[Julie] Perfect.
All right.
Can everyone hear me?
Yeah, perfect, all right.
Good afternoon everyone,
and welcome to our fall webinar presentation.
This is part of the Perinatal Quality Collaborative Vermont
Learning Series.
We have a few webinar that we do like this year,
and this is the first one for the fall.
My name is Julie Parent, I use she, her pronouns.
I am the perinatal project director
at the Vermont Child Health Improvement Program,
also known as VCHIP.
And before we get started with the content and our speaker,
I just wanted to give a shout out to the team
who works on putting together this webinar
and also all of our learning activities
for the PQC and specifically for the ICON Initiative.
I know I'm throwing a lot of acronym,
but ICON stands for
Improving Care for Opioid Exposed Newborn,
and this is a longstanding project at VCHIP.
We're kinda carrying the legacy of Dr. Ann Johnson,
who started the program I think two decades ago.
So I don't know if everyone is on the call right now,
but we have Dr. Michelle Shepard,
who will be presenting today.
She's our faculty lead on the project
and Dr. Molly Rideout, and Dr. Adrian Paul,
Dr. Bronwyn Kenny and Susan White
who are longterm been involved in this kind of work.
And our two parent advisors, Heidi and Ashley,
and Angela Zinno, who's our project coordinator,
and Avery Rasmussen,
who's our perinatal project data manager.
So that team makes all these event happening
behind the scene and they're here today to also help
Dr. Paul and Dr. Rideout and Dr. Shepard
who'll be here to just answer your question on the chat.
So maybe just a few housekeeping rule.
Angela, if you wanna just move to the next slide.
So we also have life captioning available.
I put it in a chat, but we will repost it in a minute.
As I mentioned,
we do host a lot of different learning activity
throughout the academic year.
So if you have received this invite
through a colleague or a friend
and you'd like to be added to our Listserv,
just send us an email at the email
that's indicated right here,
vchippqcvt, and we'll add you to the Listserv
and then you'll be able to join our activity,
we're planning two more webinar in the New Year
that are related to substance use.
So we would love for you to join.
And then what else?
And also, we have an evaluation at the end.
We've made it super, super, super-short,
only 5 or 6 questions, so please take a moment.
We wanna hear from you, we wanna hear your comment,
and if you have any other type of topic
that you would like to discuss.
And next slide, Angela.
All right, so we'll get started.
And Amy, I apologize,
I'm probably gonna mess up your last name,
the French Canadian accent here, but Amy's a colleague,
she's our speaker today,
and she's also a friend of ICON Project.
Amy Wenger is a registered nurse.
She's an international board-certified lactation consultant.
She's passionate about maternal child health work.
She started as a Doula and Childbirth educator 20 years ago.
She also worked on the postpartum floor at UVMMC.
She worked in pediatric clinic,
and currently she's the maternal child,
clinical nurse manager at a community home health agency
in Vermont.
And she is also the founder and co-executive director
of the Vermont Donor Milk Center,
which I think she'll talked about today,
which provide outpatient pasteurized donor human milk
to infants who requires supplementation
and is also a very good person to know
when you need resources around lactation
and postpartum resource.
And Amy last year also participated
in our storytelling project
with a different provider and also folks
that had a lived experience with
substance abuse during pregnancy.
So her actual full story is available on our website,
and I can put the link also regarding that in the chat.
And then Michelle, Dr. Shepard, will join Amy
a little bit later on.
But Dr. Shepard is our faculty lead on the ICON project.
She's also an assistant professor
at the Larner College of Medicine School,
and she is a pediatrician in the newborn nursery at UVMMC
and the mother of two, and she's involved in many things.
So I'm gonna turn it over to Amy,
and Angela's gonna advance this slide,
and please don't hesitate to add your question
into the chat.
[Amy] Thank you, Julie.
So I have no relevant financial relationships to disclose
or conflicts of interest to resolve.
That is what I'm going to start with today.
So good afternoon and thank you Julie,
and a big thanks to the ICON team and Dr. Shepard
for inviting me to speak to you all today
about cannabis pregnancy and lactation.
I'm excited to be able to present this to you,
because this is actually, it's pretty timely conversation,
because again, our communities right now as we speak,
are opening retail cannabis dispensaries
for adult and recreational sale all over.
So I would also love to get to know all of you as well.
So please introduce yourself via the chat box
and if you feel comfortable sharing
what your own personal stigma or bias around cannabis is,
we all come from different levels of knowledge,
different values and places,
and cannabis can be a very political and hot topic.
I ask that all conversation that occurs in this space
and in this chat and in general is respectful and kind.
Today, I'll be talking a little bit about
the biology of cannabis, as well as the data
that we do have,
which I'm hoping will give you all a better,
kind of a bigger baseline of knowledge
so that we can kind of dive into our bigger focus today
on the importance of having the conversation
with our pregnant and birthing clients
regarding their cannabis use.
Dr. Shepard will be discussing and giving updates
on the federal care amendment to the capital legislation,
and the Plan of Safe Care around cannabis,
navigating these conversations.
There's a lot of content in my presentation,
but I do invite you to start a conversation in the chat
as well as join in the discussion points
of this presentation when they come up.
I will be using the term, birthing and lactating people
as inclusive terminology,
and I use the term breast chest feeding
or human milk feeding as much as possible.
But you may hear the term woman, maternal,
breastfeeding, or mother.
