1 00:00:02,370 --> 00:00:03,273 [Julie] Perfect. 2 00:00:05,130 --> 00:00:06,390 All right. 3 00:00:06,390 --> 00:00:07,473 Can everyone hear me? 4 00:00:08,610 --> 00:00:10,560 Yeah, perfect, all right. 5 00:00:10,560 --> 00:00:11,850 Good afternoon everyone, 6 00:00:11,850 --> 00:00:16,850 and welcome to our fall webinar presentation. 7 00:00:17,430 --> 00:00:21,510 This is part of the Perinatal Quality Collaborative Vermont 8 00:00:21,510 --> 00:00:23,430 Learning Series. 9 00:00:23,430 --> 00:00:28,430 We have a few webinar that we do like this year, 10 00:00:29,640 --> 00:00:33,900 and this is the first one for the fall. 11 00:00:33,900 --> 00:00:36,990 My name is Julie Parent, I use she, her pronouns. 12 00:00:36,990 --> 00:00:39,840 I am the perinatal project director 13 00:00:39,840 --> 00:00:43,620 at the Vermont Child Health Improvement Program, 14 00:00:43,620 --> 00:00:45,933 also known as VCHIP. 15 00:00:47,070 --> 00:00:51,333 And before we get started with the content and our speaker, 16 00:00:52,170 --> 00:00:56,100 I just wanted to give a shout out to the team 17 00:00:56,100 --> 00:01:00,180 who works on putting together this webinar 18 00:01:00,180 --> 00:01:04,050 and also all of our learning activities 19 00:01:04,050 --> 00:01:09,050 for the PQC and specifically for the ICON Initiative. 20 00:01:09,660 --> 00:01:11,370 I know I'm throwing a lot of acronym, 21 00:01:11,370 --> 00:01:13,050 but ICON stands for 22 00:01:13,050 --> 00:01:17,340 Improving Care for Opioid Exposed Newborn, 23 00:01:17,340 --> 00:01:20,910 and this is a longstanding project at VCHIP. 24 00:01:20,910 --> 00:01:25,350 We're kinda carrying the legacy of Dr. Ann Johnson, 25 00:01:25,350 --> 00:01:30,270 who started the program I think two decades ago. 26 00:01:30,270 --> 00:01:33,180 So I don't know if everyone is on the call right now, 27 00:01:33,180 --> 00:01:36,180 but we have Dr. Michelle Shepard, 28 00:01:36,180 --> 00:01:38,280 who will be presenting today. 29 00:01:38,280 --> 00:01:42,150 She's our faculty lead on the project 30 00:01:42,150 --> 00:01:47,150 and Dr. Molly Rideout, and Dr. Adrian Paul, 31 00:01:47,250 --> 00:01:50,760 Dr. Bronwyn Kenny and Susan White 32 00:01:50,760 --> 00:01:55,760 who are longterm been involved in this kind of work. 33 00:01:55,800 --> 00:02:00,800 And our two parent advisors, Heidi and Ashley, 34 00:02:00,900 --> 00:02:05,400 and Angela Zinno, who's our project coordinator, 35 00:02:05,400 --> 00:02:07,530 and Avery Rasmussen, 36 00:02:07,530 --> 00:02:11,703 who's our perinatal project data manager. 37 00:02:12,690 --> 00:02:16,350 So that team makes all these event happening 38 00:02:16,350 --> 00:02:20,250 behind the scene and they're here today to also help 39 00:02:20,250 --> 00:02:22,997 Dr. Paul and Dr. Rideout and Dr. Shepard 40 00:02:22,997 --> 00:02:27,240 who'll be here to just answer your question on the chat. 41 00:02:27,240 --> 00:02:30,330 So maybe just a few housekeeping rule. 42 00:02:30,330 --> 00:02:34,920 Angela, if you wanna just move to the next slide. 43 00:02:34,920 --> 00:02:38,760 So we also have life captioning available. 44 00:02:38,760 --> 00:02:42,333 I put it in a chat, but we will repost it in a minute. 45 00:02:43,830 --> 00:02:44,663 As I mentioned, 46 00:02:44,663 --> 00:02:47,880 we do host a lot of different learning activity 47 00:02:47,880 --> 00:02:49,650 throughout the academic year. 48 00:02:49,650 --> 00:02:52,830 So if you have received this invite 49 00:02:52,830 --> 00:02:55,470 through a colleague or a friend 50 00:02:55,470 --> 00:02:58,800 and you'd like to be added to our Listserv, 51 00:02:58,800 --> 00:03:00,900 just send us an email at the email 52 00:03:00,900 --> 00:03:02,577 that's indicated right here, 53 00:03:02,577 --> 00:03:07,260 vchippqcvt, and we'll add you to the Listserv 54 00:03:07,260 --> 00:03:11,550 and then you'll be able to join our activity, 55 00:03:11,550 --> 00:03:15,420 we're planning two more webinar in the New Year 56 00:03:15,420 --> 00:03:18,690 that are related to substance use. 57 00:03:18,690 --> 00:03:20,733 So we would love for you to join. 58 00:03:21,780 --> 00:03:23,010 And then what else? 59 00:03:23,010 --> 00:03:26,160 And also, we have an evaluation at the end. 60 00:03:26,160 --> 00:03:28,680 We've made it super, super, super-short, 61 00:03:28,680 --> 00:03:31,710 only 5 or 6 questions, so please take a moment. 62 00:03:31,710 --> 00:03:34,380 We wanna hear from you, we wanna hear your comment, 63 00:03:34,380 --> 00:03:38,190 and if you have any other type of topic 64 00:03:38,190 --> 00:03:40,233 that you would like to discuss. 65 00:03:41,370 --> 00:03:43,113 And next slide, Angela. 66 00:03:44,280 --> 00:03:46,683 All right, so we'll get started. 67 00:03:47,640 --> 00:03:49,530 And Amy, I apologize, 68 00:03:49,530 --> 00:03:51,480 I'm probably gonna mess up your last name, 69 00:03:51,480 --> 00:03:56,160 the French Canadian accent here, but Amy's a colleague, 70 00:03:56,160 --> 00:03:58,650 she's our speaker today, 71 00:03:58,650 --> 00:04:02,670 and she's also a friend of ICON Project. 72 00:04:02,670 --> 00:04:05,550 Amy Wenger is a registered nurse. 73 00:04:05,550 --> 00:04:10,550 She's an international board-certified lactation consultant. 74 00:04:11,310 --> 00:04:14,730 She's passionate about maternal child health work. 75 00:04:14,730 --> 00:04:19,730 She started as a Doula and Childbirth educator 20 years ago. 76 00:04:21,330 --> 00:04:25,863 She also worked on the postpartum floor at UVMMC. 77 00:04:26,700 --> 00:04:28,920 She worked in pediatric clinic, 78 00:04:28,920 --> 00:04:31,650 and currently she's the maternal child, 79 00:04:31,650 --> 00:04:35,980 clinical nurse manager at a community home health agency 80 00:04:37,290 --> 00:04:38,580 in Vermont. 81 00:04:38,580 --> 00:04:43,500 And she is also the founder and co-executive director 82 00:04:43,500 --> 00:04:45,870 of the Vermont Donor Milk Center, 83 00:04:45,870 --> 00:04:47,870 which I think she'll talked about today, 84 00:04:48,780 --> 00:04:52,560 which provide outpatient pasteurized donor human milk 85 00:04:52,560 --> 00:04:56,130 to infants who requires supplementation 86 00:04:56,130 --> 00:04:59,760 and is also a very good person to know 87 00:04:59,760 --> 00:05:02,100 when you need resources around lactation 88 00:05:02,100 --> 00:05:04,470 and postpartum resource. 89 00:05:04,470 --> 00:05:07,350 And Amy last year also participated 90 00:05:07,350 --> 00:05:10,513 in our storytelling project 91 00:05:10,513 --> 00:05:13,770 with a different provider and also folks 92 00:05:13,770 --> 00:05:15,600 that had a lived experience with 93 00:05:15,600 --> 00:05:18,630 substance abuse during pregnancy. 94 00:05:18,630 --> 00:05:23,630 So her actual full story is available on our website, 95 00:05:24,570 --> 00:05:28,500 and I can put the link also regarding that in the chat. 96 00:05:28,500 --> 00:05:31,980 And then Michelle, Dr. Shepard, will join Amy 97 00:05:31,980 --> 00:05:33,210 a little bit later on. 98 00:05:33,210 --> 00:05:38,210 But Dr. Shepard is our faculty lead on the ICON project. 99 00:05:38,220 --> 00:05:40,560 She's also an assistant professor 100 00:05:40,560 --> 00:05:43,140 at the Larner College of Medicine School, 101 00:05:43,140 --> 00:05:48,140 and she is a pediatrician in the newborn nursery at UVMMC 102 00:05:49,410 --> 00:05:53,460 and the mother of two, and she's involved in many things. 103 00:05:53,460 --> 00:05:56,130 So I'm gonna turn it over to Amy, 104 00:05:56,130 --> 00:05:58,410 and Angela's gonna advance this slide, 105 00:05:58,410 --> 00:06:02,190 and please don't hesitate to add your question 106 00:06:02,190 --> 00:06:03,063 into the chat. 107 00:06:04,800 --> 00:06:06,050 [Amy] Thank you, Julie. 108 00:06:07,470 --> 00:06:11,760 So I have no relevant financial relationships to disclose 109 00:06:11,760 --> 00:06:13,950 or conflicts of interest to resolve. 110 00:06:13,950 --> 00:06:17,965 That is what I'm going to start with today. 111 00:06:17,965 --> 00:06:20,370 So good afternoon and thank you Julie, 112 00:06:20,370 --> 00:06:23,730 and a big thanks to the ICON team and Dr. Shepard 113 00:06:23,730 --> 00:06:26,610 for inviting me to speak to you all today 114 00:06:26,610 --> 00:06:29,760 about cannabis pregnancy and lactation. 115 00:06:29,760 --> 00:06:33,060 I'm excited to be able to present this to you, 116 00:06:33,060 --> 00:06:37,650 because this is actually, it's pretty timely conversation, 117 00:06:37,650 --> 00:06:40,410 because again, our communities right now as we speak, 118 00:06:40,410 --> 00:06:43,050 are opening retail cannabis dispensaries 119 00:06:43,050 --> 00:06:46,893 for adult and recreational sale all over. 120 00:06:48,660 --> 00:06:52,020 So I would also love to get to know all of you as well. 121 00:06:52,020 --> 00:06:55,110 So please introduce yourself via the chat box 122 00:06:55,110 --> 00:06:56,970 and if you feel comfortable sharing 123 00:06:56,970 --> 00:07:01,590 what your own personal stigma or bias around cannabis is, 124 00:07:01,590 --> 00:07:04,290 we all come from different levels of knowledge, 125 00:07:04,290 --> 00:07:06,009 different values and places, 126 00:07:06,009 --> 00:07:09,090 and cannabis can be a very political and hot topic. 127 00:07:09,090 --> 00:07:12,510 I ask that all conversation that occurs in this space 128 00:07:12,510 --> 00:07:16,560 and in this chat and in general is respectful and kind. 129 00:07:16,560 --> 00:07:18,270 Today, I'll be talking a little bit about 130 00:07:18,270 --> 00:07:20,700 the biology of cannabis, as well as the data 131 00:07:20,700 --> 00:07:22,530 that we do have, 132 00:07:22,530 --> 00:07:25,110 which I'm hoping will give you all a better, 133 00:07:25,110 --> 00:07:27,870 kind of a bigger baseline of knowledge 134 00:07:27,870 --> 00:07:31,110 so that we can kind of dive into our bigger focus today 135 00:07:31,110 --> 00:07:33,180 on the importance of having the conversation 136 00:07:33,180 --> 00:07:35,220 with our pregnant and birthing clients 137 00:07:35,220 --> 00:07:37,413 regarding their cannabis use. 138 00:07:38,730 --> 00:07:41,010 Dr. Shepard will be discussing and giving updates 139 00:07:41,010 --> 00:07:44,460 on the federal care amendment to the capital legislation, 140 00:07:44,460 --> 00:07:46,800 and the Plan of Safe Care around cannabis, 141 00:07:46,800 --> 00:07:49,290 navigating these conversations. 142 00:07:49,290 --> 00:07:51,420 There's a lot of content in my presentation, 143 00:07:51,420 --> 00:07:55,260 but I do invite you to start a conversation in the chat 144 00:07:55,260 --> 00:07:57,990 as well as join in the discussion points 145 00:07:57,990 --> 00:08:01,980 of this presentation when they come up. 146 00:08:01,980 --> 00:08:05,100 I will be using the term, birthing and lactating people 147 00:08:05,100 --> 00:08:07,470 as inclusive terminology, 148 00:08:07,470 --> 00:08:09,720 and I use the term breast chest feeding 149 00:08:09,720 --> 00:08:12,870 or human milk feeding as much as possible. 150 00:08:12,870 --> 00:08:15,300 But you may hear the term woman, maternal, 151 00:08:15,300 --> 00:08:16,680 breastfeeding, or mother. 152 00:08:16,680 --> 00:08:19,080 As much as I try to be really conscious of myself, 153 00:08:19,080 --> 00:08:21,990 I will always own my own privilege and my desire to be 154 00:08:21,990 --> 00:08:23,790 as inclusive as possible. 155 00:08:23,790 --> 00:08:26,010 Much of the data and research uses language 156 00:08:26,010 --> 00:08:27,900 that isn't quite as inclusive. 157 00:08:27,900 --> 00:08:30,000 So if I use a term that is not culturally 158 00:08:30,000 --> 00:08:31,470 or socially accurate, 159 00:08:31,470 --> 00:08:35,730 please feel free to email me later and gently make me aware 160 00:08:35,730 --> 00:08:38,310 so I can always learn and do better. 