they may still be in the room, but they're not absorbing anything that I've done anymore because, or anything that we do from that path forward because they're locked into that panic response from what felt like a physical threat to their life for them. And so that's what we talk about when we say, how do we integrate this understanding into our policies and procedures and our workflows, and how do we avoid re-traumatizing individuals so that they can work with us to get better outcomes for themselves? Years ago, when I started doing these talks, I had to spend quite a bit of time explaining what adverse childhood experiences are. I don't, but this is kind of a lot more commonly understood prospect now. Can I just stop and read the room for a minute? Like, are you all super comfortable? You know exactly what ACEs are and like you could recite them cold, or you've never heard of them before, or you're somewhere in the middle like, yeah, you're familiar, but it would be okay to spend a minute going over them. Okay, well, I'm just gonna, in the absence of feedback, I'm gonna run through them really quickly. And if you wanna talk more about them, we can. But I'm guessing that many of you probably know quite about this already. So ACEs or Adverse Childhood Experiences are the traumatic events that we experience as our brains are still developing. And the studies were done in defining people at 18. We all know that our brains aren't finished developing at 18. And most of us don't develop somewhere until our mid-20s fully, but nonetheless, this is kind of the critical developmental time that this study was done over. And they include basically things that are abuse, neglect, or household function, meaning things that traumatize children. Because this was done in a essentially all-white, all-middle-class study group initially, it didn't include things that we now also understand are severe traumas for children, refugee status, even just immigration as a whole, uprooting from your culture and moving to another country, even if it is in a positive light and not a refugee status, being exposed to community violence, systemic racism. These are also stressors. These also equate to Adverse Childhood Experiences, but the studies and the outcomes really specifically looked at these specific stressors, because these were the ones that were most common in the population that they were collecting information on originally. So it's physical abuse, emotional abuse, and sexual abuse, physical neglect and emotional neglect, mental illness and incarcerated relative, witnessing domestic violence in the household, substance abuse disorders, and divorce. And I do want to point out that this study was done during a time when substance abuse disorders were predominantly untreated or they were treated, and when they were treated, they were really treated with behavioral therapies only and not medication. And I point that out because there's increasing evidence that it's the chaos and dysfunction in the household and not the presence of somebody with a substance use disorder diagnosis that's actually causing the trauma. And I think that's important because this can be used to re-victimize families. If substance abuse itself, having a substance abuse disorder itself is an ACE, the traumatic factor, then when that person has a child and brings that child home, that's already a check mark that's used against them when you're talking about custody of their own children. And so it does not appear that it is that the parent has a diagnosis, it's that the chaos that's associated with these things when they're untreated is traumatic. And you can think of that in terms of, say somebody who had diabetes, if you've got a child whose parent has diabetes, and that diabetes is well-controlled, the kid may not even be aware of the diabetes or may not think much of it other than mom or dad saying, oh, I don't eat dessert after dinner or whatever the case may be. But if that parent is having hypoglycemic episodes and they're calling the ambulance regularly and the parent's passed out and seized in front of the child multiple times, that is gonna be really traumatic for the child who's exposed to it because it's scary, it's uncertain in a way that just having the diagnosis of diabetes in the household is not. And so same thing with this, it doesn't appear to be just having a diagnosis of having a substance use disorder, it's the active substance abuse and chaos that's associated with that that's the traumatizing factor. So what do we know about our patients who are coming in for substance use disorders for treatment? We know that if you're an adolescent, and you've experienced four or more ACEs in your developmental years, that you have a four to 12 fold increased risk of developing a substance use disorder. So if you're treating an adolescent who has a substance use disorder, evaluating an adolescent who has a substance use disorder, the baseline understanding is that they have several adverse childhood experiences present in their life. You may or may not know what they are, but the vast majority of them are going to. We know that women who've experienced adverse childhood experience, or adult women who've had adverse childhood experiences are about six times more likely to develop an alcohol use disorder. And interestingly, that's been linked to specific adverse childhood experiences more strongly. So emotional abuse, I'm sorry, emotional neglect, sexual abuse and physical abuse are the strongest indicators of that. So again, if you're seeing a woman with an alcohol use disorder, it doesn't mean that every single one of them has experienced all of these, but it is highly likely if you are treating a woman with alcohol use disorder that she has experienced at least one of those three factors, and probably multiple other adverse childhood experiences as well. And then for other non-alcohol related substance use disorders in women, any ACE exposure increases their risk, and the more ACEs they have, the higher that risk is. So for each one of those 11 risk factors or adverse childhood experiences, there's a 1.4 times increase in the risk for a substance use disorder. So you start adding that up, if you've got somebody who's got four or five or six or seven of these adverse childhood experiences, your rates start skyrocketing in terms of the risk of substance use disorder. And that means that if you are treating a woman with substance use disorder, it is very likely that she has had a number of those traumatic experiences in her childhood and lifetime. So what are the most common traumas that your patients will have