[Woman] All right, well, I love a good question.
All right, so I also wanna take a minute
and thank you so much.
I think the one wonderful thing about doing a Zoom meeting,
although I remember how wonderful it was
to have these conferences in person,
is that we are able to really bring about
some wonderful national leaders in the fields
to come and talk to us, as well as access people
that may not be able to travel to Chatham County.
So I'm excited to introduce Dr. Mishka Terplan,
who is a board certified OBGYN
as well as addiction medicine physician.
Primarily his clinical research,
public health and advocacy interests
are in the intersections of reproductive
and behavioral health.
He's the medical director at Friends Research Institute
and adjunct faculty
at the University of California, San Francisco,
where he is a substance use warmline clinician
for the National Clinician Consultation Center.
Dr. Terplan has active grant funding
and has published extensively on health inequities,
discrimination and access to treatment.
He's spoken at local high schools
and before the United States Congress
and has participated in federal
and international expert panels primarily on issues
related to gender reproduction and addiction.
And many of us were lucky enough to hear several talks
by Dr. Terplan over the last six months or so,
and we were so excited that he was willing
to take up our offer to come and speak today.
So I am going to turn it over.
[Dr. Terplan] Great, well, thank you.
Yeah, thank you so much for inviting me
and thank you so much for all of the work that you do
and for really sharing that data that I love.
I really want to get somewhere selfishly
more out of talks like this if I can walk away with more.
And so hence it's what you shared in the beginning.
And I do hope that we have time
for some questions and answers after this as well.
Some of this is similar
to the talks that you just mentioned,
but I really was asked to talk about screening,
assessing and treating
pregnant women with substance use disorder.
I have no disclosures.
And I want to begin by really framing this conversation
as if on a three-legged stool,
like one leg being epidemiology, the other being a history
and the third really being ethics in human rights.
So first, this is a slide from the good mocker
that talks about the reproductive health life course.
The typical woman spends five years pregnant postpartum
or trying to get pregnant
and 30 years trying to avoid pregnancy.
So although we today are talking
about the specific window of time of pregnancy,
I want to acknowledge
we put most of our public health programming
into that period,
oftentimes at the neglect of the rest
of the reproductive health life course.
Second, when we talk about drugs and pregnancy,
we are really in the shadow of the crack baby hysteria.
And I think it's important to remember
this time as well as remember the science of the time.
And this was a period of time
in which there was like a cross public media
catastrophic stories
that were echoed to a large extent in the early science,
science that was in retrospect
conducted without adequate masking,
without adequate control groups
with poor sorts of measurements
and this narrative of harm.
This idea that these infants were irreparably damaged
and were going to consequentially bankrupt
the public educational system,
that narrative was also highly racialized.
And in many ways when people talk
about "the cracked baby,"
we're really talking about where the war on drugs
intersected with the war on abortion.
And those sort of racialized
and sort of punitive reproductive health policies
are still very much active today.
And the third leg of the stool
really follows the very influential work
of primarily black feminists
in particular that formulated the movement
and the perspective of reproductive justice.
Sort of moving from reproductive health is a human right,
which is understood as the right to have a child
or not have a child,
but recognizing that human rights
somewhere are aspirational
and if you lack access to the right,
it's not meaningless, but it's not what we think it is.
So everyone has the right to vote,
but restrictions at the ballot box
make that right unrealizable.
Reproductive health is a human right,
but without access
to the means of expressing your reproductive autonomy,
that's problematic.
And so the space of social justice
is where you make, you bring the right to reality
and hence the third part of the reproductive justice value.
Not just the right to have a child or not have a child,
but the right to parent children in safe
and healthy environments
that is radical key and transformational.
So I want to hold these reproductive justice values
as we walk sort of through the rest of this talk.
So I wanna begin with this question,
why would someone who's pregnant use drugs?
And I wanna briefly discuss the science of addiction
and the science of treatment
in order to in a way problematize this
as not being the proper question to ask.
Because in the United States for the last 100 years,
drug use is common.
Most people use drugs.
These are the most recent data
from the national survey of drug use and health.
The bottom one on the right
is looking at illicit substance use only,
and this is past year.
And on the top, this is past month substance use in general,
which includes alcohol, tobacco products and vaping.
And you can see how many millions of people
like use substances either monthly or yearly
in the United States.
And most people who use drugs
do not become addicted to them.
On the left these are data from the 1990s
also national level data.
What they showed in that analysis
has been seen over and over again since.
And you might have heard people talk
about how "addictive a substance is."
And that oftentimes is from data like this
where you calculate a proportion.
In the denominators the number of people
who've used a drug in the past year
and the numerators, the number
who meet criteria for a use disorder.
And when you do that,
you see about 30% of people who've used a tobacco product,
meet criteria for a nicotine use disorder.