161 00:08:38,310 --> 00:08:41,490 We're all perfectly imperfect work's in progress. 162 00:08:41,490 --> 00:08:42,323 Next slide. 163 00:08:44,250 --> 00:08:45,873 So why cannabis? 164 00:08:47,190 --> 00:08:51,720 Well, I needed to know more. 165 00:08:51,720 --> 00:08:54,150 And I'm a lifelong questioner 166 00:08:54,150 --> 00:08:55,800 and I want to be very transparent 167 00:08:55,800 --> 00:08:58,470 that I'm also a lifelong grateful deadhead, 168 00:08:58,470 --> 00:09:00,720 but I'm not a cannabis expert, 169 00:09:00,720 --> 00:09:04,413 or at least I haven't been since about the summer of 2005. 170 00:09:05,970 --> 00:09:08,670 In that time, my own personal view of on cannabis 171 00:09:08,670 --> 00:09:11,310 has changed greatly in the past 25 years, 172 00:09:11,310 --> 00:09:14,763 especially when I became pregnant and had my own children. 173 00:09:15,750 --> 00:09:18,480 I'm still rather ambivalent about how I feel 174 00:09:18,480 --> 00:09:19,830 about recreational sales 175 00:09:19,830 --> 00:09:22,020 and how they'll impact the population of patients 176 00:09:22,020 --> 00:09:23,190 that I work with. 177 00:09:23,190 --> 00:09:26,940 I question how as a MCH home visiting nurse leader, 178 00:09:26,940 --> 00:09:29,820 working with pregnant and lactating persons daily 179 00:09:29,820 --> 00:09:33,960 is the best way to address this kind of very gray area, 180 00:09:33,960 --> 00:09:37,590 educate my patients and how I lead my nurses and community 181 00:09:37,590 --> 00:09:39,960 to react and act when a patient does disclose 182 00:09:39,960 --> 00:09:41,400 their cannabis use. 183 00:09:41,400 --> 00:09:44,490 Or what do I do if their client has their stash and bong 184 00:09:44,490 --> 00:09:46,500 just sitting on the table during a home visit, 185 00:09:46,500 --> 00:09:48,870 which is a very true story, 186 00:09:48,870 --> 00:09:52,530 especially now that it's legal for adults over 21 187 00:09:52,530 --> 00:09:53,550 to use cannabis, 188 00:09:53,550 --> 00:09:55,950 both for recreational and medicinal purposes, 189 00:09:55,950 --> 00:09:58,710 what resources are available to keep my patients 190 00:09:58,710 --> 00:09:59,910 and their families safe? 191 00:10:01,380 --> 00:10:02,911 And what do my pregnant lactating 192 00:10:02,911 --> 00:10:05,070 and parenting patients think? 193 00:10:05,070 --> 00:10:07,350 And most importantly, how do we hold safe, 194 00:10:07,350 --> 00:10:11,040 equitable trauma-informed space and not create more barriers 195 00:10:11,040 --> 00:10:13,620 to disclosure of cannabis, 196 00:10:13,620 --> 00:10:16,350 including safety for that teeny, tiny little purple elephant 197 00:10:16,350 --> 00:10:19,500 in the room who just has yet to be born? 198 00:10:19,500 --> 00:10:20,333 Next slide. 199 00:10:23,040 --> 00:10:25,530 Well, just as you may think, 200 00:10:25,530 --> 00:10:26,850 pregnancy and lactation 201 00:10:26,850 --> 00:10:29,610 are one of the last taboos of legalization, 202 00:10:29,610 --> 00:10:31,650 and many of us have gotten really good 203 00:10:31,650 --> 00:10:33,720 at not talking about it. 204 00:10:33,720 --> 00:10:36,267 For many years, providers have given the advice, 205 00:10:36,267 --> 00:10:38,220 and I'm just really generalizing here. 206 00:10:38,220 --> 00:10:40,680 Well, we just don't have enough information to tell us 207 00:10:40,680 --> 00:10:44,010 that it is or is not safe during pregnancy or lactation, 208 00:10:44,010 --> 00:10:46,560 so we recommend that you stop using it, 209 00:10:46,560 --> 00:10:49,650 because we don't fully understand the harm that can happen. 210 00:10:49,650 --> 00:10:52,320 And that's kind of the end of the conversation. 211 00:10:52,320 --> 00:10:53,223 Next slide. 212 00:10:55,740 --> 00:10:57,540 Because I know when I give this kind of an answer 213 00:10:57,540 --> 00:11:00,660 to my patients, I've just created a statement of stigma. 214 00:11:00,660 --> 00:11:03,360 They just disclosed to me that they use cannabis, 215 00:11:03,360 --> 00:11:07,860 and I just told them that because I, in a position of power, 216 00:11:07,860 --> 00:11:10,380 do not know enough about it to give them advice 217 00:11:10,380 --> 00:11:13,650 or was even curious enough to think about 218 00:11:13,650 --> 00:11:15,240 their cannabis use as something other, 219 00:11:15,240 --> 00:11:16,140 that they could stop, 220 00:11:16,140 --> 00:11:18,240 that something that they could stop without a consequence. 221 00:11:18,240 --> 00:11:21,060 And I've created a barrier in this space between us 222 00:11:21,060 --> 00:11:23,163 and they feel judged or ashamed. 223 00:11:24,060 --> 00:11:25,380 We do need to be credible, 224 00:11:25,380 --> 00:11:26,880 but we also need to be curious 225 00:11:26,880 --> 00:11:29,370 and reduce the stigma of disclosure. 226 00:11:29,370 --> 00:11:30,810 I want to be very clear 227 00:11:30,810 --> 00:11:33,120 that just because I have an open conversation 228 00:11:33,120 --> 00:11:35,370 with my patient about their cannabis use 229 00:11:35,370 --> 00:11:38,700 that supports reduction of use and not abstinence, 230 00:11:38,700 --> 00:11:40,530 does not mean that I support 231 00:11:40,530 --> 00:11:44,340 or have given them my permission to use it in pregnancy. 232 00:11:44,340 --> 00:11:45,660 I am quite clear about that, 233 00:11:45,660 --> 00:11:47,070 because we need to learn how to have 234 00:11:47,070 --> 00:11:49,440 these very real conversations. 235 00:11:49,440 --> 00:11:50,273 Next slide. 236 00:11:51,390 --> 00:11:54,453 Okay, so let's start here where it all begins, 237 00:11:54,453 --> 00:11:57,360 and it's with the patient. 238 00:11:57,360 --> 00:11:58,770 And so, let's meet her. 239 00:11:58,770 --> 00:12:00,000 This is Jane. 240 00:12:00,000 --> 00:12:01,650 Jane is 25 years old. 241 00:12:01,650 --> 00:12:04,380 She identifies her pronouns as she, her. 242 00:12:04,380 --> 00:12:06,690 Jane just found out that she's pregnant. 243 00:12:06,690 --> 00:12:09,900 She lives in rural Vermont and has a partner named Alex. 244 00:12:09,900 --> 00:12:12,000 This pregnancy was not planned 245 00:12:12,000 --> 00:12:14,970 and the couple is excited and very anxious. 246 00:12:14,970 --> 00:12:18,000 This is Jane's second pregnancy, but first with Alex, 247 00:12:18,000 --> 00:12:21,690 Jane had a 12-week loss with a former partner. 248 00:12:21,690 --> 00:12:23,250 Jane is in general good health, 249 00:12:23,250 --> 00:12:25,590 but has had a diagnosis of rheumatoid arthritis 250 00:12:25,590 --> 00:12:27,120 since she was four years old, 251 00:12:27,120 --> 00:12:29,460 and she deals with a lot of chronic pain. 252 00:12:29,460 --> 00:12:31,620 Jane has a history of trauma and grief 253 00:12:31,620 --> 00:12:33,810 and is also diagnosed with 254 00:12:33,810 --> 00:12:36,390 generalized anxiety and depression. 255 00:12:36,390 --> 00:12:39,150 Jane is screened and discloses on her first visit 256 00:12:39,150 --> 00:12:42,420 to the OB clinic that she has used cannabis daily 257 00:12:42,420 --> 00:12:44,760 to treat her chronic pain for about eight years, 258 00:12:44,760 --> 00:12:46,440 as well as her depression 259 00:12:46,440 --> 00:12:49,237 and reports that it does help with her anxiety, 260 00:12:49,237 --> 00:12:52,920 and she has not had a flare of her RA in many years. 261 00:12:52,920 --> 00:12:55,380 She believes she's currently about 10 weeks along 262 00:12:55,380 --> 00:12:56,910 and is having some intense nausea 263 00:12:56,910 --> 00:12:59,278 and reports that cannabis is helping with that as well. 264 00:12:59,278 --> 00:13:01,710 Jane lets you know that her partner, Alex, 265 00:13:01,710 --> 00:13:03,510 also uses cannabis. 266 00:13:03,510 --> 00:13:05,310 She tells you that she's very nervous 267 00:13:05,310 --> 00:13:06,780 about not using cannabis 268 00:13:06,780 --> 00:13:09,690 and has done some research online and talked to friends 269 00:13:09,690 --> 00:13:12,240 who have used cannabis during their pregnancies, 270 00:13:12,240 --> 00:13:13,919 and some of them have really encouraged her 271 00:13:13,919 --> 00:13:15,990 to continue using. 272 00:13:15,990 --> 00:13:18,270 She tells you that she's really worried 273 00:13:18,270 --> 00:13:20,340 that you're gonna make her stop smoking 274 00:13:20,340 --> 00:13:25,340 or get on new medications for her RA, pain and depression, 275 00:13:26,280 --> 00:13:28,260 and is worried if she doesn't take them 276 00:13:28,260 --> 00:13:29,940 that she might get into some sort of trouble 277 00:13:29,940 --> 00:13:31,680 or something bad will happen to her baby, 278 00:13:31,680 --> 00:13:34,950 because that is what she has heard happens. 279 00:13:34,950 --> 00:13:37,410 She then asks you if she were to get cannabis 280 00:13:37,410 --> 00:13:39,210 from the new dispensary in town, 281 00:13:39,210 --> 00:13:42,210 if that makes the cannabis safer and better for her baby. 282 00:13:42,210 --> 00:13:45,160 She admits being very worried and does not know what to do. 283 00:13:46,260 --> 00:13:49,080 So today we're gonna develop our narrative with Jane 284 00:13:49,080 --> 00:13:50,850 throughout this presentation. 285 00:13:50,850 --> 00:13:51,753 Next slide please. 286 00:13:53,580 --> 00:13:55,350 But first, let's dial it back a little bit 287 00:13:55,350 --> 00:13:57,660 for a little review of cannabis. 288 00:13:57,660 --> 00:14:00,240 Cannabis is the plant which makes Delta 9, 289 00:14:00,240 --> 00:14:04,350 also known as Tetrahydrocannabinol or THC, 290 00:14:04,350 --> 00:14:07,020 who is the star of our show here today. 291 00:14:07,020 --> 00:14:09,420 THC is the psychoactive ingredient in cannabis 292 00:14:09,420 --> 00:14:11,340 and is found in higher concentrations 293 00:14:11,340 --> 00:14:12,603 in the plant's flowers. 294 00:14:15,270 --> 00:14:17,225 There are other things like terpenes and flavanoids 295 00:14:17,225 --> 00:14:19,500 that affect the psycho-activity of cannabis, 296 00:14:19,500 --> 00:14:22,770 but today we're just gonna focus on THC. 297 00:14:22,770 --> 00:14:26,070 We then have its non-psychoactive cousin, cannabidiol, 298 00:14:26,070 --> 00:14:27,390 also known as CBD, 299 00:14:27,390 --> 00:14:30,240 which is a compound found in the cannabis plant as well 300 00:14:30,240 --> 00:14:31,980 in different concentrations. 301 00:14:31,980 --> 00:14:34,680 These two are the most well-known and most researched 302 00:14:34,680 --> 00:14:36,540 in the cannabis family, 303 00:14:36,540 --> 00:14:39,540 and these days it's not your mom's cannabis. 304 00:14:39,540 --> 00:14:42,450 Cannabis has increased in potency throughout time. 305 00:14:42,450 --> 00:14:47,010 In 1980, the THC content was less than 2%. 306 00:14:47,010 --> 00:14:51,660 In 2015, it's gone up to about 20% or more. 307 00:14:51,660 --> 00:14:53,670 If you don't know what this means, 308 00:14:53,670 --> 00:14:55,980 the higher the percentage of THC coupled with 309 00:14:55,980 --> 00:14:57,180 the way it's consumed, 310 00:14:57,180 --> 00:15:00,150 the more psychoactive the effect for the person. 311 00:15:00,150 --> 00:15:02,460 The takeaway is that unless someone knows 312 00:15:02,460 --> 00:15:04,020 what they're consuming 313 00:15:04,020 --> 00:15:06,240 or where their cannabis is coming from, 314 00:15:06,240 --> 00:15:08,280 then there is a chance that they could be getting 315 00:15:08,280 --> 00:15:11,490 into a situation for themselves that could be very risky. 316 00:15:11,490 --> 00:15:14,490 Not knowing what contaminants, pesticides, molds, 317 00:15:14,490 --> 00:15:18,420 mildews may be in the cannabis plant puts people at risk. 318 00:15:18,420 --> 00:15:21,930 We also hear rumors of illicit substances such as fentanyl 319 00:15:21,930 --> 00:15:24,240 being laced in black market cannabis. 