As much as I try to be really conscious of myself,
I will always own my own privilege and my desire to be
as inclusive as possible.
Much of the data and research uses language
that isn't quite as inclusive.
So if I use a term that is not culturally
or socially accurate,
please feel free to email me later and gently make me aware
so I can always learn and do better.
We're all perfectly imperfect work's in progress.
Next slide.
So why cannabis?
Well, I needed to know more.
And I'm a lifelong questioner
and I want to be very transparent
that I'm also a lifelong grateful deadhead,
but I'm not a cannabis expert,
or at least I haven't been since about the summer of 2005.
In that time, my own personal view of on cannabis
has changed greatly in the past 25 years,
especially when I became pregnant and had my own children.
I'm still rather ambivalent about how I feel
about recreational sales
and how they'll impact the population of patients
that I work with.
I question how as a MCH home visiting nurse leader,
working with pregnant and lactating persons daily
is the best way to address this kind of very gray area,
educate my patients and how I lead my nurses and community
to react and act when a patient does disclose
their cannabis use.
Or what do I do if their client has their stash and bong
just sitting on the table during a home visit,
which is a very true story,
especially now that it's legal for adults over 21
to use cannabis,
both for recreational and medicinal purposes,
what resources are available to keep my patients
and their families safe?
And what do my pregnant lactating
and parenting patients think?
And most importantly, how do we hold safe,
equitable trauma-informed space and not create more barriers
to disclosure of cannabis,
including safety for that teeny, tiny little purple elephant
in the room who just has yet to be born?
Next slide.
Well, just as you may think,
pregnancy and lactation
are one of the last taboos of legalization,
and many of us have gotten really good
at not talking about it.
For many years, providers have given the advice,
and I'm just really generalizing here.
Well, we just don't have enough information to tell us
that it is or is not safe during pregnancy or lactation,
so we recommend that you stop using it,
because we don't fully understand the harm that can happen.
And that's kind of the end of the conversation.
Next slide.
Because I know when I give this kind of an answer
to my patients, I've just created a statement of stigma.
They just disclosed to me that they use cannabis,
and I just told them that because I, in a position of power,
do not know enough about it to give them advice
or was even curious enough to think about
their cannabis use as something other,
that they could stop,
that something that they could stop without a consequence.
And I've created a barrier in this space between us
and they feel judged or ashamed.
We do need to be credible,
but we also need to be curious
and reduce the stigma of disclosure.
I want to be very clear
that just because I have an open conversation
with my patient about their cannabis use
that supports reduction of use and not abstinence,
does not mean that I support
or have given them my permission to use it in pregnancy.
I am quite clear about that,
because we need to learn how to have
these very real conversations.
Next slide.
Okay, so let's start here where it all begins,
and it's with the patient.
And so, let's meet her.
This is Jane.
Jane is 25 years old.
She identifies her pronouns as she, her.
Jane just found out that she's pregnant.
She lives in rural Vermont and has a partner named Alex.
This pregnancy was not planned
and the couple is excited and very anxious.
This is Jane's second pregnancy, but first with Alex,
Jane had a 12-week loss with a former partner.
Jane is in general good health,
but has had a diagnosis of rheumatoid arthritis
since she was four years old,
and she deals with a lot of chronic pain.
Jane has a history of trauma and grief
and is also diagnosed with
generalized anxiety and depression.
Jane is screened and discloses on her first visit
to the OB clinic that she has used cannabis daily
to treat her chronic pain for about eight years,
as well as her depression
and reports that it does help with her anxiety,
and she has not had a flare of her RA in many years.
She believes she's currently about 10 weeks along
and is having some intense nausea
and reports that cannabis is helping with that as well.
Jane lets you know that her partner, Alex,
also uses cannabis.
She tells you that she's very nervous
about not using cannabis
and has done some research online and talked to friends
who have used cannabis during their pregnancies,
and some of them have really encouraged her
to continue using.
She tells you that she's really worried
that you're gonna make her stop smoking
or get on new medications for her RA, pain and depression,
and is worried if she doesn't take them
that she might get into some sort of trouble
or something bad will happen to her baby,
because that is what she has heard happens.
She then asks you if she were to get cannabis
from the new dispensary in town,
if that makes the cannabis safer and better for her baby.
She admits being very worried and does not know what to do.
So today we're gonna develop our narrative with Jane
throughout this presentation.
Next slide please.
But first, let's dial it back a little bit
for a little review of cannabis.
Cannabis is the plant which makes Delta 9,
also known as Tetrahydrocannabinol or THC,
who is the star of our show here today.
THC is the psychoactive ingredient in cannabis
and is found in higher concentrations
in the plant's flowers.
There are other things like terpenes and flavanoids
that affect the psycho-activity of cannabis,
but today we're just gonna focus on THC.
We then have its non-psychoactive cousin, cannabidiol,
also known as CBD,
which is a compound found in the cannabis plant as well
in different concentrations.
These two are the most well-known and most researched
in the cannabis family,
and these days it's not your mom's cannabis.
Cannabis has increased in potency throughout time.
In 1980, the THC content was less than 2%.
In 2015, it's gone up to about 20% or more.
If you don't know what this means,
the higher the percentage of THC coupled with
the way it's consumed,
the more psychoactive the effect for the person.