About 25% of people who used heroin
meet criteria for an opioid use disorder.
And somewhere around 10% of people
who've used cannabis in the past year
meet criteria for a cannabis use disorder.
And this surprises people.
Most people think that anyone who's used an opioid
has an addiction to it.
And some people think that nobody who uses cannabis
has an addiction to it.
So there's a large science
around vulnerabilities to addiction
that's illustrated very simplistically
with this cartoon from NIDA.
There's a biological or genetic substrate
obviously for all organisms.
And there are some associations
with the development of addiction
perhaps capture at best 30% of addiction.
And then there's this larger bucket of environment,
which means things like we know
the earlier somebody uses a substance,
the more likely they are to develop an addiction.
And in particular environment also means
the experience of adverse childhood experiences
as well as other forms of childhood
or adolescent or adult trauma.
And there is an association
between the experiences of trauma
and the development and using drugs
and the development of a use disorder.
So the American Society of Addiction Medicine
several years ago, reconceptualized
the definition for addiction.
And they state that it's a treatable chronic medical disease
involving complex interactions
among brain circuits, genetics, the environment
and in individual's life experiences.
People with addiction use substances
or engage in behaviors that become compulsive
and often continue despite harmful consequences.
Prevention efforts and treatment approaches
are generally as successful
as those for other chronic conditions.
And clinically we use the DSM criteria
to diagnose use disorder.
And you'll see these are the 11 items that are used.
They are primarily grouped under behaviors,
loss of control or use despite negative consequences.
So taken really simply,
the simplest way that I define addiction,
it's a brain centered condition.
It affects the whole body,
but the visible symptoms are behaviors.
So one of the reasons we say
addiction is a chronic condition
is because it behaves like other chronic conditions.
This article was published in 2001 I think,
and it was highly influential.
And in this they sort of grouped what they called relapse
a year following diagnosis for different conditions.
And you can see here so for asthma relapse
would be you get diagnosed with asthma,
you're given an inhaler and you end up in the emergency room
with an exacerbation.
Or for hypertension,
you're diagnosed with high blood pressure,
started on medication
and your blood pressure either stays the same or increases.
And for addiction
it would be you're diagnosed with use disorder,
you're initiating non-treatment and you return to use
or you continue to use.
And the rates of this "relapse"
are similar across illness states.
In other words, addiction's a chronic condition
because it behaves like other chronic conditions.
But the goal of addiction treatment is not more treatment.
The goal is recovery.
And this is SAMHSA's working definition of recovery.
It's holistic, it crosses a multiplicity of domains,
it's much more than abstinence.
It's about integrity, connection, purpose, serenity,
and it's perfectly compatible with the use of medications.
So let's return to that initial question.
The question isn't why would somebody use
drugs in pregnancy?
The question, because most people use drugs,
some of whom get pregnant.
The question is, what happens when people who use drugs
get pregnant and stay pregnant?
These are data from the national survey
of drug use in health looking at past month use,
contrasting people who are not pregnant
versus those that are stratified by trimester
and separated by substance.
And you can see people who are not pregnant
are far more likely to report use of any substance.
Use decreases across pregnancy and it differs by substance.
People cut back alcohol the most, cigarettes the least,
and elicit substances somewhere in between.
So I look at these data and to me they support the statement
that all pregnant people are motivated
to maximize their health and that of their baby to be.
Some people can stop using substances, others can't,
those that can't likely have a use disorder.
In many ways continuation of substance use in pregnancy
is pathognomonic for having a use disorder.
So when we're talking about this topical area,
we're not talking about people who start using drugs
in pregnancy, I've never seen that.
We're talking about where the reproductive health life
course, getting pregnant, staying pregnant,
delivering an infant
intersects with an addiction life course.
Use proceeding to misuse,
and then the development of addiction
and all of this happening
in a specific period of time of pregnancy.
So we're gonna walk through what's assessment,
what's treatment, talk about the fourth trimester
and focus at the end on stigma and discrimination.
So I want to mark a distinction in terms.
When I talk about screening,
I'm talking about a verbal assessment
oftentimes using a validated instrument.
And when I'm talking about testing,
I'm talking about looking at a biological matrix
i.e urine or blood or meconium or whatever
for the presence or absence of drug metabolites
or parent compounds.
So there are two types of drug tests.
One is what we call presumptive.
This is like based upon like an ELISA immunoassay,
the technology, this is like the rapid COVID test.
It's often used, the results are rapidly obtained,
the results are reported in binary fashion
and it's inexpensive.
Definitive tests are more like the COVID PCR.
They use a different technology that actually quantifies
the exact compound and the quantity of the compound
oftentimes expressed
as something like nanograms per deciliter.
Presumptive tests the point oftentimes
but not exclusively point of care tests
yield a poor quality piece of information.