320 00:15:24,240 --> 00:15:26,730 And this makes stakes very high for everybody, 321 00:15:26,730 --> 00:15:30,210 but especially for our pregnant and lactating people. 322 00:15:30,210 --> 00:15:31,043 Next slide. 323 00:15:32,190 --> 00:15:34,890 The bioavailability of THC is also affected 324 00:15:34,890 --> 00:15:36,720 by the way it's consumed. 325 00:15:36,720 --> 00:15:39,210 For an adult, inhaled cannabis has been shown 326 00:15:39,210 --> 00:15:42,030 to have the largest amount of bioavailability, 327 00:15:42,030 --> 00:15:44,100 because the lungs have a direct and fast entry 328 00:15:44,100 --> 00:15:45,510 into the bloodstream. 329 00:15:45,510 --> 00:15:48,510 THC levels rise very quickly in the bloodstream 330 00:15:48,510 --> 00:15:50,580 and peak at about 10 minutes. 331 00:15:50,580 --> 00:15:53,637 After about an hour, 90% of the THC levels 332 00:15:53,637 --> 00:15:56,700 in the blood plasma drop very quickly, 333 00:15:56,700 --> 00:16:00,120 and the leftover amount just kind of declines over time. 334 00:16:00,120 --> 00:16:04,320 Oral consumption of THC has a much longer onset and duration 335 00:16:04,320 --> 00:16:07,080 and a much lower bio-availability. 336 00:16:07,080 --> 00:16:09,540 This is due to the edible going through the stomach, 337 00:16:09,540 --> 00:16:10,650 getting broken down there, 338 00:16:10,650 --> 00:16:14,460 and then heading to the liver for first pass metabolism. 339 00:16:14,460 --> 00:16:17,400 About 99%, ooh, the lights went out here. 340 00:16:17,400 --> 00:16:18,633 Hold on, there we go. 341 00:16:21,180 --> 00:16:24,990 So, let me come back to it. 342 00:16:24,990 --> 00:16:27,690 So this is due to the edible going through the liver, 343 00:16:27,690 --> 00:16:29,700 for first pass drug metabolism, 344 00:16:29,700 --> 00:16:32,880 about 99% of THC is metabolized in the liver 345 00:16:32,880 --> 00:16:36,810 and it's excreted through the urinary and GI system. 346 00:16:36,810 --> 00:16:41,640 In the gut, the THC Delta 9 gets converted to Delta 11, 347 00:16:41,640 --> 00:16:44,910 which is it's more potent psychoactive, 348 00:16:44,910 --> 00:16:46,350 and that's why edibles really seem to 349 00:16:46,350 --> 00:16:50,910 make people feel higher for longer than inhaled THC. 350 00:16:50,910 --> 00:16:54,000 The sublingual or submucosal route of consumption 351 00:16:54,000 --> 00:16:58,140 is usually seen in tinctures and THC-infused strips. 352 00:16:58,140 --> 00:17:00,540 Cannabinoids are permeable to the mucus membranes 353 00:17:00,540 --> 00:17:03,360 in your mouth and skips the breakdown in the stomach, 354 00:17:03,360 --> 00:17:04,200 in the liver, 355 00:17:04,200 --> 00:17:07,410 so it's onset is a bit quicker than other oral means. 356 00:17:07,410 --> 00:17:08,493 Next slide please. 357 00:17:11,250 --> 00:17:14,010 Cannabis is still classified as a scheduled 1 substance 358 00:17:14,010 --> 00:17:16,230 with no valid medical purpose. 359 00:17:16,230 --> 00:17:18,570 And just to make this even more confusing, 360 00:17:18,570 --> 00:17:21,360 this conflicts with the American Medical Institute, 361 00:17:21,360 --> 00:17:24,660 the Department of Health and Human Services, the FDA, 362 00:17:24,660 --> 00:17:26,430 and the National Academy of Sciences 363 00:17:26,430 --> 00:17:28,440 and Engineering and Medicine, 364 00:17:28,440 --> 00:17:31,890 all who recognize the medicinal effects of cannabis. 365 00:17:31,890 --> 00:17:35,174 And even though it is legal for adults over 21 in Vermont 366 00:17:35,174 --> 00:17:37,950 when it comes to pregnant birthing people, 367 00:17:37,950 --> 00:17:41,880 in the absence of any other safety or substance use issues, 368 00:17:41,880 --> 00:17:45,495 cannabis use in pregnancy is no longer reportable to DCF. 369 00:17:45,495 --> 00:17:48,663 Dr. Shepard will discuss this a bit later as well. 370 00:17:49,890 --> 00:17:53,340 Vermont legalized cannabis for recreational use for adults 371 00:17:53,340 --> 00:17:56,190 21 years and older in 2018. 372 00:17:56,190 --> 00:17:58,020 Currently, dispensaries all over the state 373 00:17:58,020 --> 00:18:00,128 are being issued licenses to open 374 00:18:00,128 --> 00:18:02,370 for recreational and medical sales 375 00:18:02,370 --> 00:18:04,170 by the Cannabis Control Board, 376 00:18:04,170 --> 00:18:06,111 who under the Tax and Regulate bill 377 00:18:06,111 --> 00:18:09,750 will be responsible for issuing licenses for retailers, 378 00:18:09,750 --> 00:18:12,810 growers, manufacturers, wholesalers, and labs. 379 00:18:12,810 --> 00:18:13,773 Next slide please. 380 00:18:15,990 --> 00:18:19,080 There is a lot of policy sufficient or not to protect anyone 381 00:18:19,080 --> 00:18:22,470 under the age of 21 from being able to access cannabis 382 00:18:22,470 --> 00:18:23,820 from the dispensaries. 383 00:18:23,820 --> 00:18:26,130 There are policies on packaging 384 00:18:26,130 --> 00:18:28,230 such as needing to have these warning label 385 00:18:28,230 --> 00:18:29,700 warning symbols on them. 386 00:18:29,700 --> 00:18:31,020 The only mention or guidance 387 00:18:31,020 --> 00:18:34,020 for pregnant or lactating people is on this label 388 00:18:34,020 --> 00:18:37,500 that must be placed on every package from the dispensary. 389 00:18:37,500 --> 00:18:40,680 There is no current statewide policy or guidance 390 00:18:40,680 --> 00:18:43,315 for dispensary owners or their budtenders, 391 00:18:43,315 --> 00:18:45,480 which is what they're called on what to do 392 00:18:45,480 --> 00:18:48,270 if a pregnant and lactating person 393 00:18:48,270 --> 00:18:51,120 asked for advice on buying cannabis. 394 00:18:51,120 --> 00:18:52,053 Next slide. 395 00:18:54,240 --> 00:18:55,410 And as we know, 396 00:18:55,410 --> 00:18:57,690 the experts who give us our professional guidelines 397 00:18:57,690 --> 00:19:00,540 and policies continue to advise to counsel abstinence 398 00:19:00,540 --> 00:19:03,753 to their patients during pregnancy and with lactation. 399 00:19:06,360 --> 00:19:08,790 The Academy of Breastfeeding Medicine 400 00:19:08,790 --> 00:19:09,990 is a little bit different. 401 00:19:09,990 --> 00:19:12,900 They really weigh the frequency of use as a factor 402 00:19:12,900 --> 00:19:15,570 in advising for lactating people, 403 00:19:15,570 --> 00:19:17,640 but feels the evidence is not strong enough 404 00:19:17,640 --> 00:19:20,220 to not recommend breast chest feeding, 405 00:19:20,220 --> 00:19:22,380 but they do urge caution, 406 00:19:22,380 --> 00:19:23,460 which I can appreciate, 407 00:19:23,460 --> 00:19:26,521 because the cost of not breast chest feeding 408 00:19:26,521 --> 00:19:29,460 has far-reaching implications. 409 00:19:29,460 --> 00:19:30,363 Next slide. 410 00:19:32,970 --> 00:19:35,670 So all that's pretty clear is mud, right? 411 00:19:35,670 --> 00:19:36,870 That's what I think too. 412 00:19:38,100 --> 00:19:38,933 Next slide. 413 00:19:40,980 --> 00:19:43,320 These are the most common forms of cannabis consumption 414 00:19:43,320 --> 00:19:45,860 that might be sold at a dispensary here in Vermont. 415 00:19:45,860 --> 00:19:48,090 It is important to note that different states 416 00:19:48,090 --> 00:19:50,130 have different regulations for the way cannabis 417 00:19:50,130 --> 00:19:51,900 is packaged and sold. 418 00:19:51,900 --> 00:19:53,670 In Vermont, the Cannabis Control Board 419 00:19:53,670 --> 00:19:56,130 has capped the maximum percentage of THC 420 00:19:56,130 --> 00:19:59,430 for cannabis flowers at 30% THC 421 00:19:59,430 --> 00:20:03,900 and the milligrams for edibles at 5 milligrams per serving. 422 00:20:03,900 --> 00:20:04,733 Next slide. 423 00:20:06,360 --> 00:20:10,080 The cannabis concentrates also called dabs, shatter, oil 424 00:20:10,080 --> 00:20:14,310 or crystal THC-A diamonds among many other names 425 00:20:14,310 --> 00:20:16,260 can have a much higher THC percentage. 426 00:20:16,260 --> 00:20:19,800 Check those almost as high as 80-99%. 427 00:20:19,800 --> 00:20:21,120 The Cannabis Control Board 428 00:20:21,120 --> 00:20:25,800 has capped the sale of THC solid concentrates at 60%, 429 00:20:25,800 --> 00:20:27,870 and they're not capping the liquid concentrates 430 00:20:27,870 --> 00:20:30,210 such as those in vape pens. 431 00:20:30,210 --> 00:20:31,043 Next slide. 432 00:20:33,180 --> 00:20:37,290 Okay, so I want to circle back to Jane 433 00:20:37,290 --> 00:20:40,380 and invite you all to think about this conversation 434 00:20:40,380 --> 00:20:44,130 that you as her provider are about to have with her. 435 00:20:44,130 --> 00:20:45,030 In the chat box, 436 00:20:45,030 --> 00:20:47,040 knowing that cannabis is legal to use, 437 00:20:47,040 --> 00:20:50,700 but also knowing what the professional guidelines are, 438 00:20:50,700 --> 00:20:53,430 as a provider, what makes you most anxious 439 00:20:53,430 --> 00:20:54,693 about advising Jane? 440 00:21:09,120 --> 00:21:11,280 I could tell you that I would be really scared 441 00:21:11,280 --> 00:21:13,710 that something was gonna happen to my license 442 00:21:13,710 --> 00:21:18,213 or if I told somebody that they could do what they wanted, 443 00:21:19,440 --> 00:21:21,690 or they took it as they could do what they wanted 444 00:21:21,690 --> 00:21:25,050 or I gave them information that made them feel 445 00:21:25,050 --> 00:21:27,510 that I wasn't clear that it's not safe, 446 00:21:27,510 --> 00:21:30,990 and something bad happened that could come back at me. 447 00:21:30,990 --> 00:21:33,540 That would be something that would make me anxious. 448 00:21:37,980 --> 00:21:40,410 Yep, knowing the exact dosage of cannabis 449 00:21:40,410 --> 00:21:43,563 acquired via friend yet processing being different. 450 00:21:48,450 --> 00:21:50,460 Yep, absolutely. 451 00:21:50,460 --> 00:21:52,083 Jesse Lynn is a great resource. 452 00:21:55,170 --> 00:21:56,003 Excellent. 453 00:21:59,520 --> 00:22:01,080 Yep, dispensary is money. 454 00:22:01,080 --> 00:22:02,400 So they may stay, yep, 455 00:22:02,400 --> 00:22:05,183 they may just stay with their friends, this is very true. 456 00:22:06,960 --> 00:22:08,103 Okay, next slide. 457 00:22:09,360 --> 00:22:12,480 So let's briefly talk about how cannabis works in the body 458 00:22:12,480 --> 00:22:14,670 and what we know about it, 459 00:22:14,670 --> 00:22:15,840 and how it works in the body 460 00:22:15,840 --> 00:22:18,570 of a pregnant and lactating person. 461 00:22:18,570 --> 00:22:20,820 I'd like you to meet the cannabinoids. 462 00:22:20,820 --> 00:22:23,310 They are here to help us kind of understand 463 00:22:23,310 --> 00:22:24,690 the bigger picture. 464 00:22:24,690 --> 00:22:26,430 So we are all born with a system 465 00:22:26,430 --> 00:22:28,860 called the endocannabinoid system. 466 00:22:28,860 --> 00:22:31,200 It is a vast network of chemical signals 467 00:22:31,200 --> 00:22:33,810 and cellular receptors that are densely packed 468 00:22:33,810 --> 00:22:35,640 throughout our brains and bodies. 469 00:22:35,640 --> 00:22:39,900 The cannabinoid receptors in the body are named CB1 and CB2, 470 00:22:39,900 --> 00:22:42,720 which are the receptors that have been studied the most. 471 00:22:42,720 --> 00:22:46,020 CB1 is found mostly in the central nervous system, 472 00:22:46,020 --> 00:22:49,380 and CB2 is found in the peripheral nervous system. 473 00:22:49,380 --> 00:22:52,410 These guys act like a traffic cop in a big city. 474 00:22:52,410 --> 00:22:54,480 They direct traffic in our bodies 475 00:22:54,480 --> 00:22:57,540 by controlling the levels of activity 476 00:22:57,540 --> 00:23:00,270 of most of the other neurotransmitters, 477 00:23:00,270 --> 00:23:04,200 they regulate the traffic by turning up or down the activity 478 00:23:04,200 --> 00:23:06,840 of whichever system needs to be adjusted. 