The takeaway is that unless someone knows
what they're consuming
or where their cannabis is coming from,
then there is a chance that they could be getting
into a situation for themselves that could be very risky.
Not knowing what contaminants, pesticides, molds,
mildews may be in the cannabis plant puts people at risk.
We also hear rumors of illicit substances such as fentanyl
being laced in black market cannabis.
And this makes stakes very high for everybody,
but especially for our pregnant and lactating people.
Next slide.
The bioavailability of THC is also affected
by the way it's consumed.
For an adult, inhaled cannabis has been shown
to have the largest amount of bioavailability,
because the lungs have a direct and fast entry
into the bloodstream.
THC levels rise very quickly in the bloodstream
and peak at about 10 minutes.
After about an hour, 90% of the THC levels
in the blood plasma drop very quickly,
and the leftover amount just kind of declines over time.
Oral consumption of THC has a much longer onset and duration
and a much lower bio-availability.
This is due to the edible going through the stomach,
getting broken down there,
and then heading to the liver for first pass metabolism.
About 99%, ooh, the lights went out here.
Hold on, there we go.
So, let me come back to it.
So this is due to the edible going through the liver,
for first pass drug metabolism,
about 99% of THC is metabolized in the liver
and it's excreted through the urinary and GI system.
In the gut, the THC Delta 9 gets converted to Delta 11,
which is it's more potent psychoactive,
and that's why edibles really seem to
make people feel higher for longer than inhaled THC.
The sublingual or submucosal route of consumption
is usually seen in tinctures and THC-infused strips.
Cannabinoids are permeable to the mucus membranes
in your mouth and skips the breakdown in the stomach,
in the liver,
so it's onset is a bit quicker than other oral means.
Next slide please.
Cannabis is still classified as a scheduled 1 substance
with no valid medical purpose.
And just to make this even more confusing,
this conflicts with the American Medical Institute,
the Department of Health and Human Services, the FDA,
and the National Academy of Sciences
and Engineering and Medicine,
all who recognize the medicinal effects of cannabis.
And even though it is legal for adults over 21 in Vermont
when it comes to pregnant birthing people,
in the absence of any other safety or substance use issues,
cannabis use in pregnancy is no longer reportable to DCF.
Dr. Shepard will discuss this a bit later as well.
Vermont legalized cannabis for recreational use for adults
21 years and older in 2018.
Currently, dispensaries all over the state
are being issued licenses to open
for recreational and medical sales
by the Cannabis Control Board,
who under the Tax and Regulate bill
will be responsible for issuing licenses for retailers,
growers, manufacturers, wholesalers, and labs.
Next slide please.
There is a lot of policy sufficient or not to protect anyone
under the age of 21 from being able to access cannabis
from the dispensaries.
There are policies on packaging
such as needing to have these warning label
warning symbols on them.
The only mention or guidance
for pregnant or lactating people is on this label
that must be placed on every package from the dispensary.
There is no current statewide policy or guidance
for dispensary owners or their budtenders,
which is what they're called on what to do
if a pregnant and lactating person
asked for advice on buying cannabis.
Next slide.
And as we know,
the experts who give us our professional guidelines
and policies continue to advise to counsel abstinence
to their patients during pregnancy and with lactation.
The Academy of Breastfeeding Medicine
is a little bit different.
They really weigh the frequency of use as a factor
in advising for lactating people,
but feels the evidence is not strong enough
to not recommend breast chest feeding,
but they do urge caution,
which I can appreciate,
because the cost of not breast chest feeding
has far-reaching implications.
Next slide.
So all that's pretty clear is mud, right?
That's what I think too.
Next slide.
These are the most common forms of cannabis consumption
that might be sold at a dispensary here in Vermont.
It is important to note that different states
have different regulations for the way cannabis
is packaged and sold.
In Vermont, the Cannabis Control Board
has capped the maximum percentage of THC
for cannabis flowers at 30% THC
and the milligrams for edibles at 5 milligrams per serving.
Next slide.
The cannabis concentrates also called dabs, shatter, oil
or crystal THC-A diamonds among many other names
can have a much higher THC percentage.
Check those almost as high as 80-99%.
The Cannabis Control Board
has capped the sale of THC solid concentrates at 60%,
and they're not capping the liquid concentrates
such as those in vape pens.
Next slide.
Okay, so I want to circle back to Jane
and invite you all to think about this conversation
that you as her provider are about to have with her.
In the chat box,
knowing that cannabis is legal to use,
but also knowing what the professional guidelines are,
as a provider, what makes you most anxious
about advising Jane?
I could tell you that I would be really scared
that something was gonna happen to my license
or if I told somebody that they could do what they wanted,
or they took it as they could do what they wanted
or I gave them information that made them feel
that I wasn't clear that it's not safe,
and something bad happened that could come back at me.
That would be something that would make me anxious.
Yep, knowing the exact dosage of cannabis
acquired via friend yet processing being different.
Yep, absolutely.
Jesse Lynn is a great resource.
Excellent.
Yep, dispensary is money.
So they may stay, yep,
they may just stay with their friends, this is very true.
Okay, next slide.
So let's briefly talk about how cannabis works in the body
and what we know about it,
and how it works in the body
of a pregnant and lactating person.
I'd like you to meet the cannabinoids.
They are here to help us kind of understand
the bigger picture.
So we are all born with a system
called the endocannabinoid system.