One, there's a bias built into it,
substances metabolize at different rates.
Therefore things that metabolize more quickly
are less visible in drug tests.
And things that stick around longer
like cannabinoid metabolites
are far more likely to be present.
So there's a bias in substance metabolism
that is reproduced in drug test results.
Also, there's multiple substances.
This is a partial list here on the left
that can cause a false positive
and presumptive test due to cross-reactivity
with the immunoassay.
Many of these are substances we prescribe during pregnancy
or during the birthing hospitalization.
These tests are also subject to true positives
that can be misinterpreted.
These are three articles and there's a fourth forthcoming
that document positive newborn drug tests for fentanyl
when the fentanyl exposure
was the epidural use during the birthing hospitalization
or during labor.
So if we don't know this,
we will misattribute the positive fentanyl test
to something that it is not.
And finally, physicians do a very bad job
at interpreting drug test results.
This is one study that uses on the right hand side,
this is the test, there were seven items.
I would sort of ping this
at the sort of medical student level and it was administered
at the largest Canadian medical conference.
And no physician got 100%.
In fact the average was about 50%
in people who said they used urine drug testing
as part of their clinical practice
scored one point lower than people who did not.
And every state is different.
But at the federal level,
CAPTA is clear that drug testing is not required by CAPTA.
Having a positive drug test
is not the same as being affected by substance exposure.
And a demonstrable health impact is needed
beyond a drug test is needed for a report or a notification.
So professional society recommendations are similarly clear.
Drug testing is not an appropriate measurement of addiction.
A drug test result, a positive result,
is evidence of exposure, not indication of health,
ill health, injury or harm
and not part of the AAP discharge criteria.
The American Society of Addiction Medicine goes further
and says that definitive testing is required
when the results informed decisions with major clinical
or non-clinical implications for the patient.
I would say that's any drug test
during the birthing hospitalization.
And everyone is clear that if you are going to drug test
consent is required.
In contrast screening is what's recommended.
And it should be voluntary and it should be universal.
There are two studies that compare
different screening instruments.
And the big takeaway is that all work decently
and you should just utilize
really what's ever already in the EHR.
But I would add to this a little bit
that we should preface screening with permission asking.
This reinforces the voluntaries.
Is it okay if I ask you some questions
about smoking, alcohol and other drugs?
And if people say no, then we don't ask.
One nice thing about prenatal care
is that it happens at multiple episodes.
And all of behavioral health work
rests upon a strong therapeutic alliance.
So asking for permission and respecting what somebody says
goes a long way in establishing that therapeutic alliance.
And the reason for screening is that we can,
from a population health perspective,
put people, organize the population into this risk pyramid.
If below risk, right?
Then we need to not ignore it
but give positive reinforcement.
Moderate risk is the place of the brief intervention.
And for people with the disease of addiction,
they need treatment.
So treatment.
The gold standard for substance use disorder treatment
in pregnancy is comprehensive co-located service delivery,
providing addiction treatment,
which is medication plus or minus behavioral care
in the same time and space as prenatal care.
And the benefits of addiction treatment
plus prenatal care date back,
the evidence dates back to the 1970s.
And this is not the first article,
but this is my favorite article.
And this is from Loretta Finnegan
in what became the MATER clinic in Philadelphia.
And these are the five categories
of analysis that she has here.
And she looked at sort of a composite obstetric complication
and the far right is low birth weight.
And some things stand out, right?
People with untreated opioid use disorder
who did not access prenatal care had low birth weight,
almost 50% had a low birth weight.
But people who got treatment and prenatal care
had a low birth weight of almost 20%,
which is much more similar
to the population of people without a use disorder
than it is to the people with untreated disease.
And this sort of observation
has been seen in a multiplicity of other studies
since the idea that healthy mother equals healthy baby.
Part of prenatal care is to optimize maternal health
via chronic disease management.
These are data from Massachusetts
separating people without addiction,
treated addiction, untreated addiction.
And you can see for every single one of these categories,
the population health burden
is in the bucket of those with untreated addiction.
And people with treated disease
have birth outcomes that are similar to
or at times identical to people without addiction.
So what about medication?
Why use an opioid to treat an opioid use disorder?
This is one of the first articles
written about heroin addiction
as the first article to describe methadone.
And it still stands to this day,
I think as one of the best articles written about addiction,
not by people who had themselves at addiction
that describes the illness state.
And you can see here on the left hand side,
we'd use slightly different words today,
but initially when people begin to use opioids,
they feel high or we'd say euphoric now,
but rapidly over time
people no longer experience euphoria or intoxication.
They're spending more and more of their time in a sick state
or a withdrawal state.
And when they're barely feeling normal.
So in many ways you've probably heard how addiction,
is sort of hijacks the reward pathway, not untrue,
but really addiction
kinda goes from being a reward seeking behavior
when it becomes a chronic condition,
it's really a relief seeking behavior.