479 00:23:06,840 --> 00:23:09,150 Whether that is hunger, temperature, alertness, 480 00:23:09,150 --> 00:23:10,950 pain, learning, memory, 481 00:23:10,950 --> 00:23:13,380 whatever your body needs at any given time 482 00:23:13,380 --> 00:23:15,213 to achieve internal stability, 483 00:23:16,680 --> 00:23:19,440 it is critical for our overall ability 484 00:23:19,440 --> 00:23:23,520 to regulate ourselves in so many ways. 485 00:23:23,520 --> 00:23:27,540 Okay, so in order to stimulate those cannabinoid receptors, 486 00:23:27,540 --> 00:23:31,969 our bodies also produce molecules called endocannabinoids, 487 00:23:31,969 --> 00:23:36,120 which are structurally similar to the delta molecules 488 00:23:36,120 --> 00:23:38,040 in the cannabis plant. 489 00:23:38,040 --> 00:23:40,380 THC when consumed, 490 00:23:40,380 --> 00:23:44,580 combined to both the CB1 and CB2 receptors, 491 00:23:44,580 --> 00:23:46,290 which causes a range of effects, 492 00:23:46,290 --> 00:23:49,590 some are desirable and others are not. 493 00:23:49,590 --> 00:23:52,320 THC cannabinoids pretty much come into the system 494 00:23:52,320 --> 00:23:54,720 and hijack the neurotransmission that is happening, 495 00:23:54,720 --> 00:23:56,820 kind of pumps up the volume. 496 00:23:56,820 --> 00:23:59,310 In pregnancy, the endocannabinoid system 497 00:23:59,310 --> 00:24:02,640 has been known to play a significant cell-signaling role 498 00:24:02,640 --> 00:24:04,983 in early embryo and placental development 499 00:24:04,983 --> 00:24:08,580 as well as new evidence that shows that 500 00:24:08,580 --> 00:24:10,770 the endocannabinoid system plays a role 501 00:24:10,770 --> 00:24:14,310 in pregnancy maintenance and the initiation of labor. 502 00:24:14,310 --> 00:24:15,143 Next slide. 503 00:24:17,100 --> 00:24:19,680 Ah, the great and mighty placenta. 504 00:24:19,680 --> 00:24:22,470 Seriously, one of the coolest organs. 505 00:24:22,470 --> 00:24:25,620 It's a transient organ that only a pregnant person's body 506 00:24:25,620 --> 00:24:28,230 makes with the sole purpose of nourishing, protecting 507 00:24:28,230 --> 00:24:29,910 and growing a baby. 508 00:24:29,910 --> 00:24:33,180 In pregnancy, the toxic effects of THC on the fetus 509 00:24:33,180 --> 00:24:34,680 are not well-studied. 510 00:24:34,680 --> 00:24:38,640 What we do know is that THC molecules are lipophilic 511 00:24:38,640 --> 00:24:41,580 or have an affinity to dissolve into fat, 512 00:24:41,580 --> 00:24:44,220 and they do pass through the placenta. 513 00:24:44,220 --> 00:24:48,390 We know that THC exposure occurs in utero, 514 00:24:48,390 --> 00:24:52,440 because THC is detected in newborn meconium and urine. 515 00:24:52,440 --> 00:24:55,140 We just don't have any conclusive studies on timing 516 00:24:55,140 --> 00:24:58,860 in the longterm effects in humans, just in animals. 517 00:24:58,860 --> 00:24:59,693 Next slide. 518 00:25:01,440 --> 00:25:05,490 During lactation, a lactating person uses cannabis 519 00:25:05,490 --> 00:25:08,130 and depending on the mode of consumption, 520 00:25:08,130 --> 00:25:12,570 has an average bioavailable dose of about 1-5% 521 00:25:12,570 --> 00:25:17,570 for oral consumption and about 5-56% for inhaled 522 00:25:17,640 --> 00:25:21,090 and that is circulating in their blood plasma. 523 00:25:21,090 --> 00:25:22,440 It's important to remember 524 00:25:22,440 --> 00:25:26,010 that whatever is in the blood plasma of a lactating person 525 00:25:26,010 --> 00:25:28,722 reflects what can be found in the breast milk. 526 00:25:28,722 --> 00:25:31,560 The THC then passes from the maternal plasma 527 00:25:31,560 --> 00:25:34,080 into the lactose sites that secrete milk 528 00:25:34,080 --> 00:25:38,422 and whatever THC is not secreted for milk production 529 00:25:38,422 --> 00:25:41,100 during that time gets stored in in the adipose 530 00:25:41,100 --> 00:25:44,100 and may come out in bits from time to time. 531 00:25:44,100 --> 00:25:45,990 The baby then feeds and digest milk. 532 00:25:45,990 --> 00:25:47,310 The milk gets metabolized 533 00:25:47,310 --> 00:25:48,930 through the baby's digestive system 534 00:25:48,930 --> 00:25:51,060 and first pass through the liver. 535 00:25:51,060 --> 00:25:55,650 And what is left has been found to be about 1-2.5% 536 00:25:55,650 --> 00:25:57,333 of the maternal dose. 537 00:25:58,380 --> 00:25:59,760 So even though that seems like 538 00:25:59,760 --> 00:26:02,010 a really small amount of exposure, 539 00:26:02,010 --> 00:26:05,040 what we don't know is what a safe level of exposure 540 00:26:05,040 --> 00:26:07,050 for a developing brain is. 541 00:26:07,050 --> 00:26:11,400 So it's hard to quantify or qualify what these levels mean, 542 00:26:11,400 --> 00:26:13,560 regarding the dose the infant gets 543 00:26:13,560 --> 00:26:15,030 and the impact that it could have, 544 00:26:15,030 --> 00:26:19,410 especially with those who chronically use cannabis. 545 00:26:19,410 --> 00:26:20,243 Next slide. 546 00:26:21,960 --> 00:26:24,398 This study was a pilot pharmacokinetic study 547 00:26:24,398 --> 00:26:27,420 by Dr. Teresa Baker and Dr. Thomas Hale 548 00:26:27,420 --> 00:26:29,250 from the Infant Risk Center 549 00:26:29,250 --> 00:26:31,920 where breast milk samples were collected from mothers 550 00:26:31,920 --> 00:26:34,260 who regularly consume cannabis. 551 00:26:34,260 --> 00:26:37,380 Total of eight women were enrolled, so really small. 552 00:26:37,380 --> 00:26:41,670 Most were occasional cannabis smokers and one chronic user. 553 00:26:41,670 --> 00:26:43,470 This was a very controlled study, 554 00:26:43,470 --> 00:26:47,220 but the results of all but one person 555 00:26:47,220 --> 00:26:49,290 was consistent with the levels in the breast milk 556 00:26:49,290 --> 00:26:51,750 peaking in about one hour post-cannabis use 557 00:26:51,750 --> 00:26:55,410 and then coming back to near baseline by hour four. 558 00:26:55,410 --> 00:26:58,830 The outlier was found to be the person who used chronically 559 00:26:58,830 --> 00:27:02,610 and had a higher concentration of plasma THC than the others 560 00:27:02,610 --> 00:27:04,503 who are only occasional smokers. 561 00:27:05,670 --> 00:27:08,010 There are other studies that show that THC 562 00:27:08,010 --> 00:27:11,130 can be found in the breast milk up to six days after use. 563 00:27:11,130 --> 00:27:12,630 The individual variability 564 00:27:12,630 --> 00:27:15,150 due to a lactating parents' metabolism, 565 00:27:15,150 --> 00:27:17,310 genetic makeup and other factors 566 00:27:17,310 --> 00:27:20,610 make cannabis very difficult to qualify its safety 567 00:27:20,610 --> 00:27:25,320 for use in lactation and safety for the infant. 568 00:27:25,320 --> 00:27:27,000 However, out of all of the studies 569 00:27:27,000 --> 00:27:30,630 on cannabis and pharmacokinetics, one thing is very clear. 570 00:27:30,630 --> 00:27:32,880 The more often a person uses cannabis, 571 00:27:32,880 --> 00:27:34,890 the higher the toxic profile 572 00:27:34,890 --> 00:27:37,080 and higher levels of accumulated THC 573 00:27:37,080 --> 00:27:40,800 is found in the blood and tissues of the body. 574 00:27:40,800 --> 00:27:43,890 More THC could consistently be crossing the placenta 575 00:27:43,890 --> 00:27:46,890 and blood-brain barrier and higher levels of THC 576 00:27:46,890 --> 00:27:48,660 could be present in human milk. 577 00:27:48,660 --> 00:27:49,493 Next slide. 578 00:27:51,201 --> 00:27:54,120 All the studies on cannabis pregnancy and lactation 579 00:27:54,120 --> 00:27:55,680 are small and underfunded, 580 00:27:55,680 --> 00:27:57,960 but at this time there is no known amount 581 00:27:57,960 --> 00:28:00,750 that is 100% safe to consume in pregnancy 582 00:28:00,750 --> 00:28:02,370 or during lactation. 583 00:28:02,370 --> 00:28:03,450 Let's be very clear 584 00:28:03,450 --> 00:28:05,850 that this is the right answer every time, 585 00:28:05,850 --> 00:28:08,850 this is what our patients or clients need to hear from us, 586 00:28:08,850 --> 00:28:11,190 but we need to inform them of the why. 587 00:28:11,190 --> 00:28:13,320 The incorrect answer for our patients 588 00:28:13,320 --> 00:28:15,810 is to just end the conversation here 589 00:28:15,810 --> 00:28:18,990 or tell them that we just don't know enough, so stop using, 590 00:28:18,990 --> 00:28:22,830 because in this era of Dr. Google and misinformation, 591 00:28:22,830 --> 00:28:24,150 if we don't help our patients 592 00:28:24,150 --> 00:28:25,830 to find what they need to hear, 593 00:28:25,830 --> 00:28:27,690 they're going to find what they want to hear, 594 00:28:27,690 --> 00:28:29,610 and our outcomes may reflect that. 595 00:28:29,610 --> 00:28:30,443 Next slide. 596 00:28:32,010 --> 00:28:33,480 Why do pregnant and lactating people 597 00:28:33,480 --> 00:28:35,220 use cannabis during pregnancy? 598 00:28:35,220 --> 00:28:37,950 Well, 5-10% of pregnant people in the United States 599 00:28:37,950 --> 00:28:41,100 have disclosed use or have had positive drug screens. 600 00:28:41,100 --> 00:28:43,320 This number will and has increased 601 00:28:43,320 --> 00:28:46,200 as more states legalized cannabis. 602 00:28:46,200 --> 00:28:48,720 And honestly, cannabis has been a part of Vermont culture 603 00:28:48,720 --> 00:28:50,310 for a really long time. 604 00:28:50,310 --> 00:28:52,890 So we kind of need to figure out those whys. 605 00:28:52,890 --> 00:28:55,530 The data shows us that most people are using cannabis 606 00:28:55,530 --> 00:28:58,770 in pregnancy for stress and anxiety above anything else 607 00:28:58,770 --> 00:29:01,440 with nausea coming in a closed second, 608 00:29:01,440 --> 00:29:03,540 even though most people believed 609 00:29:03,540 --> 00:29:06,600 it was not safe to use during pregnancy. 610 00:29:06,600 --> 00:29:07,433 Next slide. 611 00:29:09,390 --> 00:29:11,010 This study on beliefs and attitudes 612 00:29:11,010 --> 00:29:14,730 regarding prenatal cannabis are many of its kind. 613 00:29:14,730 --> 00:29:16,860 It gives us a little bit of a better understanding 614 00:29:16,860 --> 00:29:19,110 of the thought process and what that might look like 615 00:29:19,110 --> 00:29:21,873 for a pregnant person, how they regard cannabis. 616 00:29:22,890 --> 00:29:25,335 The outcomes reported that pregnant and birthing people 617 00:29:25,335 --> 00:29:30,335 who consumed higher amounts of cannabis prior to pregnancy 618 00:29:30,630 --> 00:29:32,430 really did attempt to reduce their use 619 00:29:32,430 --> 00:29:34,020 once they were pregnant. 620 00:29:34,020 --> 00:29:37,290 They used cannabis to help with nausea and appetite changes 621 00:29:37,290 --> 00:29:38,670 and improve their mood. 622 00:29:38,670 --> 00:29:41,340 And they described cannabis as natural and safe 623 00:29:41,340 --> 00:29:44,970 when compared to other substances such as alcohol, tobacco, 624 00:29:44,970 --> 00:29:47,340 and other recreational drugs, 625 00:29:47,340 --> 00:29:49,470 including prescribed medications. 626 00:29:49,470 --> 00:29:51,840 And a lot of them had a lot of conflicting opinions 627 00:29:51,840 --> 00:29:54,840 whether or not cannabis was addictive. 628 00:29:54,840 --> 00:29:57,930 I'll also mention that there are not many, if any, 629 00:29:57,930 --> 00:30:00,900 comprehensive studies on partners and partner beliefs 630 00:30:00,900 --> 00:30:04,290 around cannabis, pregnancy and lactation as well. 631 00:30:04,290 --> 00:30:05,123 Next slide. 632 00:30:06,720 --> 00:30:10,260 As many as 1 in 5 pregnant or postpartum Vermonters 633 00:30:10,260 --> 00:30:13,860 suffer from symptoms of depression and/or anxiety 634 00:30:13,860 --> 00:30:15,660 during the perinatal period. 635 00:30:15,660 --> 00:30:17,550 Early data suggests that this number 636 00:30:17,550 --> 00:30:20,280 is now significantly higher 637 00:30:20,280 --> 00:30:23,160 at 1 in 3 women experiencing symptoms, 638 00:30:23,160 --> 00:30:28,020 most likely due to the kind of a fallout from the pandemic. 