experienced? We know that women with substance use disorders have a higher rate of lifetime psychiatric diagnoses. That's important because just receiving psychiatric care can be traumatizing in and of itself, unless the situation is much different in New York than it is here. If you're having acute psychiatric crisis and you go into the emergency room, you may spend hours or days there awaiting appropriate psychiatric care. And for any of you who have been in the emergency room, I'm sure you are aware that that is about the least calming, soothing, and supportive place that you can possibly be. It's life-saving when you need it, but it's not a place that, it's not a place that's without its kind of own psychological stressors. We know that there's high rates of physical and sexual abuse in both children and in both childhood and adulthood for women who have substance use disorders. And we know that for women with substance use disorders, that about two thirds of those have experienced or are experiencing intimate partner violence, as opposed to only about a quarter of women who do not have substance use disorders. So again, high rates of historical physical and sexual abuse and high risks of intimate partner violence historically and currently in women that you're treating with substance use disorders. And then there's some secondary relationships and it's not clear that it's the substance use disorder itself that's really linked to this. It's more likely that it's the factors that you experience in childhood that associate with both substance use disorders, as well as higher unemployment rates, higher separation and divorce rates and decreased family and social status. And this higher separation and divorce rates are important because while being married isn't inherently or necessarily a good thing, our country, our social structures are still such that unmarried women and women who are single parenting are at higher, have higher rates of poverty, they have less economic opportunity, they have less support. And so those things become traumas, kind of recurring traumas in and of themselves. And it's really easy for us to actually look at that and be like, well, of course they're unemployed. Of course, their relationships fall apart. Of course, they're estranged from their family because people who use substances are difficult to deal with and they're unreliable and therefore their substance use led to these things. But it's more commonly that all of these things contribute to the picture that makes a substance use disorder more visible and more impactful in that person. And so if you wanna look at this a different way, I am a upper middle class, white, well-educated and high income individual. If I were to develop a substance use disorder, and I used to say if I were to start using heroin, although like in California, nobody uses heroin anymore, it's all fentanyl. I haven't seen heroin in a patient in probably three years, but if I were to start using illicit opioids at this point in my life, I could probably get away with that for quite a while before it actually started causing impact on my life. I'm a physician with a high degree of job flexibility. So if I was to not feel well and call off my schedule one day or several days, people wouldn't necessarily notice I could get a pass on that if my behavior changes and I'm argumentative or irritable or difficult to deal with. Again, I'm a physician and people just tend to assume that's what you're supposed to do and you get a little bit of a pass on it. Oh, I was up late last night with an emergency or whatever the case may be. And because I'm well-resourced, I could afford to buy drugs in a way that was less risky and with less inconsistency than somebody whose finances are more limited. And so a lot of these things that we attribute to drug use, losing your job, breaking down your relationships, they're really more reflections of our socioeconomic status than they are the presence of drug use to begin with. And so it is kind of important that we remember that and that we recognize that these factors, they contribute to the person's substance use problem. They're not exclusively caused by the substance use problem. And that's important because even when we get their substance use under control, these other factors don't just go away. The lack of economic opportunity, the lack of education opportunities, the interpersonal and family challenges that were there, these don't magically go away when somebody is in treatment for substance use disorder because they weren't caused by their substance use disorder. The problems may have been exacerbated by it, but they weren't caused by it. They're caused by the society that we live in and the exposures that people have. This is just a different way of looking at this. If you look at purely physical and sexual violence and people who are in substance use disorder treatment, if you look at men who are in treatment, about 30% of them will have a history of sexual, physical, or sexual and physical abuse at some point in the past. About 70% of them will not report those particular traumas. But if you look at women, you'll see that only a quarter of them actually have no history of physical or sexual trauma if there is somebody who's in a substance use treatment program. But actually, two-thirds to three-quarters of them will have a history of either sexual abuse or physical abuse or both sexual and physical abuse. This is, again, really high rates. I see a question, does the different generations affect the ACEs? And I'm not quite sure what you're asking. Do you wanna unmute and clarify that for me? Yeah, like, okay, so like the baby boomers, what they call abuse today was discipline back then. So things like that within different generations. Yeah, so yes and no. So I think what you're talking about is some of the things like spanking was fairly common in that era. It's generally frowned upon now, although not entirely banned. But there's some clarifications in how they define like physical abuse or, well, specifically physical abuse and or emotional abuse in this one. But interestingly, no, actually exposure to physical abuse, exposure to emotional neglect, which are probably the two things that are most stereotypically different about parenting in the baby boomer era, that exposure to those things, regardless of whether or not your society recognized they were bad at the time is still associated with an increased risk in those individuals. So that increased risk is present in baby boomers, it's present in Gen Xers at this point and millennials and like that we see that across the