And when somebody is untreated opioid use disorder,
they're using opioids multiple times a day
and they're experiencing withdrawal multiple times a day.
And if they're pregnant, so is the fetus.
And it's actually those multiple episodes of withdrawal
in the untreated state that cause stress
that lead to sort of premature activation
of the hypothalamic pituitary access
and a cascade of events culminating in free term birth
and low birth weight.
So when we stabilize the pregnant person with medication
is illustrated here on the right.
When you dose methadone correctly,
people don't feel intoxicated,
they don't feel sick, they feel normal.
When we stabilize the intrauterine environment,
we stabilize the pregnant person.
We stabilize the intrauterine environment,
allow the fetus to grow,
normally deliver at term of a normal healthy birth weight.
So the goals of medication pharmacologically
first is to really control withdrawal
and that happens at the lowest dose.
Second is to eliminate cravings
and that happens at a slightly higher dose.
And third is to sort of achieve
what we call an opioid blockade
to prevent the feeling when somebody uses an opioid
on top of their medication.
And so I think of medication
as like a platform for recovery.
We know people who receive medication
are more likely to engage in behavioral care,
engagement in prenatal care,
decreased acquisition and transmission of HIV and Hep C.
And we know that medications are very successful
at preventing overdose and overdose death.
And that is a brief summary of what you know stands behind
these SAMHSA clinical guidance recommendations.
And these were the three
sort of highest level recommendations from this process
that buprenorphine and methadone
are the safest medications for OUD.
Medically supervised withdrawal is not recommended
and switching from one to the other is not recommended.
And all of this is great,
but most people receive no treatment.
In general, only 11% of US adults with a use disorder
report receipt of any treatment in the past year.
A number that is unchanged in decades.
And contrast that to about 85% of people with hypertension
or depression or asthma or diabetes receive care.
So there's a market disconnect
across chronic conditions in the United States.
In pregnancy, treatment is slightly higher,
but still these are data from national level data
only one third of people who have opioid use disorder
and are pregnant reported receipt of any treatment
in the past year.
And there are marked racial inequities in treatment receipt.
The left hand side, these are data from Massachusetts
illustrating that black non-Hispanic patients
had 0.4 times the odds of receiving any medication
for opioid use in pregnancy
compared to white non-Hispanic patients.
And on the right,
this is one program in Philadelphia
and looking at the mean methadone dose.
And whereas white non-Hispanic patients on average
had 145 milligrams of daily dose
black patients had less than 100 milligrams.
So when we put this all together,
you got the universe of pregnant people
with a substance use disorder of whom from national data,
only one third receive any treatment
of whom I didn't show you these data,
but only half actually are receiving medication
of whom like a smaller proportion
are receiving the comprehensive co-located services,
which we think of as the standard of care
and have been described in the literature for 50 years.
So to summarize,
most people quit or cut back use in pregnancy.
Those that don't likely have a use disorder,
people with addiction need and benefit from treatment,
but most people don't receive any treatment
because treatment doesn't always exist.
And what exists may not be welcoming or safe,
especially for pregnant or parenting people.
I have to call out naloxone, I'm sure you all do this,
but naloxone is a critical component
of the public health response to the opioid crisis.
It's high affinity, it reverses an overdose,
it's not scheduled, FDA just made it over the counter.
It only works in people who have an opioid in their system.
It is safe for pets, for children,
for people who are pregnant, for anyone.
But the thing to know is that it's short acting.
And in particular in this age of fentanyl,
people oftentimes need multiple doses.
There's no limit to how much you can give somebody.
And I really like this Missouri opioid state
targeted response, scratching out more heroin,
we need Mo' Heroes.
So let's turn now and talk a little bit
about the fourth trimester.
This is the term to describe the year following birth.
And I like the language of fourth trimester.
It may not be mathematical,
but it's inclusive of sort of the rest of pregnancy.
And this is a time of increased vulnerabilities.
People go from weekly visits with their physician
to maybe one or two visits in the postpartum period.
Care shifts from being focused on the pregnant person
to being focused on the newborn.
And generally speaking,
care shifts away from healthcare settings
and to other services in the public health space
such as WIC, home visiting and et cetera,
things that are actually disconnected
from formal health treatment.
This is a time of insurance churn,
a time of welfare realignment,
and a time of that we kind of withdraw care
in many ways at the most critical time when people need it.
Hence this is a time of a return to use overdose
and overdose death.
This is one of the biggest success stories
I think of 20th century medicine,
which is the market decrease in maternal mortality.
Death rates in the late 1800s approached 5% during birth
and plummeted following the advent of anesthesia,
blood products and antibiotics in particular.
And when I started my training,
the rates of maternal deaths in the United States
was about one in 10,000.