639 00:30:28,020 --> 00:30:29,460 Postpartum cannabis use 640 00:30:29,460 --> 00:30:31,590 is associated with depressed symptoms 641 00:30:31,590 --> 00:30:34,530 and shorter breastfeeding duration. 642 00:30:34,530 --> 00:30:37,980 Cannabis use disorder is defined as cannabis use 643 00:30:37,980 --> 00:30:40,740 with significant impairment or distress. 644 00:30:40,740 --> 00:30:43,350 Symptoms can look similar to pregnant people 645 00:30:43,350 --> 00:30:46,500 who present with cannabis hyperemesis syndrome, 646 00:30:46,500 --> 00:30:49,569 but should not be confused with hyperemesis gravidarum 647 00:30:49,569 --> 00:30:52,650 that comes as a severe pregnancy symptom, 648 00:30:52,650 --> 00:30:55,263 but as you can imagine, the two may coexist. 649 00:30:56,790 --> 00:30:59,640 Pregnant and birthing people who have used cannabis 650 00:30:59,640 --> 00:31:02,460 were also more likely than those who did not 651 00:31:02,460 --> 00:31:05,340 to have an anxiety disorder, a depressive disorder, 652 00:31:05,340 --> 00:31:07,860 depressive symptoms, a trauma diagnosis, 653 00:31:07,860 --> 00:31:11,070 and self-reported intimate partner violence. 654 00:31:11,070 --> 00:31:12,300 And this is so relevant, 655 00:31:12,300 --> 00:31:14,850 because what I see often in our communities 656 00:31:14,850 --> 00:31:17,520 is that providers are still reducing 657 00:31:17,520 --> 00:31:19,320 or taking pregnant people 658 00:31:19,320 --> 00:31:21,712 off of their psychotropic medications 659 00:31:21,712 --> 00:31:24,300 and clients are increasing their cannabis use 660 00:31:24,300 --> 00:31:27,240 when their psych meds are removed or reduced. 661 00:31:27,240 --> 00:31:29,100 This is not best practice. 662 00:31:29,100 --> 00:31:32,790 And here in Vermont we have a lot of resources 663 00:31:32,790 --> 00:31:36,060 to help to support providers with this. 664 00:31:36,060 --> 00:31:36,893 Next slide. 665 00:31:38,370 --> 00:31:41,040 I've put this slide together on some of the resources 666 00:31:41,040 --> 00:31:42,520 that can be referred to 667 00:31:44,460 --> 00:31:47,643 and when these slides are shared, 668 00:31:48,749 --> 00:31:50,099 you'll have a copy of that. 669 00:31:51,000 --> 00:31:51,833 Next slide. 670 00:31:54,900 --> 00:31:58,950 So about 61% of providers are specifically asking 671 00:31:58,950 --> 00:32:01,080 about cannabis use. 672 00:32:01,080 --> 00:32:03,930 And while most healthcare providers indicated cannabis use 673 00:32:03,930 --> 00:32:07,710 during pregnancy and breastfeeding and it's not safe, 674 00:32:07,710 --> 00:32:12,240 many do not address safety or they really do 675 00:32:12,240 --> 00:32:14,580 just directly discourage use. 676 00:32:14,580 --> 00:32:17,370 Providers perceive cannabis really isn't as dangerous 677 00:32:17,370 --> 00:32:19,290 as other perinatal substance use 678 00:32:19,290 --> 00:32:21,870 and admit prioritizing other counseling topics 679 00:32:21,870 --> 00:32:23,760 over perinatal cannabis 680 00:32:23,760 --> 00:32:26,460 and counseling strategies really focused on policy 681 00:32:26,460 --> 00:32:28,650 and legal consequences. 682 00:32:28,650 --> 00:32:31,110 Providers identified competing time demands 683 00:32:31,110 --> 00:32:33,660 and a need to prioritize what topics get covered. 684 00:32:33,660 --> 00:32:35,850 And this is a real valid concern. 685 00:32:35,850 --> 00:32:39,180 ACOG clinical guidelines already really advocate that 686 00:32:39,180 --> 00:32:42,630 obstetric providers should address so many other topics 687 00:32:42,630 --> 00:32:44,490 in pregnancy during obstetric visits, 688 00:32:44,490 --> 00:32:46,653 particularly in those very first visits. 689 00:32:47,550 --> 00:32:48,453 Next slide. 690 00:32:50,610 --> 00:32:53,310 And more pregnant and lactating people want to feel safe 691 00:32:53,310 --> 00:32:56,190 disclosing to their clinical providers, 692 00:32:56,190 --> 00:32:58,860 but due to the stigma and fear they do not 693 00:32:58,860 --> 00:33:02,550 and they are turning to the Google for advice. 694 00:33:02,550 --> 00:33:04,350 As dispensaries open up, 695 00:33:04,350 --> 00:33:06,390 they will also be turning to budtenders 696 00:33:06,390 --> 00:33:09,150 for advice on safety and use. 697 00:33:09,150 --> 00:33:11,670 When Colorado legalized cannabis in 2012, 698 00:33:11,670 --> 00:33:14,670 they did a research study where they called dispensaries 699 00:33:14,670 --> 00:33:16,200 pretending to be a pregnant person 700 00:33:16,200 --> 00:33:18,111 dealing with pregnancy nausea. 701 00:33:18,111 --> 00:33:23,111 Researchers found that employees at 69% of dispensaries 702 00:33:25,560 --> 00:33:29,220 recommended treating pregnancy-related nausea with cannabis 703 00:33:29,220 --> 00:33:34,170 and only 32% recommended consulting and clinical provider 704 00:33:34,170 --> 00:33:37,080 and only about 4.7% of them answered 705 00:33:37,080 --> 00:33:39,993 that there was any chance of fetal risk or harm. 706 00:33:41,040 --> 00:33:41,873 Next slide. 707 00:33:43,260 --> 00:33:45,360 So where are pregnant and lactating people 708 00:33:45,360 --> 00:33:47,310 getting their information? 709 00:33:47,310 --> 00:33:49,860 This slide represents the many different platforms 710 00:33:49,860 --> 00:33:52,890 at a simple search on social media will bring up 711 00:33:52,890 --> 00:33:54,210 who specifically support 712 00:33:54,210 --> 00:33:58,440 pregnant, birthing and lactating people who use cannabis. 713 00:33:58,440 --> 00:34:01,770 And honestly, the problem really does not come from 714 00:34:01,770 --> 00:34:05,040 the people that lead these platforms necessarily, 715 00:34:05,040 --> 00:34:07,260 but from the community of people behind the veil 716 00:34:07,260 --> 00:34:10,800 of social media land that give a lot of unsolicited advice 717 00:34:10,800 --> 00:34:12,660 that might not be appropriate. 718 00:34:12,660 --> 00:34:14,250 There's actually a lot of evidence 719 00:34:14,250 --> 00:34:16,470 that those who use cannabis in pregnancy 720 00:34:16,470 --> 00:34:19,743 has spent quite a bit of time researching on their own. 721 00:34:20,610 --> 00:34:21,443 Next slide. 722 00:34:22,620 --> 00:34:24,213 So disclosure is a gift. 723 00:34:25,240 --> 00:34:28,290 There's such an opportunity for providers everywhere 724 00:34:28,290 --> 00:34:31,260 to be able to use cannabis to help build connection 725 00:34:31,260 --> 00:34:32,757 and encourage change in pregnancy. 726 00:34:32,757 --> 00:34:35,730 The touchpoint is wide open. 727 00:34:35,730 --> 00:34:38,519 This is a time when people are open to trying new things 728 00:34:38,519 --> 00:34:40,110 that develop new skills 729 00:34:40,110 --> 00:34:43,440 and bridge their social and emotional capital. 730 00:34:43,440 --> 00:34:44,400 In order to do this, 731 00:34:44,400 --> 00:34:46,650 we have to learn to accept and grant 732 00:34:46,650 --> 00:34:51,330 and dance in this gray area of what to do and how to advise. 733 00:34:51,330 --> 00:34:52,163 Next slide. 734 00:34:53,670 --> 00:34:56,310 Where we need to start is by honoring that harm and risk 735 00:34:56,310 --> 00:34:59,130 are not inverse, but they walk next to each other 736 00:34:59,130 --> 00:35:00,330 hand in hand. 737 00:35:00,330 --> 00:35:02,604 Harm is something that I can tell you or show you 738 00:35:02,604 --> 00:35:06,390 and it's negative effects that can potentially happen 739 00:35:06,390 --> 00:35:08,640 to our patients if they choose to do something 740 00:35:08,640 --> 00:35:10,860 or take in something that could hurt them. 741 00:35:10,860 --> 00:35:14,460 Risk however, is a personal measurement and judgment. 742 00:35:14,460 --> 00:35:18,480 We judge our own personal risk every minute of every day. 743 00:35:18,480 --> 00:35:20,853 For example, in its very simplest form, 744 00:35:22,950 --> 00:35:25,080 a couple weeks ago I was out to dinner 745 00:35:25,080 --> 00:35:27,720 and I had eaten a big, full dinner 746 00:35:27,720 --> 00:35:30,436 and I was offered a piece of chocolate maple cream pie. 747 00:35:30,436 --> 00:35:33,120 Now this girl here, she left me some pie. 748 00:35:33,120 --> 00:35:34,050 And even better yet, 749 00:35:34,050 --> 00:35:37,140 it was from one of my favorite bakeries, Poorhouse Pies. 750 00:35:37,140 --> 00:35:38,910 I was still very full from dinner 751 00:35:38,910 --> 00:35:41,640 and I knew that it was not going to make me feel good. 752 00:35:41,640 --> 00:35:43,830 And I can get pretty sick when I'm over full. 753 00:35:43,830 --> 00:35:46,050 And even though this was a special occasion, 754 00:35:46,050 --> 00:35:47,880 I knew that this could be the bite 755 00:35:47,880 --> 00:35:49,230 that sent me over the edge. 756 00:35:49,230 --> 00:35:52,620 But because I love pie more than to ever say no, 757 00:35:52,620 --> 00:35:54,360 I accepted the piece of pie, 758 00:35:54,360 --> 00:35:56,580 kind of knowing what I was gonna do next. 759 00:35:56,580 --> 00:35:58,740 I took a bite, licked my fork clean 760 00:35:58,740 --> 00:36:00,450 and enjoyed the heck out of it. 761 00:36:00,450 --> 00:36:01,680 But after that bite, 762 00:36:01,680 --> 00:36:03,810 even though it took all my inner dialogue 763 00:36:03,810 --> 00:36:06,390 and an argument between my stomach and brain, 764 00:36:06,390 --> 00:36:08,070 I stopped eating the pie. 765 00:36:08,070 --> 00:36:10,830 I knew that the harm would be, but the harm would be, 766 00:36:10,830 --> 00:36:12,000 and I put that right up against 767 00:36:12,000 --> 00:36:13,890 the risk of feeling too sick. 768 00:36:13,890 --> 00:36:16,140 I knew that a piece would be too much, 769 00:36:16,140 --> 00:36:17,580 but a bite should be okay. 770 00:36:17,580 --> 00:36:21,450 I reduced the harm by my own inner dialogue and choice. 771 00:36:21,450 --> 00:36:24,150 And for all those anxious about that extra pie, don't worry, 772 00:36:24,150 --> 00:36:26,640 my husband is a human garbage can. 773 00:36:26,640 --> 00:36:27,903 So no pie was wasted. 774 00:36:29,010 --> 00:36:29,843 Next slide. 775 00:36:31,770 --> 00:36:33,713 Harm reduction begins with an acceptance 776 00:36:33,713 --> 00:36:36,120 that substances and substance use 777 00:36:36,120 --> 00:36:39,630 and negative health choices are part of the world we live in 778 00:36:39,630 --> 00:36:42,360 and we do not have the power to make them disappear, 779 00:36:42,360 --> 00:36:45,994 but we can work to minimize the effects in a holistic way. 780 00:36:45,994 --> 00:36:48,180 Harm reduction is an intervention 781 00:36:48,180 --> 00:36:50,790 that focuses on reducing the negative, 782 00:36:50,790 --> 00:36:53,760 the potential negative social and legal impacts 783 00:36:53,760 --> 00:36:58,760 associated for the sake of this discussion on cannabis. 784 00:36:58,920 --> 00:37:02,370 It focuses on positive change and is grounded in compassion, 785 00:37:02,370 --> 00:37:04,650 working with people without coercion, 786 00:37:04,650 --> 00:37:06,450 judgment and discrimination 787 00:37:06,450 --> 00:37:09,120 within the principle that the patient does not have 788 00:37:09,120 --> 00:37:11,910 to stop using cannabis to get continued support 789 00:37:11,910 --> 00:37:14,220 from the providers about it. 790 00:37:14,220 --> 00:37:17,790 The most important and radical part about harm reduction 791 00:37:17,790 --> 00:37:20,910 is to demonstrate with our words and our actions 792 00:37:20,910 --> 00:37:23,820 that we respect and love people who use substances 793 00:37:23,820 --> 00:37:27,150 or historically have made poor choices 794 00:37:27,150 --> 00:37:29,910 and honor who they are and their life journey 795 00:37:29,910 --> 00:37:31,346 that brought them there. 