It is a vast network of chemical signals
and cellular receptors that are densely packed
throughout our brains and bodies.
The cannabinoid receptors in the body are named CB1 and CB2,
which are the receptors that have been studied the most.
CB1 is found mostly in the central nervous system,
and CB2 is found in the peripheral nervous system.
These guys act like a traffic cop in a big city.
They direct traffic in our bodies
by controlling the levels of activity
of most of the other neurotransmitters,
they regulate the traffic by turning up or down the activity
of whichever system needs to be adjusted.
Whether that is hunger, temperature, alertness,
pain, learning, memory,
whatever your body needs at any given time
to achieve internal stability,
it is critical for our overall ability
to regulate ourselves in so many ways.
Okay, so in order to stimulate those cannabinoid receptors,
our bodies also produce molecules called endocannabinoids,
which are structurally similar to the delta molecules
in the cannabis plant.
THC when consumed,
combined to both the CB1 and CB2 receptors,
which causes a range of effects,
some are desirable and others are not.
THC cannabinoids pretty much come into the system
and hijack the neurotransmission that is happening,
kind of pumps up the volume.
In pregnancy, the endocannabinoid system
has been known to play a significant cell-signaling role
in early embryo and placental development
as well as new evidence that shows that
the endocannabinoid system plays a role
in pregnancy maintenance and the initiation of labor.
Next slide.
Ah, the great and mighty placenta.
Seriously, one of the coolest organs.
It's a transient organ that only a pregnant person's body
makes with the sole purpose of nourishing, protecting
and growing a baby.
In pregnancy, the toxic effects of THC on the fetus
are not well-studied.
What we do know is that THC molecules are lipophilic
or have an affinity to dissolve into fat,
and they do pass through the placenta.
We know that THC exposure occurs in utero,
because THC is detected in newborn meconium and urine.
We just don't have any conclusive studies on timing
in the longterm effects in humans, just in animals.
Next slide.
During lactation, a lactating person uses cannabis
and depending on the mode of consumption,
has an average bioavailable dose of about 1-5%
for oral consumption and about 5-56% for inhaled
and that is circulating in their blood plasma.
It's important to remember
that whatever is in the blood plasma of a lactating person
reflects what can be found in the breast milk.
The THC then passes from the maternal plasma
into the lactose sites that secrete milk
and whatever THC is not secreted for milk production
during that time gets stored in in the adipose
and may come out in bits from time to time.
The baby then feeds and digest milk.
The milk gets metabolized
through the baby's digestive system
and first pass through the liver.
And what is left has been found to be about 1-2.5%
of the maternal dose.
So even though that seems like
a really small amount of exposure,
what we don't know is what a safe level of exposure
for a developing brain is.
So it's hard to quantify or qualify what these levels mean,
regarding the dose the infant gets
and the impact that it could have,
especially with those who chronically use cannabis.
Next slide.
This study was a pilot pharmacokinetic study
by Dr. Teresa Baker and Dr. Thomas Hale
from the Infant Risk Center
where breast milk samples were collected from mothers
who regularly consume cannabis.
Total of eight women were enrolled, so really small.
Most were occasional cannabis smokers and one chronic user.
This was a very controlled study,
but the results of all but one person
was consistent with the levels in the breast milk
peaking in about one hour post-cannabis use
and then coming back to near baseline by hour four.
The outlier was found to be the person who used chronically
and had a higher concentration of plasma THC than the others
who are only occasional smokers.
There are other studies that show that THC
can be found in the breast milk up to six days after use.
The individual variability
due to a lactating parents' metabolism,
genetic makeup and other factors
make cannabis very difficult to qualify its safety
for use in lactation and safety for the infant.
However, out of all of the studies
on cannabis and pharmacokinetics, one thing is very clear.
The more often a person uses cannabis,
the higher the toxic profile
and higher levels of accumulated THC
is found in the blood and tissues of the body.
More THC could consistently be crossing the placenta
and blood-brain barrier and higher levels of THC
could be present in human milk.
Next slide.
All the studies on cannabis pregnancy and lactation
are small and underfunded,
but at this time there is no known amount
that is 100% safe to consume in pregnancy
or during lactation.
Let's be very clear
that this is the right answer every time,
this is what our patients or clients need to hear from us,
but we need to inform them of the why.
The incorrect answer for our patients
is to just end the conversation here
or tell them that we just don't know enough, so stop using,
because in this era of Dr. Google and misinformation,
if we don't help our patients
to find what they need to hear,
they're going to find what they want to hear,
and our outcomes may reflect that.
Next slide.
Why do pregnant and lactating people
use cannabis during pregnancy?
Well, 5-10% of pregnant people in the United States
have disclosed use or have had positive drug screens.
This number will and has increased
as more states legalized cannabis.
And honestly, cannabis has been a part of Vermont culture
for a really long time.
So we kind of need to figure out those whys.
The data shows us that most people are using cannabis
in pregnancy for stress and anxiety above anything else
with nausea coming in a closed second,
even though most people believed
it was not safe to use during pregnancy.
Next slide.
This study on beliefs and attitudes
regarding prenatal cannabis are many of its kind.
It gives us a little bit of a better understanding
of the thought process and what that might look like
for a pregnant person, how they regard cannabis.
The outcomes reported that pregnant and birthing people
who consumed higher amounts of cannabis prior to pregnancy
really did attempt to reduce their use
once they were pregnant.