But since then, through the whole course of my career,
rates of maternal death
have only been increasing in the United States.
And this is in contrast
to every other "northern or developed economy nation."
And there are market racial inequities
in maternal deaths in the United States.
Black women are four to five times
more likely to die during birth than white women are
and so are people with opioid use disorder.
There are two studies that look at the odds of death
during the birthing hospitalization
comparing people with OUD to those without,
and they report similar results
somewhere between three and a half to four and a half times
the odds of death during the birthing hospitalization
compared to people without opioid use disorder.
And this risk of death
is really like the tip of the iceberg, right?
When we think about all overdose events,
many overdose events don't end in death.
These are data from Massachusetts
looking at overdose events
prior to delivery through pregnancy and after.
And you can see whereas the overdose events decreased
through the course of pregnancy, they increase postpartum.
In fact their highest at the end of the postpartum period.
And I'm not showing you data,
I've looked at this in a different state
in this second year after birth
and overdose rates remain elevated
compared to pregnancy two years out.
And on the bottom this shows you
sort of the protective benefit of medication
to prevent overdose and also overdose death.
But the unique vulnerabilities postpartum
are not only limited to overdose and overdose death.
Other important things to think about include hepatitis C.
These are data from Ohio looking at rates of hepatitis C
at birth, comparing 2006 to 2015.
And you can see a market increase.
In parts of the state having in 2016 greater than 5%
of all births that are positive for hepatitis C.
Yet we do a really bad job of assessing,
educating and treating people for hepatitis C.
These are two nice studies
by Liz Krantz and others in Pittsburgh
that first look at like sort of hepatitis C knowledge
amongst pregnant people low.
And second, looking at what happens
in our screening pathway.
They had about 400 people that had opioid use disorder
of whom only half got tested for hepatitis C
amongst those who were positive
all got referred for definitive testing,
but not everybody got it.
And then postpartum the referral to an ID
or hepatology doc to begin medication,
only one person actually completed that referral
and that person did not initiate medication.
So we have this sort of like,
this is saying nothing of the newborn testing,
which is equally poor,
but we have this sort of pending sort of tsunami
of liver disease that's related to the opioid crisis
and to our sort of not taking the moment of pregnancy
well enough to engage in prevention.
And the final thing relates to contraception.
We know from the Colorado experiment
that if we can provide people access to larks,
many people will uptake them.
But, and this is also work from Liz Krantz.
In pregnancy when we talk,
this is the sort of cascade of care
of people who had wanted a lark
or expressed interest in a lark during prenatal care.
As you go through this,
like very few people actually ended up
getting the contraceptive option that they wanted.
So finally, let's talk about stigma and discrimination.
So stigma is a term that comes from Goffman
who is a sociologist in the latter half of the 20th century.
It's really sort of the experience
of being deeply discredited or marked
due to one's undesired differentness.
To be stigmatized, to be held in contempt, shunned,
or rendered socially invisible
because of a socially disapproved status.
Stigma is a mark of otherness
due to deviation from social norms.
And people who are pregnant who use drugs
experience sort of like compounded stigmas
around drug use, around addiction
and around motherhood and reproduction.
But in many ways stigma is like a them problem, right?
It's a label, a mark of otherness.
It comes from the word stigmata,
from the crucifixion of Christ.
I prefer the term discrimination
because discrimination is how we treat other people.
And we can do something, it's hard to change social norms,
but it is possible to change our own behaviors.
And one of the ways that we can sort of respond to stigma
and discrimination is by attention to the words that we use.
This is a reference called the "Addictionary"
that's wonderful and worth exploring.
And the general principles
are that we can reflect the worth of dignity of all persons
by using people first language.
When we talk about addiction, treatment and recovery,
we should focus on the medical nature of SUD,
focus on treatment and promote the recovery process
in the words that we use.
We should also avoid perpetuating negative stereotypes
and biases through slang and idioms.
Addiction treatment is a unique space clinically.
It's a space really of mutual mistrust.
And I wanna unpack that a little bit.
I had almost no education
around addiction as a medical student,
but I was taught two things.
One, I was taught when I took an alcohol history
to at least double what the patient told me
to get to the true result.
And the other thing that was thrown around was this phrase,
denial is a symptom of addiction.
Both of those are examples of mistrust
from providers, right?
We're not trusting
what the person in front of us is telling us.
And I would say that our mistrust as providers
is often misplaced, it's rooted in discrimination
and in prejudice.
Patients mistrust us.
And that mistrust in contrast to our mistrust is warranted
in particular by those who've experienced oppression,
in particular by those that have experienced discrimination
in healthcare settings.
In other words, patient mistrust is legitimate
due to historic memory and everyday discrimination.
Now what if I trust a patient I should not have trusted.