796 00:37:31,346 --> 00:37:33,330 I know many of you here today 797 00:37:33,330 --> 00:37:35,730 and know that many of you are already using harm reduction 798 00:37:35,730 --> 00:37:40,050 in your practice and but I also wanna honor us as providers 799 00:37:40,050 --> 00:37:43,650 who daily must take several deep breaths 800 00:37:43,650 --> 00:37:45,720 and sit on our hands and our voice 801 00:37:45,720 --> 00:37:48,180 to care for some patients or clients 802 00:37:48,180 --> 00:37:52,380 who continue to make choices that are causing a lot of harm. 803 00:37:52,380 --> 00:37:54,990 Our eyes and ears have have seen the worst of it, 804 00:37:54,990 --> 00:37:57,750 but I know that we also get to bear witness to miracles 805 00:37:57,750 --> 00:37:59,850 and a lot of successes. 806 00:37:59,850 --> 00:38:01,860 This is what I love about this practice too. 807 00:38:01,860 --> 00:38:03,870 It really humanizes our work 808 00:38:03,870 --> 00:38:06,252 and celebrates even the smallest success. 809 00:38:06,252 --> 00:38:09,450 Harm reduction and the strategies can seem a bit sappy 810 00:38:09,450 --> 00:38:10,530 and intense at times, 811 00:38:10,530 --> 00:38:13,890 but really, harm reduction is a mindset. 812 00:38:13,890 --> 00:38:16,260 It also takes the onus off of them 813 00:38:16,260 --> 00:38:18,990 to fix them or write them, 814 00:38:18,990 --> 00:38:23,990 which whether that is theoretical or in more concrete ways. 815 00:38:24,030 --> 00:38:25,980 It's not a fair expectation. 816 00:38:25,980 --> 00:38:29,640 We cannot and are not responsible to fix years of trauma 817 00:38:29,640 --> 00:38:32,190 or change someone's childhood ACE score 818 00:38:32,190 --> 00:38:35,820 and that's not a fair ask, even the most learned doctor, 819 00:38:35,820 --> 00:38:38,940 they can't do it or even Wonder Woman for that matter. 820 00:38:38,940 --> 00:38:43,160 But what we can do is get curious and sit with the patient 821 00:38:43,160 --> 00:38:46,410 in their world for a bit and understand their why 822 00:38:46,410 --> 00:38:47,910 and help guide them. 823 00:38:47,910 --> 00:38:51,390 And it really puts the responsibility of change on them 824 00:38:51,390 --> 00:38:54,090 by affirming their individual story and autonomy, 825 00:38:54,090 --> 00:38:56,970 because we must believe that they have the ability 826 00:38:56,970 --> 00:38:59,370 within them to do so no matter how many times 827 00:38:59,370 --> 00:39:00,750 they must start over. 828 00:39:00,750 --> 00:39:01,593 Next slide. 829 00:39:03,450 --> 00:39:07,230 We all have a bias and I thank you guys 830 00:39:07,230 --> 00:39:09,150 for sharing yours earlier 831 00:39:09,150 --> 00:39:12,780 and the language that we use is very important to make sure 832 00:39:12,780 --> 00:39:15,300 that we are not shaming or creating barriers 833 00:39:15,300 --> 00:39:16,770 for our clients. 834 00:39:16,770 --> 00:39:18,750 Having worked in the community for a long time, 835 00:39:18,750 --> 00:39:21,420 I know that what was most likely discussed 836 00:39:21,420 --> 00:39:24,570 and what the patient hears or felt can be very different 837 00:39:24,570 --> 00:39:26,100 from what was intended. 838 00:39:26,100 --> 00:39:27,480 So we must check it. 839 00:39:27,480 --> 00:39:30,116 Everyone comes from somewhere and has their own experience 840 00:39:30,116 --> 00:39:32,067 as their own experiences with cannabis 841 00:39:32,067 --> 00:39:33,780 and those who use it. 842 00:39:33,780 --> 00:39:36,570 We also must acknowledge that race and implicit bias 843 00:39:36,570 --> 00:39:38,560 continue to infiltrate our systems 844 00:39:38,560 --> 00:39:40,830 and care for our patients. 845 00:39:40,830 --> 00:39:44,820 Black women are 10 times more likely to be reported to DCF 846 00:39:44,820 --> 00:39:48,390 for positive drug screens than a White woman. 847 00:39:48,390 --> 00:39:52,890 We also need to recognize the realities of poverty, class, 848 00:39:52,890 --> 00:39:56,760 social isolation, past trauma, sex-based discrimination, 849 00:39:56,760 --> 00:39:58,950 and other social inequalities 850 00:39:58,950 --> 00:40:02,010 and how that affects people's vulnerability to 851 00:40:02,010 --> 00:40:05,400 and capacity for effectively developing ambivalence 852 00:40:05,400 --> 00:40:07,650 within their own environments. 853 00:40:07,650 --> 00:40:09,540 I also hear this a lot. 854 00:40:09,540 --> 00:40:12,480 Well, at least it's not insert opiates, 855 00:40:12,480 --> 00:40:14,220 insert methamphetamines. 856 00:40:14,220 --> 00:40:18,840 Remember even those who are on MAT who use cannabis 857 00:40:18,840 --> 00:40:21,990 should be counseled about the risks in reducing their use 858 00:40:21,990 --> 00:40:24,990 if possible during pregnancy and lactation. 859 00:40:24,990 --> 00:40:29,400 And we must also have the resources to deal with 860 00:40:29,400 --> 00:40:30,690 the answers that we do get 861 00:40:30,690 --> 00:40:32,700 and we need to have 'em at the ready 862 00:40:32,700 --> 00:40:35,820 to support the person to cease use if they want to 863 00:40:35,820 --> 00:40:37,830 or/and to have to deal with the other side 864 00:40:37,830 --> 00:40:40,200 of their increased anxiety and depression 865 00:40:40,200 --> 00:40:44,310 and feeling uncomfortable and especially during pregnancy, 866 00:40:44,310 --> 00:40:47,010 so that they can choose this path with support. 867 00:40:47,010 --> 00:40:47,843 Next slide. 868 00:40:49,530 --> 00:40:52,080 Motivational interviewing is a great way 869 00:40:52,080 --> 00:40:55,830 to guide a conversation that sits between active listening 870 00:40:55,830 --> 00:40:57,750 and giving advisement. 871 00:40:57,750 --> 00:41:01,140 The underpinnings of MI facilitates change 872 00:41:01,140 --> 00:41:02,400 by empowering the patient 873 00:41:02,400 --> 00:41:05,100 to evoke their own meaning and importance 874 00:41:05,100 --> 00:41:07,890 and their capacity to ship their own constructs, 875 00:41:07,890 --> 00:41:11,940 to develop discrepancy in a respectful and autonomous way. 876 00:41:11,940 --> 00:41:16,428 It really makes us as a provider kind of take off 877 00:41:16,428 --> 00:41:18,990 our provider armor for a moment, 878 00:41:18,990 --> 00:41:22,110 place it down beside us so that we can kind of sit 879 00:41:22,110 --> 00:41:24,030 with our patient and partnership 880 00:41:24,030 --> 00:41:25,920 to help them develop discrepancy, 881 00:41:25,920 --> 00:41:28,140 which is the gap between what is happening 882 00:41:28,140 --> 00:41:29,340 and where they wanna be, 883 00:41:29,340 --> 00:41:31,080 because that right there is the space 884 00:41:31,080 --> 00:41:32,970 where change can happen. 885 00:41:32,970 --> 00:41:34,830 It's not about getting people to change 886 00:41:34,830 --> 00:41:36,480 or being confrontational, 887 00:41:36,480 --> 00:41:39,000 it's about being curious about their journey 888 00:41:39,000 --> 00:41:42,060 and reflecting it back to them in a strength-based way 889 00:41:42,060 --> 00:41:44,789 that re-frames the story a bit and plants the seed. 890 00:41:44,789 --> 00:41:47,790 Then personally I like to let that seed marinate 891 00:41:47,790 --> 00:41:49,620 and revisit it again, 892 00:41:49,620 --> 00:41:52,980 and then sometimes I have to replant that feed again. 893 00:41:52,980 --> 00:41:55,590 Normalizing what they're going through empathy, 894 00:41:55,590 --> 00:41:56,700 compassion, and humor 895 00:41:56,700 --> 00:41:58,500 really helps to form connection 896 00:41:58,500 --> 00:42:01,080 and it humanizes us as providers. 897 00:42:01,080 --> 00:42:04,290 If there's anything that I suggest learning and practicing 898 00:42:04,290 --> 00:42:06,870 and getting good at is a skill, 899 00:42:06,870 --> 00:42:09,480 where I just gave you a really brief overview 900 00:42:09,480 --> 00:42:11,220 of motivational interviewing. 901 00:42:11,220 --> 00:42:14,430 It is the best strategy to keep the conversation going 902 00:42:14,430 --> 00:42:16,350 so you as a provider can return to it 903 00:42:16,350 --> 00:42:18,243 and continue to reduce the harm. 904 00:42:19,680 --> 00:42:22,320 There are several trainings and resources that you can use 905 00:42:22,320 --> 00:42:24,090 to support learning this as well. 906 00:42:24,090 --> 00:42:24,923 Next slide. 907 00:42:26,460 --> 00:42:28,920 So using a harm reduction model of care 908 00:42:28,920 --> 00:42:30,180 in motivational interviewing, 909 00:42:30,180 --> 00:42:33,487 this is how I may open the conversation with Jane. 910 00:42:33,487 --> 00:42:36,450 "Jane, first I wanna thank you for telling me 911 00:42:36,450 --> 00:42:39,450 that you're using cannabis for your RA pain, 912 00:42:39,450 --> 00:42:40,720 your nausea and anxiety. 913 00:42:40,720 --> 00:42:43,684 That must have taken a lot of courage for you to tell me. 914 00:42:43,684 --> 00:42:47,550 It sounds as if cannabis is something that really helps you. 915 00:42:47,550 --> 00:42:50,940 I wanna let you know that you are not in any trouble here 916 00:42:50,940 --> 00:42:53,970 and I understand your inner conflict, you're not alone. 917 00:42:53,970 --> 00:42:57,660 So many other new parents have the same concerns. 918 00:42:57,660 --> 00:42:59,190 There's a lot of information out there 919 00:42:59,190 --> 00:43:00,960 and it can be really confusing to know 920 00:43:00,960 --> 00:43:03,660 what the actual risks are for you and your baby. 921 00:43:03,660 --> 00:43:05,250 I also hear your concern 922 00:43:05,250 --> 00:43:07,890 over taking new medications when pregnant. 923 00:43:07,890 --> 00:43:09,840 It can be really hard to think about changing 924 00:43:09,840 --> 00:43:13,530 what's been working well and you obviously know your body 925 00:43:13,530 --> 00:43:14,940 and have done a really great job 926 00:43:14,940 --> 00:43:18,420 not having any flares or complications for so long. 927 00:43:18,420 --> 00:43:20,160 The goal is to help you get to a place 928 00:43:20,160 --> 00:43:22,590 where you can understand the information 929 00:43:22,590 --> 00:43:24,540 and make the best choice for you and your baby 930 00:43:24,540 --> 00:43:27,420 and give you the resources you need to change things 931 00:43:27,420 --> 00:43:29,010 as you want to. 932 00:43:29,010 --> 00:43:31,320 This is not something that we might fully answer today, 933 00:43:31,320 --> 00:43:32,430 but if it's okay with you, 934 00:43:32,430 --> 00:43:34,920 we can start the conversation on what we do know 935 00:43:34,920 --> 00:43:37,462 about cannabis and pregnancy and what we don't 936 00:43:37,462 --> 00:43:40,890 and what some of the other options that you could try 937 00:43:40,890 --> 00:43:42,870 and help you come up with a plan that works for you. 938 00:43:42,870 --> 00:43:44,037 How does that sound?" 939 00:43:44,940 --> 00:43:46,020 It seems pretty simple. 940 00:43:46,020 --> 00:43:47,670 The conversation not only put Jane 941 00:43:47,670 --> 00:43:48,990 in the driver's seat of her care, 942 00:43:48,990 --> 00:43:52,260 but it affirms that I see and hear her fears that she has 943 00:43:52,260 --> 00:43:54,270 and it lets her know I care about her 944 00:43:54,270 --> 00:43:58,110 and want to help her process to get to the next step. 945 00:43:58,110 --> 00:44:00,150 I normalize and have asked permission 946 00:44:00,150 --> 00:44:01,710 to continue the conversation. 947 00:44:01,710 --> 00:44:02,543 Next slide. 948 00:44:04,050 --> 00:44:06,250 So what could the options be for my patient? 949 00:44:07,230 --> 00:44:09,420 Could they delay their use until pregnancy 950 00:44:09,420 --> 00:44:11,950 or see pregnancy's over or ceasing lactation? 951 00:44:11,950 --> 00:44:15,060 Could they try another therapy that is more compatible 952 00:44:15,060 --> 00:44:16,940 with pregnancy and lactation? 