span. And it's also been shown to be present across multiple different cultures. So, I mean, there was a question initially, when we first, like most things in medicine, when we first did the studies, we're like, oh, we studied this white middle-class population, this is true for everybody and never even questioned whether or not it was. And then as time went on and we kind of got more, better understanding of the equity impacts, we recognized that, well, no, it's not inherently true for everybody just because it's true for white middle-class population. But in fact, it has been studied in multiple other countries, multiple other cultures now looking at that association between these childhood exposures and long-term health outcomes. And it is consistent across culture, across gender, across ages and races that when we see this exposure in childhood, that it correlates with worse health outcomes and increased risks of multiple diseases and behavioral health problems and substance use disorders. And we'll talk in a minute about actually, I think we'll talk on the next slide actually about why that is. So great segue for this, which is why is that? Why does this exposure to adverse childhood experiences cause these things? And so here's the answer that as humans, our brain's job is to assess the environment and adapt our response to the environment so that we can survive. That's what we do. And so I think many of you who are counselors have probably done training someplace in the past, and I'm blanking on the name right now, but it's Maslow's hierarchy of needs, this kind of, it's imperative that we have faith that our basic needs will be met so that we can develop comfortably. And when we live in fear that our needs will not be met, we have to take adaptive strategies to actually get those needs met. So kids who have experienced severe repeated traumas in their early childhood, their system that regulates their acute response, their acute stress response, it becomes dysregulated. It doesn't function right because it had to over-function constantly to help them survive as a child. And when that happens, you program your brain to be hyper-responsive to stress and or dangerous situations. So this is really in essence a chronic form of, a chronic developmental form of PTSD, post-traumatic stress disorder, where you're, and we recognize this in veterans and survivors of like severe violent events, that you can have a stressor that overtaxes your system so much that it changes the way you react to stress after that. Well, now imagine a child who grows up in that environment, always overstressed to that level. It changes the way their brain's processing of stressors develops. And this is a, both a physical and a chemical process. So it starts in the amygdala, the section of our brain that responds to fear. It sends signals to our hypothalamus, which activates our autonomic nervous system. And then that causes our sympathetic system to trigger our adrenal glands. And then we dump stress hormones into our system, right? And many of us after the last five years can appreciate what it feels like to function overstressed and overtaxed for a sustained period of time and how that starts to change the way that you physically react to things, emotionally react to things. You're less resilient, you have less coping ability. Doesn't mean that those systems can't be patched or that you can't learn coping skills, but it does mean that you're starting out at a disadvantage. So I just wanna say that when we over-trigger this acute stress system, when it's dysregulated and not functioning well, this is physically what that can look like. Increased heart rate and blood pressure, paler fleshing of skin, changes in our pain response, dilated pupils, feeling on edge, distorted or unclear memories of an event that's happening, being tense or trembling and having trouble with involuntary control of your bowels and bladder. What does that sound like to you? Right? There's an awful lot of overlap there between those symptoms and the symptoms of both some types of intoxications and many types of withdrawal, right? And if you think about that, when our patients who are in substance use disorder treatment, there are a variety of things that can contribute to lapsing, to going back to use, to full-blown relapses in patients. And very commonly, it's some type of a stressful event that triggers that, not always, but very commonly. If you think about that, if your body overreacts to acute stress and triggers this cascade of symptoms that look and feel an awful lot like withdrawal can, and your brain knows that in the past you've stopped that feeling by using substances, it's a pretty normal adaptive response to think, hey, maybe I can stop this out of control set of feelings I have right now by using substances. It's so normal that it happens at a subconscious level without the person actually really thinking it through and understanding that's why they're doing it. And this is part of why that concept of trauma-informed care is so important, is if we understand this, and we understand that this is expected and normal, we can coach people about that and help them understand that, hey, when you get really stressed out, that can feel similar to like when you're in withdrawal. And that's one of the reasons why you start to crave that drug again when you're in this situation, because you're trying to make the feeling go away. But in fact, what we really want to do is focus on how to help you learn how to deal with stress when it occurs, because the problem that you're having that's causing this feeling is not a lack of drugs in your body. It's that your stress system is responding the way it was programmed to because of your childhood, but you're not actually in this life or death danger. You don't actually have a drug shortage in your body that you need to treat with drugs. This is normal and expected. Let's talk about ways you can deal with this when it happens, right? And you'll know that. You'll know that people are more likely to actually reach for their drug of choice when they're feeling stressed or they have something they can't deal with. But we still tend to kind of lean on that and think, well, it's because they're trying to take the easy way out there. They don't want to deal with them. And I guess that is one way to describe it, but a more scientifically accurate way to describe it would be that their body is experiencing this excess rush of hormones and their brain is trying to find some way to mitigate that and bring it back to homeostasis. And it's a completely logical jump for their brain to make