The consequences of that misplaced trust are minor.
But what if a patient trusts me
and they shouldn't have trusted me?
The consequences of that misplaced trust can be severe.
And this difference
reflects the power differential of care, right?
The risk and vulnerability of the interaction
it differs incredibly.
And this means that the responsibility
for overcoming mistrust does not rest with the patient,
it rests with us.
And we can address like that mistrust,
we can build trust through clinical discussion.
And these are just some examples of questions
that there's thousands that you can ask that are open-ended
and that give people back the dignity and respect
that they deserve and create space to overcome mistrust.
What's the most important thing to you
about treatment or recovery?
What do you know about different medications?
Do you have fears or concerns from previous experiences?
What do you need to feel safe?
What are you looking for in a provider?
How do you feel your care is going?
Because I think we have to recognize that birth is not safe
in particular for people who use drugs.
And the work that you do that is focused on patient safety,
I would urge you to think about discrimination
as a patient safety issue.
Because we have pathways driver diagrams,
stuff like this that we can address patient safety,
that we can actually tackle discrimination through.
And these are sort of like the two,
I would say most appropriate professional society statements
recently that relate to this space.
And the first is from ASAM
that states that equating a positive toxicology test
with child abuse or neglect
is scientifically inaccurate, inappropriate,
and can lead to an unnecessarily punitive approach,
which harms clinician patient trust
and person engagements in healthcare systems.
An ACOG now a couple of years ago
called out in particular the practice of drug testing
and reflex reporting to child welfare.
And they said that the laws, regulations and policies
that require healthcare practitioners
and human service workers to respond to substance use
and use disorder in a primarily punitive way
require healthcare providers
to function as agents of law enforcement.
In other words, the proximity of policing
is nowhere closer than it is
during the birthing hospitalization.
And these practices, they don't go this far,
but I would say are contrary to the professional ethics
of the healing professions.
So in contrast to that punitive model,
really we need to stand on the dyad, right?
And this is Dr. Winnicott,
he was a pediatrician who then retrained as a psychiatrist.
He's the person who first described the blankie.
The attachment a child has to an object.
And he described really the dyad this way.
There's no such thing as a baby.
If you set out to describe a baby,
you will find you are describing a baby and someone,
a baby cannot exist alone,
but is essentially part of a relationship.
And in the most recent sort of update
the standardization of the clinical definition
of opioid withdrawal in the neonate, the citation is here.
We really tried to embed some foundational principles
into this document and into this definition.
Really these are to serve as guardrails.
And I think as you do the work you do,
centering it around foundational principles
and thinking about guardrails to the work
is critical in keeping things at least in lane.
And these were the four foundational principles
that we agreed upon.
Use disorders a disease required requiring compassionate,
ethical and evidence-based care.
The dyad is the appropriate subject of care.
A diagnosis of withdrawal does not imply harm,
nor should it be used to assess child's social welfare risk
or status, should not be used to prosecute
or punish the mother as evidence
or as evidence to remove and neonate.
And that environmental factors,
family influences and social structures
strongly influence neonatal outcomes
and should be recognized.
And so when I think about the work that we do, right?
Both from a public health and a medical perspective,
the work we want to do
is something that is both evidence-based
and person-centered.
And what this means is evidence-based care
is something that's grounded in science.
And generally speaking, in this topical area,
we exaggerate the harms of illegal substances
and we minimize those of legal ones.
More importantly,
we overstate the importance of the intrauterine environment
and neglect the role of the caregiving environment.
By person-centered care, this means care that's ethical,
that's grounded in human rights,
that's ground that recognizes reproductive health
as a human right.
And in particular acknowledges
those reproductive justice values,
specifically the right to raise children
in safe and sustainable environments.
Person-centered care also means supporting autonomy
and maternal subjectivity
and decision making surrounding pregnancy.
Which means as providers we must remain attuned
to the unique demands that we,
that society places on pregnant and parenting people
on their bodies and on their minds.
And with that, thank you.
This is the information here for the substance use form line
that I share in the...
It's an underutilized service, it's rant funded
and it's free to any provider
anywhere in the United States to call
and get help with anything related to drugs.
So thank you.
With that, I'm gonna stop sharing
and I hope that there's some time
for questions and et cetera.
All right.
-[Marge] Well, I'll start. -[Woman] Me too, thank you.
So hopefully Marge is gonna jump in.
I see her, she's ready to go.
[Dr. Terplan] Oh, hey Marge.
[Marge] Thank you so much.
I wish you could have come here in person
and I just know somebody's asking
for the warm line information,
so maybe I can put that...
I have a copy and I'll put it in the chat.
And just as I was so happy that you could come and talk
because we've been treating people for a very long time
and as we've moved people into community-based care,
we've tried to keep people in their community
and it's a relatively low volume.