They used cannabis to help with nausea and appetite changes
and improve their mood.
And they described cannabis as natural and safe
when compared to other substances such as alcohol, tobacco,
and other recreational drugs,
including prescribed medications.
And a lot of them had a lot of conflicting opinions
whether or not cannabis was addictive.
I'll also mention that there are not many, if any,
comprehensive studies on partners and partner beliefs
around cannabis, pregnancy and lactation as well.
Next slide.
As many as 1 in 5 pregnant or postpartum Vermonters
suffer from symptoms of depression and/or anxiety
during the perinatal period.
Early data suggests that this number
is now significantly higher
at 1 in 3 women experiencing symptoms,
most likely due to the kind of a fallout from the pandemic.
Postpartum cannabis use
is associated with depressed symptoms
and shorter breastfeeding duration.
Cannabis use disorder is defined as cannabis use
with significant impairment or distress.
Symptoms can look similar to pregnant people
who present with cannabis hyperemesis syndrome,
but should not be confused with hyperemesis gravidarum
that comes as a severe pregnancy symptom,
but as you can imagine, the two may coexist.
Pregnant and birthing people who have used cannabis
were also more likely than those who did not
to have an anxiety disorder, a depressive disorder,
depressive symptoms, a trauma diagnosis,
and self-reported intimate partner violence.
And this is so relevant,
because what I see often in our communities
is that providers are still reducing
or taking pregnant people
off of their psychotropic medications
and clients are increasing their cannabis use
when their psych meds are removed or reduced.
This is not best practice.
And here in Vermont we have a lot of resources
to help to support providers with this.
Next slide.
I've put this slide together on some of the resources
that can be referred to
and when these slides are shared,
you'll have a copy of that.
Next slide.
So about 61% of providers are specifically asking
about cannabis use.
And while most healthcare providers indicated cannabis use
during pregnancy and breastfeeding and it's not safe,
many do not address safety or they really do
just directly discourage use.
Providers perceive cannabis really isn't as dangerous
as other perinatal substance use
and admit prioritizing other counseling topics
over perinatal cannabis
and counseling strategies really focused on policy
and legal consequences.
Providers identified competing time demands
and a need to prioritize what topics get covered.
And this is a real valid concern.
ACOG clinical guidelines already really advocate that
obstetric providers should address so many other topics
in pregnancy during obstetric visits,
particularly in those very first visits.
Next slide.
And more pregnant and lactating people want to feel safe
disclosing to their clinical providers,
but due to the stigma and fear they do not
and they are turning to the Google for advice.
As dispensaries open up,
they will also be turning to budtenders
for advice on safety and use.
When Colorado legalized cannabis in 2012,
they did a research study where they called dispensaries
pretending to be a pregnant person
dealing with pregnancy nausea.
Researchers found that employees at 69% of dispensaries
recommended treating pregnancy-related nausea with cannabis
and only 32% recommended consulting and clinical provider
and only about 4.7% of them answered
that there was any chance of fetal risk or harm.
Next slide.
So where are pregnant and lactating people
getting their information?
This slide represents the many different platforms
at a simple search on social media will bring up
who specifically support
pregnant, birthing and lactating people who use cannabis.
And honestly, the problem really does not come from
the people that lead these platforms necessarily,
but from the community of people behind the veil
of social media land that give a lot of unsolicited advice
that might not be appropriate.
There's actually a lot of evidence
that those who use cannabis in pregnancy
has spent quite a bit of time researching on their own.
Next slide.
So disclosure is a gift.
There's such an opportunity for providers everywhere
to be able to use cannabis to help build connection
and encourage change in pregnancy.
The touchpoint is wide open.
This is a time when people are open to trying new things
that develop new skills
and bridge their social and emotional capital.
In order to do this,
we have to learn to accept and grant
and dance in this gray area of what to do and how to advise.
Next slide.
Where we need to start is by honoring that harm and risk
are not inverse, but they walk next to each other
hand in hand.
Harm is something that I can tell you or show you
and it's negative effects that can potentially happen
to our patients if they choose to do something
or take in something that could hurt them.
Risk however, is a personal measurement and judgment.
We judge our own personal risk every minute of every day.
For example, in its very simplest form,
a couple weeks ago I was out to dinner
and I had eaten a big, full dinner
and I was offered a piece of chocolate maple cream pie.
Now this girl here, she left me some pie.
And even better yet,
it was from one of my favorite bakeries, Poorhouse Pies.
I was still very full from dinner
and I knew that it was not going to make me feel good.
And I can get pretty sick when I'm over full.
And even though this was a special occasion,
I knew that this could be the bite
that sent me over the edge.
But because I love pie more than to ever say no,
I accepted the piece of pie,
kind of knowing what I was gonna do next.
I took a bite, licked my fork clean
and enjoyed the heck out of it.
But after that bite,
even though it took all my inner dialogue
and an argument between my stomach and brain,
I stopped eating the pie.
I knew that the harm would be, but the harm would be,
and I put that right up against
the risk of feeling too sick.
I knew that a piece would be too much,
but a bite should be okay.
I reduced the harm by my own inner dialogue and choice.
And for all those anxious about that extra pie, don't worry,
my husband is a human garbage can.
So no pie was wasted.
Next slide.
Harm reduction begins with an acceptance
that substances and substance use
and negative health choices are part of the world we live in
and we do not have the power to make them disappear,
but we can work to minimize the effects in a holistic way.