that, hey, if I took some drugs, it would settle this back down again. So what are normal stress reactions, right? Like when we're past the ability to cope, so stressors we can cope with, we might increase our stress hormones a little bit. Our thinking might get a little sharper. Our focus may get a little sharper. We get through the situation and then we take a breath and calm down. But when our ability to deal with the stress is overwhelmed, what do we do? And that's when we drop into what's known as the fight or flight, or probably more accurately, the fight, flight or freeze response, right? So if we, if we find ourselves in a stress level where we're overwhelmed, we don't know what to do. Our body dumps stress hormones into our system. And we select one of these responses, not consciously, we don't choose, but, but subconsciously. And there's a fourth reaction that we're going to talk about a little bit, because this one is actually much more common in women with substance use disorders than it is in other populations. And so it's important to understand because it can have serious implications for our female presenting patients with substance use disorders when their stress system is overwhelmed. And that's the FON response we'll talk about in a minute. But the idea that the intention behind all of these states is to get us to safety or get us through the situation to safety so that our body can start to calm down and react to the environment again. So they're all about survival. So fight. If we think we have a chance to actually fight off if we believe and again, this is often at an unconscious level, or subconscious level, not at a conscious level. So if your stress response is overwhelmed, you don't typically sit there and think about, well, I'm 150. And I do kickboxing in the gym, and that person's only about four foot eight. And they don't look like they exercise, I think I can take them like it's not that kind of a process. It's more about what you've done effectively in the past. So if you've been somebody who's fought back effectively in the past, and that's worked for you, then you're likely to revert to that again, subconsciously, when you're in that situation. If you're somebody who's smaller or weaker, a child, a smaller woman, who's who has attempted to fight back in the past in some situations, but has never been successful at that, they're much more likely to actually respond with a flight type of response. But but let's focus on fight for a minute. So this can look like, you know, jaw tight, grinding your teeth, feeling the urge to punch or kick something, feelings of intense anger, being so angry, you're crying, which is actually a little bit more common in women than in men that can happen in either gender, a burning or not a sensation in your stomach, or lashing out or attacking the source of danger. So, again, if you're working with somebody who uses substances, and you're talking about kind of what the triggers for those things are, and understanding the trauma that you've experienced that leads you to this, helping people understand that when you're feeling this way, when you're seeing these things, that's a sign that your body is overwhelmed, you may feel angry, then you may feel whatever, but that's actually a risk time for you to go back to using again, to try and treat these, let's talk about some ways that you can deal with these circumstances. So first of all, we don't, you know, beat up on people, that they feel angry, we recognize that that anger is part of their stress response and start talking to them about how to deal with that. And you'll see this in your patients, right, the patients that come in, and they yell at the front desk, or they yell at the providers, and they get kind of large and looming and sort of aggressive, it may not be super effective to have this conversation with them in that moment. But you know, the patients who are prone to that, and at times when they're calm is a perfect time to talk about, hey, this looks like part of your stress response when this is happening, let's talk about how to recognize when you're starting to feel this way, talk about why you're doing this. And then let's talk about what you need or want. And what are other approaches you could take with our front office staff, or with your provider to get this thing it is that you that you are feeling threatened about that you need, or you want this fear that you're going to be cut off from your care, or whatever it is, it's driving this thing in the first place. Light. So again, if your body doesn't believe you can fight off whatever this existential threat is to you, then then its next response is to try and get away. And, again, in your patients, this can manifest different ways. And this is actually really important, because some of these things are like, at least superficially positive things. So this could look like excessive exercising in somebody. But it could also manifest as feeling fidgety or tense or trapped, constantly moving your legs or feet, restless body, this sensation of kind of numbness or tingling in your body, dilated and darting eyes. So again, being aware of this as a response, sometimes our patients will come in and be like, yeah, yeah, I you know, I'm really taking better care of myself. And I've started this exercise program and exercising a lot. And you're like, great, right? Well, yes, if they're doing regular exercise, that's good. But if they're exercising for eight or 10 hours a day compulsively, this may actually be a sign that their stress system is really triggered. And they're doing this as an escape mechanism. So kind of understanding that can help us ask better questions about well, tell me about you know, what does that program looks like for you? And they're like, Oh, I go to the gym, you know, for an hour in the evening with a girlfriend and we talk it's great. Like, good, excellent. Like, oh, well, I run for five hours straight a day and I'm not training for a marathon or doing you know, any kind of specific thing that may actually be an escape mechanism and understanding that can help us address that with the patient instead of being like, good for you that you're exercising more carry on. Freeze. This one's important for us to understand because this is what happens when our body believes that we can't fight and we can't run and we're so panicked, we have no idea what to do. And I think the important thing for us about this as health care providers or as counselors, people who work with people with substance use disorders, that if that patient's trauma is triggered, if they're activated with their when