You saw those pieces,
the numbers that Michelle presented earlier
between COVID and everything, our turnover.
And so we really lost a huge amount
of this sort of statewide knowledge.
And then at the same time, sort of CAPTA came in
and these other reporting things
that made it very difficult
to like kind of level set a lot of the things
that you talked about.
And I'm curious about whether or not
that's something that's unique to hear
or if we've seen a change over relatively recently.
I feel like we had made a lot of inroads about stigma
and how we talked to people that sort of backslid
and I'm just curious about if that was just us
or if that was nationally
and strategies people have used to recover from that.
[Dr. Terplan] Yeah, thank you.
I mean, overwhelmingly,
I think like Vermont is functioning at a higher level
in this space than other states are.
But we observed sort of the same thing
in Maryland following CAPTA CARA,
that we had an anonymous reporting mechanism
in child welfare before that it actually opened.
I was really skeptical of it,
but I was delighted it opened up
all these resources for people
that were unrelated to addiction, housing, transportation,
stuff like this that I felt was somewhere was even unfair
that only people who use drugs got access to those things
and they should have been more universalized.
And then with the most recent captor reauthorization
really shut that down and shunted everybody.
There was no longer that sort of alternative reporting
mechanism and access.
CAPTA was supposed to have been reauthorized
in the last congressional session.
And it was held up at the last minute really by a couple of,
well, one Texas senator in particular
who wanted that transgender care
be labeled as child abuse.
So one is hopeful that it's overdue for reauthorization.
So one's hopeful that it will be this time,
but I think some of those kinda anti-trans motivations
might come into play again.
But the proposed new CAPTA
actually mirrors what you're already doing.
One is that notifications are anonymous
and not to child welfare but to public health agencies
who is changing the language of plans of safe care
to family care plans.
So acknowledging a family,
which is a big thing language-wise.
And two, removing
sort of this oftentimes misleading language around safety.
Right now there's market heterogeneity across states.
There are some states that are doing some really,
I think incredible work legislatively.
One would be the State of Washington.
There's something called House Bill 1227,
which is going into effect in a couple of months,
which really this is about the standards
around child removal uses ICWA,
the Indian Child Welfare Act standard
and applying it to all children.
So removals only happen if there's a threat of imminent arm.
And for drugs it's unclear what the drug use
leading to the threat
so that there has to be a causal connection
between something and the threat.
Second piece is that the court must consider
the risks of removal to the child and to the parent,
not just the risks of remaining together.
And the third is that they're parents
have to be given preventative services
prior to removals happening.
So that's actually to some extent like this incredibly,
I think like a model that other states could follow.
We'll see what happens with ICWA in the Supreme Court
'cause there was a hearing around that.
But at least anyway, that standard was kind of mapped out.
The other thing,
and is I urge anyone on this call to do this,
we have I think a posity in the published literature
on how useful plans of safe care can be,
not just in preventing removals,
but in supporting recovery and parenting and communities.
I know, I mean, it's a tool just like anything.
It's not categorically good or bad, depends how we use it.
Some people are using it really well
and some people are using it superficially and poorly.
But those people that are using it well,
which it sounded like, I mean for the little bit I know
like in Vermont it's being used well.
It can be a super helpful tool.
So I would encourage you
and those of you that have access to those data
to share how it's used well,
how it helps keep families together,
how it helps support recovery,
how it helps kind of communities remain intact.
So it's not exactly answering your question,
but I share with you like at some degree a backsliding,
but it's contrasted with like on the one hand
some excellent legislation in the State of Washington
and some other things here and there.
And also as we see
like an increasingly punitive environment,
state environment in particular for reproductive health
in particular in certain places.
And many of us are very concerned
about what those abortion restrictions and criminalization
are going to mean in general,
but also for pregnant and parenting people who use drugs.
[Marge] Thanks, always a pleasure to hear your thoughts
and yeah, I think looking up that legislation
would probably help us a lot as a guidepost.
So thanks.
[Dr. Terplan] And I'm happy to put you in touch
with the advocates who really were behind that bill
in Washington State because it came from lawyers.
(Dr. Terplan laughs)
Not from doctors.
(Dr. Terplan laughs)
Other questions?
Oh, somebody has their hand up.
Yeah.
[Woman] Thanks so much.
I don't usually put my hand up,
but I wasn't sure if that was the procedure this morning.
Thank you so much for this talk.
I have a lot of thoughts.
The whole frame is so lovely and helpful
and also just thanks for acknowledging Vermont's work
in this space.
We do have some pretty remarkable heroes on this call,
on this Zoom.
So my question for you,
I loved when you said very powerfully
that postpartum supports are sort of uncoupled
from medical care.
And what I thought about in that setting,
I'm a pediatrician, I think the pediatric piece
is pretty connected to those public health programs
you mentioned like WIC home visiting,
but you framed it in the context
of the substance use disorder.