Harm reduction is an intervention
that focuses on reducing the negative,
the potential negative social and legal impacts
associated for the sake of this discussion on cannabis.
It focuses on positive change and is grounded in compassion,
working with people without coercion,
judgment and discrimination
within the principle that the patient does not have
to stop using cannabis to get continued support
from the providers about it.
The most important and radical part about harm reduction
is to demonstrate with our words and our actions
that we respect and love people who use substances
or historically have made poor choices
and honor who they are and their life journey
that brought them there.
I know many of you here today
and know that many of you are already using harm reduction
in your practice and but I also wanna honor us as providers
who daily must take several deep breaths
and sit on our hands and our voice
to care for some patients or clients
who continue to make choices that are causing a lot of harm.
Our eyes and ears have have seen the worst of it,
but I know that we also get to bear witness to miracles
and a lot of successes.
This is what I love about this practice too.
It really humanizes our work
and celebrates even the smallest success.
Harm reduction and the strategies can seem a bit sappy
and intense at times,
but really, harm reduction is a mindset.
It also takes the onus off of them
to fix them or write them,
which whether that is theoretical or in more concrete ways.
It's not a fair expectation.
We cannot and are not responsible to fix years of trauma
or change someone's childhood ACE score
and that's not a fair ask, even the most learned doctor,
they can't do it or even Wonder Woman for that matter.
But what we can do is get curious and sit with the patient
in their world for a bit and understand their why
and help guide them.
And it really puts the responsibility of change on them
by affirming their individual story and autonomy,
because we must believe that they have the ability
within them to do so no matter how many times
they must start over.
Next slide.
We all have a bias and I thank you guys
for sharing yours earlier
and the language that we use is very important to make sure
that we are not shaming or creating barriers
for our clients.
Having worked in the community for a long time,
I know that what was most likely discussed
and what the patient hears or felt can be very different
from what was intended.
So we must check it.
Everyone comes from somewhere and has their own experience
as their own experiences with cannabis
and those who use it.
We also must acknowledge that race and implicit bias
continue to infiltrate our systems
and care for our patients.
Black women are 10 times more likely to be reported to DCF
for positive drug screens than a White woman.
We also need to recognize the realities of poverty, class,
social isolation, past trauma, sex-based discrimination,
and other social inequalities
and how that affects people's vulnerability to
and capacity for effectively developing ambivalence
within their own environments.
I also hear this a lot.
Well, at least it's not insert opiates,
insert methamphetamines.
Remember even those who are on MAT who use cannabis
should be counseled about the risks in reducing their use
if possible during pregnancy and lactation.
And we must also have the resources to deal with
the answers that we do get
and we need to have 'em at the ready
to support the person to cease use if they want to
or/and to have to deal with the other side
of their increased anxiety and depression
and feeling uncomfortable and especially during pregnancy,
so that they can choose this path with support.
Next slide.
Motivational interviewing is a great way
to guide a conversation that sits between active listening
and giving advisement.
The underpinnings of MI facilitates change
by empowering the patient
to evoke their own meaning and importance
and their capacity to ship their own constructs,
to develop discrepancy in a respectful and autonomous way.
It really makes us as a provider kind of take off
our provider armor for a moment,
place it down beside us so that we can kind of sit
with our patient and partnership
to help them develop discrepancy,
which is the gap between what is happening
and where they wanna be,
because that right there is the space
where change can happen.
It's not about getting people to change
or being confrontational,
it's about being curious about their journey
and reflecting it back to them in a strength-based way
that re-frames the story a bit and plants the seed.
Then personally I like to let that seed marinate
and revisit it again,
and then sometimes I have to replant that feed again.
Normalizing what they're going through empathy,
compassion, and humor
really helps to form connection
and it humanizes us as providers.
If there's anything that I suggest learning and practicing
and getting good at is a skill,
where I just gave you a really brief overview
of motivational interviewing.
It is the best strategy to keep the conversation going
so you as a provider can return to it
and continue to reduce the harm.
There are several trainings and resources that you can use
to support learning this as well.
Next slide.
So using a harm reduction model of care
in motivational interviewing,
this is how I may open the conversation with Jane.
"Jane, first I wanna thank you for telling me
that you're using cannabis for your RA pain,
your nausea and anxiety.
That must have taken a lot of courage for you to tell me.
It sounds as if cannabis is something that really helps you.
I wanna let you know that you are not in any trouble here
and I understand your inner conflict, you're not alone.
So many other new parents have the same concerns.
There's a lot of information out there
and it can be really confusing to know
what the actual risks are for you and your baby.
I also hear your concern
over taking new medications when pregnant.
It can be really hard to think about changing
what's been working well and you obviously know your body
and have done a really great job
not having any flares or complications for so long.
The goal is to help you get to a place
where you can understand the information
and make the best choice for you and your baby
and give you the resources you need to change things
as you want to.
This is not something that we might fully answer today,
but if it's okay with you,
we can start the conversation on what we do know
about cannabis and pregnancy and what we don't
and what some of the other options that you could try
and help you come up with a plan that works for you.
How does that sound?"
It seems pretty simple.
The conversation not only put Jane
in the driver's seat of her care,
but it affirms that I see and hear her fears that she has
and it lets her know I care about her
and want to help her process to get to the next step.