953 00:44:16,940 --> 00:44:18,750 If cessation's on an option, 954 00:44:18,750 --> 00:44:22,290 reducing the frequency to the lowest possible amount, 955 00:44:22,290 --> 00:44:25,470 consider micro-dosing, minimum effective dose. 956 00:44:25,470 --> 00:44:27,480 Make sure that you're using clean cannabis 957 00:44:27,480 --> 00:44:29,460 and clean consumption methods 958 00:44:29,460 --> 00:44:32,700 and choosing the most compatible dose or form. 959 00:44:32,700 --> 00:44:34,770 You can refer to my friend Jesse Lynn, 960 00:44:34,770 --> 00:44:36,266 who's on this call today, 961 00:44:36,266 --> 00:44:41,266 who is, she's started the Vermont Cannabis Nurse Association 962 00:44:41,800 --> 00:44:46,800 and you can receive free confidential evidence-based support 963 00:44:46,860 --> 00:44:50,490 or try something new to reduce stress for your patient 964 00:44:50,490 --> 00:44:51,750 to reduce stress for the patient. 965 00:44:51,750 --> 00:44:54,270 Walking, yoga, this is the time when people 966 00:44:54,270 --> 00:44:57,150 are going to be open to trying things like that 967 00:44:57,150 --> 00:44:59,370 so that they can have a different path 968 00:44:59,370 --> 00:45:02,797 and different things moving forward. 969 00:45:02,797 --> 00:45:05,700 So now I'm gonna hand it off to Dr. Michelle Shepard 970 00:45:05,700 --> 00:45:08,250 where we'll hopefully and we'll hopefully have some time 971 00:45:08,250 --> 00:45:09,500 for questions at the end. 972 00:45:13,440 --> 00:45:15,120 [Michelle] Awesome, thanks so much Amy, 973 00:45:15,120 --> 00:45:17,692 you did a wonderful job wrapping all that stuff up. 974 00:45:17,692 --> 00:45:20,640 And we're using a transition slide here, 975 00:45:20,640 --> 00:45:22,890 because here in Vermont, as was discussed, 976 00:45:22,890 --> 00:45:24,150 cannabis is legal. 977 00:45:24,150 --> 00:45:28,320 So why do we still need to do the Plan of Safe Care 978 00:45:28,320 --> 00:45:33,300 and what can we all do to arm ourself 979 00:45:33,300 --> 00:45:34,410 with accurate information 980 00:45:34,410 --> 00:45:36,690 to share with our patients and clients? 981 00:45:36,690 --> 00:45:38,073 So next slide please. 982 00:45:39,120 --> 00:45:41,520 Oh, you can skip to the next one. 983 00:45:41,520 --> 00:45:43,680 So as was just mentioned, 984 00:45:43,680 --> 00:45:48,120 the rate of cannabis use and pregnant people is pretty high. 985 00:45:48,120 --> 00:45:51,120 But also the reminder is when I look at this slide, 986 00:45:51,120 --> 00:45:53,340 I see that in the eight states 987 00:45:53,340 --> 00:45:56,850 in this 2017 PRAMS data sampling 988 00:45:56,850 --> 00:46:01,850 that 10% of people reported using cannabis before pregnancy, 989 00:46:02,130 --> 00:46:04,800 but only 4.2% of those people continue 990 00:46:04,800 --> 00:46:05,880 to use during pregnancy. 991 00:46:05,880 --> 00:46:08,520 So there is a large proportion of people 992 00:46:08,520 --> 00:46:13,520 that are able to delay use, decrease use, or cease use, 993 00:46:14,220 --> 00:46:17,010 similar to alcohol during pregnancy. 994 00:46:17,010 --> 00:46:19,500 In Vermont, we're about 10% during pregnancy. 995 00:46:19,500 --> 00:46:24,500 So similar total amount, but higher during pregnancy use. 996 00:46:24,850 --> 00:46:26,343 Next slide please. 997 00:46:27,480 --> 00:46:29,640 So this is something I'm gonna come back to, 998 00:46:29,640 --> 00:46:32,310 but I always feel like clear communication, 999 00:46:32,310 --> 00:46:35,250 shared languaging and shared messaging 1000 00:46:35,250 --> 00:46:37,590 is the best thing we can do all around. 1001 00:46:37,590 --> 00:46:41,190 So substance use, including tobacco, 1002 00:46:41,190 --> 00:46:43,170 including alcohol, including cannabis, 1003 00:46:43,170 --> 00:46:46,980 is not recommended and we should work on 1004 00:46:46,980 --> 00:46:50,190 decreasing or stopping use using some of the same techniques 1005 00:46:50,190 --> 00:46:52,410 that were already highlighted. 1006 00:46:52,410 --> 00:46:55,260 It is so important to know the state's 1007 00:46:55,260 --> 00:46:56,820 CARA and CAPTA policies. 1008 00:46:56,820 --> 00:46:59,760 So New Hampshire's policies and Vermont's policies 1009 00:46:59,760 --> 00:47:02,040 and New York's policies are all very different. 1010 00:47:02,040 --> 00:47:04,420 It's important that we know how that 1011 00:47:05,460 --> 00:47:07,830 either legislation as in New Hampshire 1012 00:47:07,830 --> 00:47:12,830 or policies as in Vermont can impact the involvement of DCF 1013 00:47:13,200 --> 00:47:16,770 and when or how a Plan of Safe Care is developed. 1014 00:47:16,770 --> 00:47:19,710 We want to provide pregnant people with accurate information 1015 00:47:19,710 --> 00:47:22,050 and answer questions and if you don't know the answer, 1016 00:47:22,050 --> 00:47:23,942 we can point you to where you can find it 1017 00:47:23,942 --> 00:47:25,957 and then use the available resources 1018 00:47:25,957 --> 00:47:29,670 that are out there already that are state-specific 1019 00:47:29,670 --> 00:47:32,370 for both yourself and for your patients. 1020 00:47:32,370 --> 00:47:33,483 Next slide please. 1021 00:47:35,130 --> 00:47:38,010 So the CARA and CAPTA amendments, 1022 00:47:38,010 --> 00:47:41,580 you'll hear people throw the word CAPTA around a lot. 1023 00:47:41,580 --> 00:47:44,220 CAPTA is a huge piece of federal legislation 1024 00:47:44,220 --> 00:47:47,250 known as the Child Abuse Prevention and Treatment Act. 1025 00:47:47,250 --> 00:47:50,670 Cara, which is the Comprehensive Addiction and Recovery Act, 1026 00:47:50,670 --> 00:47:54,270 was a 2016 amendment and it's just one tiny slice 1027 00:47:54,270 --> 00:47:58,050 of this huge body of legislation. 1028 00:47:58,050 --> 00:48:03,050 The overall goal of CARA was to address the needs of infants 1029 00:48:03,090 --> 00:48:05,730 specifically affected by substance use, withdrawal 1030 00:48:05,730 --> 00:48:08,040 or fetal alcohol spectrum disorders. 1031 00:48:08,040 --> 00:48:09,360 And per federal law, 1032 00:48:09,360 --> 00:48:11,700 substance use includes cannabis 1033 00:48:11,700 --> 00:48:13,980 and that's where we get the need 1034 00:48:13,980 --> 00:48:15,750 to do the Plan of Safe Care. 1035 00:48:15,750 --> 00:48:17,820 So the requirements of this amendment 1036 00:48:17,820 --> 00:48:20,760 were that each state developed their own pathway 1037 00:48:20,760 --> 00:48:24,093 around identifying infants affected by substance use. 1038 00:48:24,093 --> 00:48:27,630 Healthcare providers needed to notify. 1039 00:48:27,630 --> 00:48:31,500 Now this is not report, this is not chastised, 1040 00:48:31,500 --> 00:48:33,090 this is not take children away. 1041 00:48:33,090 --> 00:48:36,330 They need to notify Child Protective Services, 1042 00:48:36,330 --> 00:48:38,610 develop a Plan of Safe care, 1043 00:48:38,610 --> 00:48:41,370 and then the Child Protective Service Agency of the state 1044 00:48:41,370 --> 00:48:44,550 has to send a certain subset of data, 1045 00:48:44,550 --> 00:48:47,880 which is literally overall numbers for the year 1046 00:48:47,880 --> 00:48:49,800 to the Children's Bureau. 1047 00:48:49,800 --> 00:48:51,063 Next slide please. 1048 00:48:52,770 --> 00:48:55,350 So what we've tried to do is make it as simple 1049 00:48:55,350 --> 00:48:57,180 and straightforward as as possible. 1050 00:48:57,180 --> 00:49:00,150 In Vermont, we do not have overarching legislation 1051 00:49:00,150 --> 00:49:00,990 that governs this. 1052 00:49:00,990 --> 00:49:03,510 We are working on DCF policies 1053 00:49:03,510 --> 00:49:06,630 and a governor's assurance that we're in compliance. 1054 00:49:06,630 --> 00:49:09,270 So the difference between a DCF Report, 1055 00:49:09,270 --> 00:49:11,430 we all know what a DCF Report is, right? 1056 00:49:11,430 --> 00:49:14,340 This is an identified call to the intake hotline. 1057 00:49:14,340 --> 00:49:18,210 You give out significant amounts of personal information 1058 00:49:18,210 --> 00:49:23,210 about the parent and this is only indicated in the times 1059 00:49:23,460 --> 00:49:26,130 where legal substances are used 1060 00:49:26,130 --> 00:49:28,500 in the third trimester of pregnancy. 1061 00:49:28,500 --> 00:49:32,400 There is misuse or use of non-prescribed medications 1062 00:49:32,400 --> 00:49:34,456 in the third trimester or the concern 1063 00:49:34,456 --> 00:49:37,328 for fetal alcohol spectrum disorder. 1064 00:49:37,328 --> 00:49:39,240 There's a little bit of a gray area 1065 00:49:39,240 --> 00:49:43,053 around alcohol use disorder in the third trimester. 1066 00:49:44,580 --> 00:49:47,460 A separate pathway that we have developed in Vermont 1067 00:49:47,460 --> 00:49:49,950 is called the CAPTA Notification pathway. 1068 00:49:49,950 --> 00:49:51,990 This is a de-identified tracking form 1069 00:49:51,990 --> 00:49:56,190 that is not sent through the DCF Report network. 1070 00:49:56,190 --> 00:50:00,090 This is indicated in the times 1071 00:50:00,090 --> 00:50:02,694 where there is Medications for Opioid Use disorder, 1072 00:50:02,694 --> 00:50:06,360 also commonly called MAT 1073 00:50:06,360 --> 00:50:09,333 or Medications for Addiction Treatment. 1074 00:50:10,710 --> 00:50:14,520 People that are using prescribed opioids or benzodiazepines 1075 00:50:14,520 --> 00:50:17,970 during pregnancy or any use of cannabis during pregnancy 1076 00:50:17,970 --> 00:50:19,620 after the first trimester. 1077 00:50:19,620 --> 00:50:20,463 Next slide. 1078 00:50:21,540 --> 00:50:22,800 This may be a little hard to see. 1079 00:50:22,800 --> 00:50:24,810 So I'm gonna point everyone to the flow charts 1080 00:50:24,810 --> 00:50:27,540 that are available on the DCF website. 1081 00:50:27,540 --> 00:50:31,830 These were developed to really help make it easy to know, 1082 00:50:31,830 --> 00:50:35,070 do you need to make a call to DCF? 1083 00:50:35,070 --> 00:50:37,300 Do you need to report DCF 1084 00:50:38,340 --> 00:50:41,280 concern for substance use during pregnancy? 1085 00:50:41,280 --> 00:50:44,310 So this is again, last trimester only. 1086 00:50:44,310 --> 00:50:47,010 We're allowed to make prenatal reports in Vermont. 1087 00:50:47,010 --> 00:50:49,274 This is not the case in other states. 1088 00:50:49,274 --> 00:50:52,590 But in Vermont we can open DCF cases 1089 00:50:52,590 --> 00:50:54,390 30 days before the delivery date 1090 00:50:54,390 --> 00:50:58,110 in order to help families get all of the supports 1091 00:50:58,110 --> 00:51:01,361 they can get to safely and confidently parents, 1092 00:51:01,361 --> 00:51:04,590 this is not done in order to take a child away. 1093 00:51:04,590 --> 00:51:06,720 This is done to try to adjust any problems 1094 00:51:06,720 --> 00:51:09,303 that are modifiable to keep this family together. 1095 00:51:10,320 --> 00:51:12,120 So if the substance use is limited 1096 00:51:12,120 --> 00:51:16,290 to any of those prescribed medications and/or marijuana, 1097 00:51:16,290 --> 00:51:19,650 so this can be all four, it can be one, it can be two, 1098 00:51:19,650 --> 00:51:22,240 it can be marijuana alone 1099 00:51:23,760 --> 00:51:27,870 and there are not any concerns, so this is important, 1100 00:51:27,870 --> 00:51:30,630 no concerns for the newborn safety, 1101 00:51:30,630 --> 00:51:32,970 then there's no prenatal report. 1102 00:51:32,970 --> 00:51:34,920 Anytime you have a concern for newborn safety, 1103 00:51:34,920 --> 00:51:38,040 now this can be, it's completely separate from substance use 1104 00:51:38,040 --> 00:51:40,410 of course, concern for safety 1105 00:51:40,410 --> 00:51:43,230 should go through the reporting mechanism. 1106 00:51:43,230 --> 00:51:46,770 But what I wanna remind people is that we really love it 1107 00:51:46,770 --> 00:51:48,450 if we can start the conversation 1108 00:51:48,450 --> 00:51:49,560 about the Plan of Safe Care, 1109 00:51:49,560 --> 00:51:54,560 what it is and what it isn't, and have involved caregivers, 1110 00:51:54,720 --> 00:51:56,460 pregnant people, and their providers 1111 00:51:56,460 --> 00:51:59,970 starting this prior to delivery. 