they're with us, they're going to be more If they're activated with their when they're with us, and they have this kind of a reaction, our only awareness of that may be that they seem a little less engaged, right? And, and maybe they're in a in a counseling group, or maybe they're on a one on one and they just kind of shut down and they're not responding anymore. And we're like, hey, Joe, Mary, you're not paying attention, you're not responding, right? And we kind of see that as a non compliance, not participating, not meeting expectations, when in fact, that person may be completely kind of locked down inside their own head, they may be in freeze mode, and us badgering them, or assigning them a non compliant status because they're not responding is is not a fair, accurate thing to do in that situation. And so understanding that when somebody actually quits interacting with you, when they quit interacting with the group, they may just not be that interested in what you're doing that day, they may be feeling resistant and don't want to talk. But they may actually be in that freeze response to stress, because remember, your stress response is dysregulated. And so you respond to even things that are not life threatening, as potentially life threatening. So something as simple as a harsh, perceived insult from somebody else in the group, or a sound that they hear on the street passing by outside, or a scent or an odor, a smell that's associated with some abuse that they've experienced in the past, all of those things can be something that triggers them to respond with a freeze. And then here's the last one, I think that is important, particularly if we're talking about women with substance use disorders, which is that remember that many women who have substance use disorders have experienced physical abuse and emotional neglect and sexual abuse or some combination of those things in their past. And it tends to happen to them as young, small children when they're incapable of fighting back, hiding, getting away or saving themselves in any other way. And one of the things that happens in that situation is, is actually attempting to appease or make your abuser happy to try and control the amount of damage that happens to you. It's a subconscious thing, right? This is this is a response mechanism of smaller, weaker people who are persistently abused, who cannot escape in any way, shape or form what's happening to them. And this can look like overagreement, trying to be overly helpful, which you can be on the receiving end of as a provider in the office or primarily concerned with making somebody else happy. This can result in women going back to their abusive partners over and over again, or to dangerous situations over and over again. And we as providers tend to actually get angry or irritable about that. You know, why do you keep making these stupid choices? Why do you keep putting yourself in risk like this? And the answer is, because this is the survival mechanism that their brain was trained in as a child. It is the thing that kept them alive in that environment. And if we don't understand that, and we keep kind of coming back to them, like, why are you making these dumb choices without understanding? This is how you survived as a child. This was an adaptive adaptive technique for you that actually worked. So of course, your brain is trained to do this, then we're going to miss an opportunity to actually help correct these patterns. What are the pregnancy related barriers to seeking care? Well, that's easy. They're all of the barriers that everybody else has to seeking care for substance use disorders, with the added problems of depending on where you are just using substances while you're pregnant, maybe a punishable crime in and of itself. Even if it isn't a punishable crime in and of itself, it's still often prosecuted as a crime. And you could lose custody of your child. Right? Those are major barriers to seeking care. And yes, it's unreasonable to think that if you somehow just avoid care, that none of those bad things will happen and you won't lose your child. But quite honestly, if you told me I was at risk of having my child taken away for seeking medical care for a problem that I had, I would probably try to take care of my medical problem myself too, rather than take that risk. It's not an unreasonable decision for somebody to make. And then if they're already a parent, they have, you know, previous child welfare involvement, possibly that's coloring their interactions with us this time. And just the logistics of trying to get to a medical appointment when you have another child you've got to make arrangements for. I think many of us can probably relate to how difficult it can be to juggle our own schedule, a child's schedule, work schedule, and still get some medical appointments that we need to be at. And I am going to speed up a little bit because I see that I did not time this very well. Maybe I stalled longer than I thought I was going to. So I don't or I shouldn't need to tell you guys that substance use disorders are a chronic disease. Pregnancy is a temporary condition. We have historically framed substance use treatment during pregnancy as this is a thing you need to do because it's good for the baby. How dare you not take care of the baby. But the reality is a woman who has a substance disease who is pregnant is a woman who has a chronic, potentially fatable disease that has effective treatment available. We treat her not because she's pregnant. We don't treat her because it's good for the baby. We treat her because she has a life threatening disease that has effective treatment available. And aren't we all lucky that that treatment also happens to be good for the baby. But that isn't why we do it. We do it because mom is a human being who is deserving of treatment for her life threatening condition and because we have treatment that works. And that is important framework because you'll see women who are pressured to stop treatment once they deliver their baby. You'll see women who who all of this is really framed around. This is what's good for your baby. And yeah, it's nice that it is good for the baby. But that's telling mom she is nothing but a vessel who's gestating an infant and she has no value herself. We're only concerned about the well-being of the baby. So the really important focus here is you have a disease. You are worthy of treatment and we have effective treatment and good news for you. Just like other diseases that affect women, when you get treatment for your disease, diabetes, hypertension, depression, substance use disorder during