I normalize and have asked permission
to continue the conversation.
Next slide.
So what could the options be for my patient?
Could they delay their use until pregnancy
or see pregnancy's over or ceasing lactation?
Could they try another therapy that is more compatible
with pregnancy and lactation?
If cessation's on an option,
reducing the frequency to the lowest possible amount,
consider micro-dosing, minimum effective dose.
Make sure that you're using clean cannabis
and clean consumption methods
and choosing the most compatible dose or form.
You can refer to my friend Jesse Lynn,
who's on this call today,
who is, she's started the Vermont Cannabis Nurse Association
and you can receive free confidential evidence-based support
or try something new to reduce stress for your patient
to reduce stress for the patient.
Walking, yoga, this is the time when people
are going to be open to trying things like that
so that they can have a different path
and different things moving forward.
So now I'm gonna hand it off to Dr. Michelle Shepard
where we'll hopefully and we'll hopefully have some time
for questions at the end.
[Michelle] Awesome, thanks so much Amy,
you did a wonderful job wrapping all that stuff up.
And we're using a transition slide here,
because here in Vermont, as was discussed,
cannabis is legal.
So why do we still need to do the Plan of Safe Care
and what can we all do to arm ourself
with accurate information
to share with our patients and clients?
So next slide please.
Oh, you can skip to the next one.
So as was just mentioned,
the rate of cannabis use and pregnant people is pretty high.
But also the reminder is when I look at this slide,
I see that in the eight states
in this 2017 PRAMS data sampling
that 10% of people reported using cannabis before pregnancy,
but only 4.2% of those people continue
to use during pregnancy.
So there is a large proportion of people
that are able to delay use, decrease use, or cease use,
similar to alcohol during pregnancy.
In Vermont, we're about 10% during pregnancy.
So similar total amount, but higher during pregnancy use.
Next slide please.
So this is something I'm gonna come back to,
but I always feel like clear communication,
shared languaging and shared messaging
is the best thing we can do all around.
So substance use, including tobacco,
including alcohol, including cannabis,
is not recommended and we should work on
decreasing or stopping use using some of the same techniques
that were already highlighted.
It is so important to know the state's
CARA and CAPTA policies.
So New Hampshire's policies and Vermont's policies
and New York's policies are all very different.
It's important that we know how that
either legislation as in New Hampshire
or policies as in Vermont can impact the involvement of DCF
and when or how a Plan of Safe Care is developed.
We want to provide pregnant people with accurate information
and answer questions and if you don't know the answer,
we can point you to where you can find it
and then use the available resources
that are out there already that are state-specific
for both yourself and for your patients.
Next slide please.
So the CARA and CAPTA amendments,
you'll hear people throw the word CAPTA around a lot.
CAPTA is a huge piece of federal legislation
known as the Child Abuse Prevention and Treatment Act.
Cara, which is the Comprehensive Addiction and Recovery Act,
was a 2016 amendment and it's just one tiny slice
of this huge body of legislation.
The overall goal of CARA was to address the needs of infants
specifically affected by substance use, withdrawal
or fetal alcohol spectrum disorders.
And per federal law,
substance use includes cannabis
and that's where we get the need
to do the Plan of Safe Care.
So the requirements of this amendment
were that each state developed their own pathway
around identifying infants affected by substance use.
Healthcare providers needed to notify.
Now this is not report, this is not chastised,
this is not take children away.
They need to notify Child Protective Services,
develop a Plan of Safe care,
and then the Child Protective Service Agency of the state
has to send a certain subset of data,
which is literally overall numbers for the year
to the Children's Bureau.
Next slide please.
So what we've tried to do is make it as simple
and straightforward as as possible.
In Vermont, we do not have overarching legislation
that governs this.
We are working on DCF policies
and a governor's assurance that we're in compliance.
So the difference between a DCF Report,
we all know what a DCF Report is, right?
This is an identified call to the intake hotline.
You give out significant amounts of personal information
about the parent and this is only indicated in the times
where legal substances are used
in the third trimester of pregnancy.
There is misuse or use of non-prescribed medications
in the third trimester or the concern
for fetal alcohol spectrum disorder.
There's a little bit of a gray area
around alcohol use disorder in the third trimester.
A separate pathway that we have developed in Vermont
is called the CAPTA Notification pathway.
This is a de-identified tracking form
that is not sent through the DCF Report network.
This is indicated in the times
where there is Medications for Opioid Use disorder,
also commonly called MAT
or Medications for Addiction Treatment.
People that are using prescribed opioids or benzodiazepines
during pregnancy or any use of cannabis during pregnancy
after the first trimester.
Next slide.
This may be a little hard to see.
So I'm gonna point everyone to the flow charts
that are available on the DCF website.
These were developed to really help make it easy to know,
do you need to make a call to DCF?
Do you need to report DCF
concern for substance use during pregnancy?
So this is again, last trimester only.
We're allowed to make prenatal reports in Vermont.
This is not the case in other states.
But in Vermont we can open DCF cases
30 days before the delivery date
in order to help families get all of the supports
they can get to safely and confidently parents,
this is not done in order to take a child away.
This is done to try to adjust any problems
that are modifiable to keep this family together.
So if the substance use is limited
to any of those prescribed medications and/or marijuana,
so this can be all four, it can be one, it can be two,
it can be marijuana alone
and there are not any concerns, so this is important,
no concerns for the newborn safety,
then there's no prenatal report.