1112 00:51:59,970 --> 00:52:00,803 Next slide. 1113 00:52:02,520 --> 00:52:05,580 This is a similar flow chart for newborns 1114 00:52:05,580 --> 00:52:06,780 exposed to substances. 1115 00:52:06,780 --> 00:52:09,300 So this is after birth. 1116 00:52:09,300 --> 00:52:11,880 And again, this is the exact same pathway. 1117 00:52:11,880 --> 00:52:14,310 If there's no concerns for newborn safety, 1118 00:52:14,310 --> 00:52:16,920 the only thing that must happen is the Plan of Safe Care 1119 00:52:16,920 --> 00:52:19,380 should be done with the caregivers. 1120 00:52:19,380 --> 00:52:22,020 It should be shared with the infant's PCP 1121 00:52:22,020 --> 00:52:24,840 and the de-identified notification forms 1122 00:52:24,840 --> 00:52:27,153 should be faxed or emailed over. 1123 00:52:28,380 --> 00:52:29,820 And then, just the reminder 1124 00:52:29,820 --> 00:52:33,120 that there are certain newborn reports. 1125 00:52:33,120 --> 00:52:34,410 And that's again, 1126 00:52:34,410 --> 00:52:38,760 if there are signs of withdrawal due to substances 1127 00:52:38,760 --> 00:52:40,173 that were not prescribed, 1128 00:52:41,220 --> 00:52:43,110 that would go through the reporting. 1129 00:52:43,110 --> 00:52:45,630 But up on the top you can see that the DCF policy 1130 00:52:45,630 --> 00:52:50,630 on cannabis use since 2017 is that cannabis use alone 1131 00:52:51,420 --> 00:52:52,890 is not accepted. 1132 00:52:52,890 --> 00:52:53,730 So you could call, 1133 00:52:53,730 --> 00:52:55,710 but they're not going to accept this 1134 00:52:55,710 --> 00:52:58,860 as an open case unless there are other concerns. 1135 00:52:58,860 --> 00:53:00,033 Next slide please. 1136 00:53:01,620 --> 00:53:02,970 I just wanted people to see 1137 00:53:02,970 --> 00:53:04,620 what the Plan of Safe Care looks like. 1138 00:53:04,620 --> 00:53:07,170 So the Plan of Safe Care is an identified document 1139 00:53:07,170 --> 00:53:08,880 and that's identified for a reason, 1140 00:53:08,880 --> 00:53:11,613 because it's given to the caregivers. 1141 00:53:12,690 --> 00:53:15,420 The indication up on the top there 1142 00:53:15,420 --> 00:53:18,300 is just helpful for people to follow up on. 1143 00:53:18,300 --> 00:53:19,350 And so again, 1144 00:53:19,350 --> 00:53:21,960 cannabis use alone or in combination 1145 00:53:21,960 --> 00:53:25,170 from any of the other three categories 1146 00:53:25,170 --> 00:53:27,570 should trigger a Plan of Safe Care development. 1147 00:53:27,570 --> 00:53:29,280 This needs to be completed by the time 1148 00:53:29,280 --> 00:53:30,930 of hospital discharge. 1149 00:53:30,930 --> 00:53:33,930 It's all about the referrals and follow ups. 1150 00:53:33,930 --> 00:53:35,133 Next slide please. 1151 00:53:36,180 --> 00:53:38,430 So what you can see on the remainder 1152 00:53:38,430 --> 00:53:42,450 of the Plan of Safe Care is a listing of services, 1153 00:53:42,450 --> 00:53:44,130 supports and referrals. 1154 00:53:44,130 --> 00:53:47,880 These are split into infant supports and caregiver supports. 1155 00:53:47,880 --> 00:53:49,320 And there's many things on here. 1156 00:53:49,320 --> 00:53:52,170 Again, people may be receiving all of these things 1157 00:53:52,170 --> 00:53:55,167 or they may discuss them and not be interested in them 1158 00:53:55,167 --> 00:53:56,741 and that is okay. 1159 00:53:56,741 --> 00:53:58,710 There is nothing about this 1160 00:53:58,710 --> 00:54:02,190 that is going to be shared with DCF. 1161 00:54:02,190 --> 00:54:05,820 There is nothing about this that is going to be published. 1162 00:54:05,820 --> 00:54:10,200 It's all about here is a way to get contact information 1163 00:54:10,200 --> 00:54:12,540 for the person you should call at WIC 1164 00:54:12,540 --> 00:54:14,580 for childcare resources, 1165 00:54:14,580 --> 00:54:17,700 for children's integrated services, for home visiting. 1166 00:54:17,700 --> 00:54:20,070 It can be really nice to have all that information 1167 00:54:20,070 --> 00:54:21,600 in one place. 1168 00:54:21,600 --> 00:54:22,773 Next slide please. 1169 00:54:24,030 --> 00:54:27,540 This is the de-identified Vermont CAPTA Notification. 1170 00:54:27,540 --> 00:54:29,403 This has check boxes on it. 1171 00:54:31,650 --> 00:54:35,310 Again, here is your recreational versus prescribed cannabis 1172 00:54:35,310 --> 00:54:37,830 as we were trying to track the difference 1173 00:54:37,830 --> 00:54:40,650 and whether we were seeing a difference 1174 00:54:40,650 --> 00:54:44,793 as cannabis is legalized into a more recreational use, 1175 00:54:45,810 --> 00:54:47,760 we're also looking at other exposures 1176 00:54:47,760 --> 00:54:49,410 including alcohol and nicotine. 1177 00:54:49,410 --> 00:54:51,240 That's really important. 1178 00:54:51,240 --> 00:54:54,300 Those co-exposures have their own known effects 1179 00:54:54,300 --> 00:54:58,148 on the infant and their longterm development. 1180 00:54:58,148 --> 00:54:59,940 And then, at the bottom are the things 1181 00:54:59,940 --> 00:55:01,590 that we have to report. 1182 00:55:01,590 --> 00:55:05,400 So in that final box, the only things that are going off 1183 00:55:05,400 --> 00:55:08,070 to the Children's Bureau are these three things. 1184 00:55:08,070 --> 00:55:09,870 Whether the Plan of Safe Care was completed 1185 00:55:09,870 --> 00:55:11,790 and sent to the PCP, 1186 00:55:11,790 --> 00:55:14,010 whether the individual was engaged in services 1187 00:55:14,010 --> 00:55:17,250 prior to delivery, and whether new referrals were made. 1188 00:55:17,250 --> 00:55:19,680 That is all of the tracking that has to happen 1189 00:55:19,680 --> 00:55:21,990 per the capital law. 1190 00:55:21,990 --> 00:55:23,163 Next slide please. 1191 00:55:24,270 --> 00:55:26,700 So here we are back to clear communication 1192 00:55:26,700 --> 00:55:29,790 and using available resources for more information. 1193 00:55:29,790 --> 00:55:30,693 Next slide. 1194 00:55:32,040 --> 00:55:34,628 So here's one that again, it's hard to see on the slide, 1195 00:55:34,628 --> 00:55:37,200 but please go and take a look at it. 1196 00:55:37,200 --> 00:55:38,668 We had a wonderful student working with us 1197 00:55:38,668 --> 00:55:40,890 that helped us develop this infographic 1198 00:55:40,890 --> 00:55:43,740 around cannabis use and breastfeeding. 1199 00:55:43,740 --> 00:55:48,060 And we have some Vermont-specific QR codes and websites 1200 00:55:48,060 --> 00:55:51,240 to visit for people that have more information. 1201 00:55:51,240 --> 00:55:52,533 Next slide please. 1202 00:55:54,000 --> 00:55:57,300 Also, please use the Plan of Safe Care website. 1203 00:55:57,300 --> 00:55:59,760 Unfortunately, it's a little bit buried. 1204 00:55:59,760 --> 00:56:02,910 It currently lives under DCFS Family Services Division. 1205 00:56:02,910 --> 00:56:04,410 We're hoping to move that, 1206 00:56:04,410 --> 00:56:06,540 but it has all of the following resources here, 1207 00:56:06,540 --> 00:56:08,040 including several different 1208 00:56:08,040 --> 00:56:09,750 frequently asked questions, documents. 1209 00:56:09,750 --> 00:56:10,583 Next slide. 1210 00:56:12,120 --> 00:56:13,920 Here's the frequently asked questions, 1211 00:56:13,920 --> 00:56:15,840 marijuana use in pregnancy. 1212 00:56:15,840 --> 00:56:16,923 Next slide. 1213 00:56:18,270 --> 00:56:21,690 And what I thought was the most important apparent handout 1214 00:56:21,690 --> 00:56:24,120 on the Vermont Plan of Safe Care and what it is 1215 00:56:24,120 --> 00:56:25,830 and what it isn't. 1216 00:56:25,830 --> 00:56:27,630 So this is something you can hand to people 1217 00:56:27,630 --> 00:56:29,460 so they're not hearing about the Plan of Safe Care 1218 00:56:29,460 --> 00:56:32,010 for the first time at hospital discharge. 1219 00:56:32,010 --> 00:56:32,853 Next slide. 1220 00:56:34,200 --> 00:56:38,084 One more conversation is a Vermont Department of Health 1221 00:56:38,084 --> 00:56:41,430 campaign that has lots of information for providers. 1222 00:56:41,430 --> 00:56:43,500 There's a whole toolkit for providers, 1223 00:56:43,500 --> 00:56:46,620 but also education materials for parents. 1224 00:56:46,620 --> 00:56:47,453 Next slide. 1225 00:56:48,630 --> 00:56:51,390 And here's the Cannabis Use During Pregnancy slide. 1226 00:56:51,390 --> 00:56:55,770 So again, it has more information and available resources. 1227 00:56:55,770 --> 00:56:56,643 Next slide. 1228 00:56:57,960 --> 00:57:00,240 And this is the last thing I want to summarize, 1229 00:57:00,240 --> 00:57:02,850 'cause I feel like people get really nervous 1230 00:57:02,850 --> 00:57:04,050 about the Plan of Safe Care. 1231 00:57:04,050 --> 00:57:06,570 The Plan of Safe Care is a living document 1232 00:57:06,570 --> 00:57:08,160 that's created with the pregnant person 1233 00:57:08,160 --> 00:57:11,430 and their involved supports. 1234 00:57:11,430 --> 00:57:13,980 It documents their current supports, strengths, needs, 1235 00:57:13,980 --> 00:57:15,300 and new referrals, 1236 00:57:15,300 --> 00:57:18,180 and is shared with the infant's primary care provider. 1237 00:57:18,180 --> 00:57:20,760 This is to facilitate followup on referrals 1238 00:57:20,760 --> 00:57:24,420 for both the infant and to check in with that caregiver. 1239 00:57:24,420 --> 00:57:26,160 This is not a form for hospitals 1240 00:57:26,160 --> 00:57:28,140 and it's not a form for providers. 1241 00:57:28,140 --> 00:57:30,270 There is nothing punitive about this 1242 00:57:30,270 --> 00:57:32,100 and it is not shared with DCF 1243 00:57:32,100 --> 00:57:34,440 unless they are already involved for their own 1244 00:57:34,440 --> 00:57:36,300 child safety concerns. 1245 00:57:36,300 --> 00:57:40,050 And in yellow highlight a Vermont Plan Safe Care is required 1246 00:57:40,050 --> 00:57:42,480 along with the de-identified CAPTA Notification 1247 00:57:42,480 --> 00:57:44,970 for any pregnant person using cannabis 1248 00:57:44,970 --> 00:57:46,710 after the first trimester. 1249 00:57:46,710 --> 00:57:47,853 Next slide please. 1250 00:57:49,950 --> 00:57:51,333 And I'll turn it back over. 1251 00:57:55,559 --> 00:57:59,490 [Amy] So I think, just kind of to wrap up, 1252 00:57:59,490 --> 00:58:01,350 we've got one minute. 1253 00:58:01,350 --> 00:58:03,540 If there are any pressing questions, 1254 00:58:03,540 --> 00:58:06,810 you can feel free to email ICON. 1255 00:58:06,810 --> 00:58:10,230 I think, just learning how to discuss it and complete it 1256 00:58:10,230 --> 00:58:15,230 with your patients is going to be 1257 00:58:15,600 --> 00:58:20,600 and how to introduce it is in a really safe, really easy way 1258 00:58:21,810 --> 00:58:24,150 is gonna be the best thing for you. 1259 00:58:24,150 --> 00:58:27,156 So I thank everybody for coming together today 1260 00:58:27,156 --> 00:58:30,873 to hear us speak about this topic. 1261 00:58:31,890 --> 00:58:32,973 Go to the next slide. 1262 00:58:35,670 --> 00:58:39,180 [Julie] Thank you Amy. Thank you Dr. Shepard. 1263 00:58:39,180 --> 00:58:40,923 Thank you everybody for joining. 1264 00:58:42,030 --> 00:58:44,730 I can't believe we're right on time, that's excellent. 1265 00:58:44,730 --> 00:58:49,730 I'm just putting the link here for the evaluation. 1266 00:58:50,040 --> 00:58:54,923 We will put the recording and the slide on our website, 1267 00:58:56,640 --> 00:58:57,930 might take a few days, 1268 00:58:57,930 --> 00:59:02,930 but you'll be able to find both of them on our website. 1269 00:59:03,300 --> 00:59:06,450 Please don't hesitate to reach out if you have any question. 1270 00:59:06,450 --> 00:59:10,653 Thank you for your participation and have a great afternoon.