And what that sparked for me is challenges
with treatment providers
not working in the public health prevention newborn space.
And that's nothing about our obstetrical care,
it's about the community-based treatment providers.
I'm curious if you have any advice for us
about how do we get those tried and true treatment providers
who are really passionate about their work
to understand the broader context
of public health postpartum supports
that are like really solid in Vermont
and have a nice uptake.
We have a bit of a chasm there.
[Dr. Terplan] Yeah, I mean,
I would also add though that before I answer that,
that obstetricians and people,
the whole like universe of people who work,
who intersect with birth are less aware
than most pediatricians that these services
such as home visiting early headstart exist,
much less how to access that care.
And I say this 'cause one of the motivations
that health professionals have to report
a family to child welfare is from the recognition
that this is a family that has needs,
I don't know how to get those needs to them,
but there's this agency that can.
Now that agency can or cannot,
like your agencies are better than other states,
but there's many places where child welfare agencies
are primarily agencies of surveillance.
They can mandate services,
but they don't themselves provide those services.
And I contrast that around addiction
with like how we deal with folks in the cancer center.
Somebody has cancer, they're seeing in the cancer center,
they're having difficulty with transportation.
The cancer center provides,
can help assist in providing transportation.
The cancer center can even sometimes
provide counseling to children
whose one of two parents like has a maybe a fatal diagnosis.
And so we take as a health system,
we take that sort of social responsibility
for certain illness states such as cancer, well-resourced,
but we don't for other illness states such as addiction.
And that reflects a value or a devalue.
So I think there are ways to try to connect some...
We have social workers
who are embedded in birthing hospitals
who sometimes not always where you are,
but whose primary job is actually reporting people
for social service receipt
rather than providing those services
themselves as they might
if they worked in a different part of the hospital.
So that's worth sort of reflecting back and unpacking.
In terms of the drug treatment system.
I mean, it's historical, right?
It's only recently and in completely
that addiction is incorporated
within formal traditional healthcare systems.
So the system we have emerged
because of neglect from normal dominant healthcare
and it's a funny system, right?
We've got OTPs, highly regulated methadone
with daily observed dosing.
You have residential programming,
you've got partial hospitalization,
you have intensive outpatient,
you've got stuff that's organized that no other illness,
no other mental illness either organizes things this way.
It's this historical structure that generally speaking
has been disconnected from healthcare.
And so it has its own culture, it has its own thing.
And on the hold it was really built to take care of men,
not to take care of people,
women and other people who are capable of becoming pregnant,
much less welcoming to people who might be parenting.
So there's a lot of work that kinda needs to be done
to make a more welcoming environment in that space.
But I think some of it is to connect
like these things better.
What is it 7% of people
who are eligible for early headstart in the United States
receive even a referral to early headstart.
I would say there's got a minority of obstetrician,
gynecologists even know what early headstart is
much less that it starts in pregnancy.
There are some examples of things that are more integrated.
I think some nurse family partnerships
or family nurse partnerships and things like that.
But those that tend to have a pretty high threshold
for engagement as opposed to sort of like a low threshold,
which works a whole lot better for most of the people.
So what do we do with the addiction treatment services?
We engage with them, we bring them into the conversations,
we invite them to the tables such as this table here today.
We think about the services that they're not providing
and how can we go there to provide those services
in particular sort of reproductive healthcare.
Is there a way to embed like or period,
like either go to the clinic and provide like contraception
or like make the transfer back and forth.
So I think it's really through the lens
of sort of collaborative public health work
and moving towards sort of integrated service delivery.
And somewhere, I will say like this,
the addiction treatment system is absurd
and really the model is primary care, right?
Integrated, comprehensive co-located services.
Why every FQHC should provide,
pap smears should provide,
contraception should provide addiction treatment.
[Woman] So, great we do have one pediatric practice
in Vermont that provides treatment services for parents,
which is also a model that really works,
but it takes an enormous commitment and also a willingness
to go beyond your traditional role, right?
As a pediatric provider, which has some trepidation.
Thank you so much.
[Dr. Terplan] Yeah, there's a real role
the federal agencies in this, which they have not done.
Like to guidance from the top HRSA,
like laying out like sort of requirements
for continuation of the financial benefit of being an FQHC
that's tied to really holistic service delivery.
But reflects a devalue of women's health that it isn't.
And we need to call it out as such.
[Woman] Oh, my goodness.
This was a wonderful thought and discussion.
Yay.
[Dr. Terplan] Oh wait, we're out of time.
I'm sorry, so sorry.
[Woman] But if anyone has any additional questions
or comments, certainly reach out to our team,
send us an email.
We certainly can help get some comments back and forth
and answer any questions that come up.
And we're really...