your pregnancy, the outcomes for your pregnancy are also better. But we don't treat your diabetes because you're pregnant. We don't treat your hypertension because you're pregnant. We don't treat your depression because you're pregnant. We treat them because those are diseases that impact your life and we have effective treatment available. Same for substance use disorders. Another thing that's really important to remember is that 75 percent, you know, three quarters to two thirds of women who are opioid abusing did not intend their pregnancy, right? These are accidental, unintended, unplanned pregnancies. Unintended or unplanned pregnancies, however, does not mean unwanted pregnancies and pregnancy can be a powerful catalyst for change. So it can be a great time to intervene with women but it can also be a significant source of shame and stigma that can make treatment more difficult and so it's just one of those things that you really want to recognize and again not focus in on you need to do this for your baby but you do this because treatment is good for you and it's also helpful for the pregnancy. Another thing to remember is that many women who have opioid use disorder who've been abusing opioids regularly have disrupted their hormone cycle so much that they're not ovulating anymore and so they typically don't get pregnant terribly easy. This becomes important when they come into treatment. they've been having unprotected sex for five or 10 or 15 years and not gotten pregnant. So they think they can't get pregnant anymore. And you get them on treatment and you stabilize them. And before you know it, they're pregnant because they've started ovulating again. So it is really important that when you're seeing women who are coming in for treatment for opioid use disorder and they are in that potentially get pregnant phase of life, you know, anywhere between like 12 and 60, that you're thinking about whether or not contraception is appropriate and you don't just kind of accept a statement, oh, I can't get pregnant because probably the reason they can't get pregnant has more to do with hormonal disruption from their opioid use disorder than it does with actual infertility. And a lot of accidental pregnancies happen when people enter into treatment. I'm gonna kind of skip over this and just say that like, we don't detox women during pregnancy. It's actually reached a point now where it's considered medical malpractice to recommend that a woman detoxes, meaning withdraw from and get off all medications during pregnancy or get all opioids during pregnancy. And the reason we don't do that is because it doesn't improve outcomes for the pregnancy when we do that. And the treatment itself fails so often that the outcomes in women are worse, meaning that something like three quarters to 80% of individuals who go through a detox will have relapsed within 30 days. And when relapse from your disease is potentially life-threatening from overdose, it's unacceptable to recommend a treatment that has a 80% failure rate at 30 days when you have a treatment like bup or methadone that has a 65, 70% success rate with treatment. So it's just, it's unacceptable. It's an inferior treatment and it's reached a point where it's actually considered malpractice if you're recommending that anymore. And I'm gonna jump over this and just say that many providers who are new to pregnancy and substance use disorder, myself included, many years ago are like, hey, if you take treatment during pregnancy, it's really great. It helps all of these wonderful things, including helping your baby to be born at a higher birth weight and higher, bigger head circumference, right? Bigger baby, bigger head. And as doctors who treat pregnant women, like we say that excitedly because we know that women who use substances tend to have smaller babies and that smaller birth weight and smaller head circumference are associated with a number of less good health outcomes. But when you say to a young first-time pregnant individual that if she takes this treatment, her baby's gonna be bigger and have a bigger head, yay, that doesn't sound good to a young delivering mom. So we do wanna be careful that when we're explaining things, we understand how patients are hearing them. And if you're using this, you probably wanna be careful to say that, that like any chronic disease, women with substance use disorders during pregnancy tend to have a little bit smaller babies and that smaller baby can be associated with some increased health risks. And being on treatment is associated with having a closer to normal weight baby, a normal size baby. And that's a good thing rather than kind of stressing big or bigger. So trauma-informed care for pregnant individuals who have substance use disorders, what does that mean? It means actually advising them that even when their opioid use disorder is well-controlled with their pharmacotherapy, the baby can still have withdrawal, right? It's not their fault. It's not because they did anything. I had severe diabetes during my pregnancy. I had to take high doses of insulin during both of my pregnancies. And both of my babies ended up in the ICU needing feeding support because they couldn't control their blood sugars for about a week after they were born. Everybody knew it was gonna happen. I knew it was gonna happen. The NICU team knew it was gonna happen. We were all prepared for it. It was a consequence of the disease I had during pregnancy. It wasn't my fault. It's not because I'm a bad person. It's not, you know, it just was a normal expected consequence of my disease. And we need to actually understand that ourselves and educate our patients to expect that as well, that being in treatment doesn't mean your baby won't have withdrawal and you're not a bad person if your baby has withdrawal. That is just a consequence of the chronic disease that you have. We need to actually work to educate our partners about that. We need to make sure that our patients and we understand the potential medical outcomes and legal outcomes in the environment that we practice in. If you work at a, or your patients deliver at a hospital where the nurses call child welfare services every time somebody comes in drug positive, regardless of whether or not they're on treatment and regardless of whether or not they're stable, you wanna warn your patients about that so they can be prepared. And you wanna be prepared to advocate for your patient. I cannot tell you how many patients I have had who have been stable on buprenorphine therapy for at least six months at the time of their delivery who haven't had a single relapse, who've