Anytime you have a concern for newborn safety,
now this can be, it's completely separate from substance use
of course, concern for safety
should go through the reporting mechanism.
But what I wanna remind people is that we really love it
if we can start the conversation
about the Plan of Safe Care,
what it is and what it isn't, and have involved caregivers,
pregnant people, and their providers
starting this prior to delivery.
Next slide.
This is a similar flow chart for newborns
exposed to substances.
So this is after birth.
And again, this is the exact same pathway.
If there's no concerns for newborn safety,
the only thing that must happen is the Plan of Safe Care
should be done with the caregivers.
It should be shared with the infant's PCP
and the de-identified notification forms
should be faxed or emailed over.
And then, just the reminder
that there are certain newborn reports.
And that's again,
if there are signs of withdrawal due to substances
that were not prescribed,
that would go through the reporting.
But up on the top you can see that the DCF policy
on cannabis use since 2017 is that cannabis use alone
is not accepted.
So you could call,
but they're not going to accept this
as an open case unless there are other concerns.
Next slide please.
I just wanted people to see
what the Plan of Safe Care looks like.
So the Plan of Safe Care is an identified document
and that's identified for a reason,
because it's given to the caregivers.
The indication up on the top there
is just helpful for people to follow up on.
And so again,
cannabis use alone or in combination
from any of the other three categories
should trigger a Plan of Safe Care development.
This needs to be completed by the time
of hospital discharge.
It's all about the referrals and follow ups.
Next slide please.
So what you can see on the remainder
of the Plan of Safe Care is a listing of services,
supports and referrals.
These are split into infant supports and caregiver supports.
And there's many things on here.
Again, people may be receiving all of these things
or they may discuss them and not be interested in them
and that is okay.
There is nothing about this
that is going to be shared with DCF.
There is nothing about this that is going to be published.
It's all about here is a way to get contact information
for the person you should call at WIC
for childcare resources,
for children's integrated services, for home visiting.
It can be really nice to have all that information
in one place.
Next slide please.
This is the de-identified Vermont CAPTA Notification.
This has check boxes on it.
Again, here is your recreational versus prescribed cannabis
as we were trying to track the difference
and whether we were seeing a difference
as cannabis is legalized into a more recreational use,
we're also looking at other exposures
including alcohol and nicotine.
That's really important.
Those co-exposures have their own known effects
on the infant and their longterm development.
And then, at the bottom are the things
that we have to report.
So in that final box, the only things that are going off
to the Children's Bureau are these three things.
Whether the Plan of Safe Care was completed
and sent to the PCP,
whether the individual was engaged in services
prior to delivery, and whether new referrals were made.
That is all of the tracking that has to happen
per the capital law.
Next slide please.
So here we are back to clear communication
and using available resources for more information.
Next slide.
So here's one that again, it's hard to see on the slide,
but please go and take a look at it.
We had a wonderful student working with us
that helped us develop this infographic
around cannabis use and breastfeeding.
And we have some Vermont-specific QR codes and websites
to visit for people that have more information.
Next slide please.
Also, please use the Plan of Safe Care website.
Unfortunately, it's a little bit buried.
It currently lives under DCFS Family Services Division.
We're hoping to move that,
but it has all of the following resources here,
including several different
frequently asked questions, documents.
Next slide.
Here's the frequently asked questions,
marijuana use in pregnancy.
Next slide.
And what I thought was the most important apparent handout
on the Vermont Plan of Safe Care and what it is
and what it isn't.
So this is something you can hand to people
so they're not hearing about the Plan of Safe Care
for the first time at hospital discharge.
Next slide.
One more conversation is a Vermont Department of Health
campaign that has lots of information for providers.
There's a whole toolkit for providers,
but also education materials for parents.
Next slide.
And here's the Cannabis Use During Pregnancy slide.
So again, it has more information and available resources.
Next slide.
And this is the last thing I want to summarize,
'cause I feel like people get really nervous
about the Plan of Safe Care.
The Plan of Safe Care is a living document
that's created with the pregnant person
and their involved supports.
It documents their current supports, strengths, needs,
and new referrals,
and is shared with the infant's primary care provider.
This is to facilitate followup on referrals
for both the infant and to check in with that caregiver.
This is not a form for hospitals
and it's not a form for providers.
There is nothing punitive about this
and it is not shared with DCF
unless they are already involved for their own
child safety concerns.
And in yellow highlight a Vermont Plan Safe Care is required
along with the de-identified CAPTA Notification
for any pregnant person using cannabis
after the first trimester.
Next slide please.
And I'll turn it back over.
[Amy] So I think, just kind of to wrap up,
we've got one minute.
If there are any pressing questions,
you can feel free to email ICON.
I think, just learning how to discuss it and complete it
with your patients is going to be
and how to introduce it is in a really safe, really easy way
is gonna be the best thing for you.
So I thank everybody for coming together today
to hear us speak about this topic.
Go to the next slide.
[Julie] Thank you Amy. Thank you Dr. Shepard.
Thank you everybody for joining.
I can't believe we're right on time, that's excellent.
I'm just putting the link here for the evaluation.
We will put the recording and the slide on our website,
might take a few days,
but you'll be able to find both of them on our website.
Please don't hesitate to reach out if you have any question.
Thank you for your participation and have a great afternoon.