still had child welfare services reported on them because somebody filed a complaint or made a report at the hospital. And if you have just delivered and somebody shows up in your room and says, hey, you don't know me, I'm a stranger, but I'm here to decide whether or not you can keep your kid, the normal reaction to that is to lose your shit and fight back, right? That is the only normal reaction to that situation. And when they do that, that's often used as evidence that they're unstable or not able to be an appropriate parent. So it's really important that you understand what your patients may be facing after they deliver and that you coach them. I used to send my patients to the delivery hospital with a sealed letter from me saying, hey, this is Mary, she's been my patient for nine months, she's doing great, her drug screens look fabulous, here's my office number, you can call me, here's my personal cell phone number, you can call me directly if you show up to evaluate my patient and if you have any questions and give it to the patient. So they were like prepared to give it to the child welfare services worker if somebody showed up. Little things like that can make a really big difference for your patients. Screening. I'm gonna skip over this because I don't think I need to tell you guys how to screen for substance use disorder, you're a substance use disorder treatment program, you're already there, they're already diagnosed by the time they get to you. And I threw this slide in just for reference, it's a link to the different laws around reporting substance use disorder in pregnancy in New York, you're probably very familiar with them, but sometimes I get called out on the laws in my own state and people argue with me so I like to keep the links available and easy. In New York, it's not specifically a crime to use substances during pregnancy and in fact, there's a state Supreme Court decision that actually says that actions taken while a woman's pregnant including drug use don't constitute child endangerment or abuse and there is no legal requirement for you to report substance use tests that are positive during pregnancy. There's further clarification in your state laws that say that factors that are caused by poverty, culture and other things also don't constitute child abuse and so there has to be evidence of actual abuse or suspected actual abuse or risk. And I say that just because there are a number of people who really do consider using substances while you're pregnant to be abusing the child and assume that people who have substance use disorders cannot be good or even decent parents and just arbitrarily use that as a reporting factor. So these two slides are both links around that. And I'm totally out of time so I'm gonna stop for just a minute and say I misjudged that entirely. I have a couple of slides that are comments about pain control during delivery process, pain control after delivery, breastfeeding and birth control that I'd be happy to go over with you but I also wanna be very respectful of your time and recognize that you still have a whole afternoon in front of you left to work. So I'm gonna pause and say that for those of you who need to jump off now, there is a survey slide, like you to capture that and it's on the end of your slide deck. And I think Katie will probably send out the link again after the training to Rosemary to distribute. So I wanna give you a second to get that. Yeah, I will. And then I'll stop and ask, would you like me to take about six more minutes to jump through these next three slides or should we just end it here? You'll have copies of the slides so you'll have the information if you want it. Well, I have no problem. Okay. Well, how about this then? Since I know at least you wanna stay, I'll go through the next slides and I will not be at all offended if everybody else or anybody else jumps off since I am running over on time. So no one expects that in a treatment program that you're gonna be managing the pain control during delivery to process after delivery. And I don't know whether your group actually handles contraception or not. I'd guess that you probably do sometimes, but you should still understand what the recommendations are so that you know how to actually educate your patients about it as well as you know how to recognize if somebody is offering your patient or suggesting care for your patient that isn't appropriate. So one, how do we control pain during delivery? The short answer is that if your patient is experiencing something that is causing severe pain during delivery, treating their pain during delivery is not going to somehow make their substance use disorder worse. And so we really do need to advocate for our patients that just because you're on buprenorphine or methadone for your substance use disorder, the level that you're on for that is what's necessary to stabilize your addictive process. It is not going to provide adequate pain relief for an intensely painful experience. And so if you do have a bad tear during delivery, if you do have a prolonged and painful delivery, if you need a C-section, your baseline level of buprenorphine or methadone is not going to adequately treat that pain. And we need to actually be advocates for our patients that they may need additional pain control during that time. Doesn't mean everybody will, but it is absolutely appropriate to give additional pain treatment during that time if it's necessary for pain control. And we want to talk to our patients about what their desires are for pain control and help advocate for that. Some patients absolutely do not want pain meds during their delivery process or postpartum period. They're either really proud of the fact that they're not taking any of those meds anymore and don't want to do it, or they're really scared that it may trigger them to relapse and it's okay to respect that if they don't. It's also okay to tell them we will avoid it, but if your pain is worse than you're expecting, you can talk to us about it again and we will not think that you are just drug seeking if you do that. I also have some patients that are absolutely terrified that they're going to be left in severe pain and no one will treat their pain because they do have a history of addiction. And it is also okay to advocate for treating pain at a lower threshold in those individuals. That's a re-traumatizing experience, right? If you've been left in pain for long periods of time before because people don't want to treat you because you have a history of addiction. So, and you've all probably seen this, somebody who has a long history of addiction, in recurring use who goes into the ER with a broken arm that's displaced and then they set their arm and give them a shot while they're in the hospital, but they don't want to send them home with any pain meds because of their history of addiction or it gives me that pain is real and it is appropriate to treat pain even in patients who have a history of addiction. It doesn't mean all the narcotics all the time, but it may mean that some narcotics are appropriate for pain relief. And having that conversation with your patient in advance can really help them feel more empowered and less afraid of the upcoming delivery process and can help them be better advocates for themselves with their other healthcare providers and at times you may need to be help be better or you may need to be an advocate with their other healthcare providers. Breastfeeding is a little tricky on methadone and buprenorphine for women who have opioid use disorders is absolutely okay. And in fact, it's still beneficial to breastfeed for those individuals. We don't recommend breastfeeding in individuals who are still using illicit drugs, particularly once we're using methamphetamines or cocaine. Stimulants actually get concentrated in the breast milk and so the baby gets some at a much higher level than what mom is actually getting. And with illicit drugs, there can be any number of other chemicals and contaminants that in there that are dangerous. But if a mom is stable on methadone or buprenorphine and not using stimulants, she should be encouraged and supported to breastfeed if she wants to. And keeping in mind that many women with substance use disorders have a history of sexual abuse and that they may have hangups to breastfeeding where they're resistant to it. And so do recognize that you may get a lot of resistance from a few of these women when you try to push breastfeeding with them. And if you are getting that resistance and they're giving you reasons that seem kind of silly or don't make sense, you may wanna recognize that under that may be some history of sexual trauma that's causing them to react that way. And birth control, last one. So all women, all people, anybody who has popped out a baby should be encouraged not to give birth again for another 12 months, to space the next pregnancy by at least 12 months. And that is because being pregnant more frequently than that can cause unnecessary physical stressors on the mom and increases the risk of the infant actually having worse health outcomes for both the infant that was already born and the infant for which you are pregnant. So all people should be encouraged to space pregnancies by at least 12 months because it will help you be healthier. And we should offer that same advice in that same way to our pregnant patients with substance use disorders. We should not target them explicitly. You don't deserve to be pregnant. What's wrong with you getting pregnant while you have a substance use disorder? Don't you know that can hurt your baby? Which are things that our patients hear from us sometimes. And so conversation about postpartum contraception should start at the visit when you diagnose the pregnancy. And when you're talking with your patients who are pregnant you're probably not providing their pregnancy care. But again, you should be talking to them about how they want to help make sure they space their next pregnancy from the very beginning. We wanna make sure that we're doing that the same with everybody that we're not targeting just patients who have substance use disorders as if they're somehow bad or don't deserve to be pregnant. Women with all kinds of chronic diseases choose to get pregnant. Women with all kinds of chronic diseases have their diseases managed while they're pregnant and accept that while there might be some slight health risks associated for the pregnancy that is still very reasonable to decide to get pregnant. Me, 600 units of insulin a day chose to get pregnant again a second time even though I knew my baby was gonna end up in the ICU. And even though I knew it was likely I would too by the end, right? People don't judge me for that. They might look at me a little funny but they didn't act like I was a bad person for making that decision. Our patients who have substance use disorders also deserve to have control and decision-making autonomy in their own reproductive processes. But best medical advice is that everybody spaced by 12 months, it's good for you. And then keep in mind that six months after delivery is where most of the time we start patting ourselves on our back and telling ourselves that mom and baby are doing well. In most types of OB care, six to 12 months after pregnancy is the time that a individual who is pregnant is at the highest risk of overdose death. So we start telling ourselves things are going well we don't need to watch as closely but this is exactly the time when they are at the highest risk. So if you are treating substance use disorders in people who also get pregnant make sure that you have some kind of a built-in tickler reminder system to start paying extra attention and start doing extra support around that six month mark because that six to 12 month mark is the high point risk for overdose death in those individuals. There, I was close to that. Okay, I totally fibbed, I was like eight more minutes not six, but I am done. So feel free to reach out anytime if you have additional questions. I am so sorry for keeping you late today and I am gonna jump back to that survey slide so that you have it up. And I've included the lists and links to all the citations at the end. And if you have any questions at any time feel free to reach out. Thank you so much for your time. You learned a lot, so I appreciate that. Thank you so much. Great, and I am able to hang out for another few minutes if anybody wants to ask questions now but like I said, I feel very guilty about keeping you late already, so I don't wanna. Actually they're about to leave because they have to get their bags because they all moved together in one room. So they have to go through this a lot. But if you have any questions, I guess you can email the questions, if there's any questions, okay? Yeah, absolutely, feel free to email me with anything. Thanks so much. Bye-bye. Thanks, Katie. Sorry, Katie, I'll do better with time next time. No, it's okay, you're fine. All important information. Bye.

trauma-informed care

women

substance use disorders

trauma impact on behaviors

brain stress response system

safe and supportive environment

common traumas

intimate partner violence

pregnant individuals

pain relief and support