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[Woman] All right, well,
I love a good question.

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All right, so I also wanna take a minute

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and thank you so much.

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I think the one wonderful thing
about doing a Zoom meeting,

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although I remember how wonderful it was

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to have these conferences in person,

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is that we are able to really bring about

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some wonderful national
leaders in the fields

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to come and talk to us,
as well as access people

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that may not be able to
travel to Chatham County.

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So I'm excited to introduce
Dr. Mishka Terplan,

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who is a board certified OBGYN

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as well as addiction medicine physician.

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Primarily his clinical research,

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public health and advocacy interests

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are in the intersections of reproductive

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and behavioral health.

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He's the medical director at
Friends Research Institute

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and adjunct faculty

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at the University of
California, San Francisco,

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where he is a substance
use warmline clinician

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for the National Clinician
Consultation Center.

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Dr. Terplan has active grant funding

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and has published extensively
on health inequities,

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discrimination and access to treatment.

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He's spoken at local high schools

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and before the United States Congress

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and has participated in federal

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and international expert
panels primarily on issues

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related to gender
reproduction and addiction.

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And many of us were lucky
enough to hear several talks

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by Dr. Terplan over the
last six months or so,

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and we were so excited that he was willing

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to take up our offer to
come and speak today.

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So I am going to turn it over.

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[Dr. Terplan] Great, well, thank you.

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Yeah, thank you so much for inviting me

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and thank you so much for
all of the work that you do

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and for really sharing
that data that I love.

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I really want to get somewhere selfishly

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more out of talks like this
if I can walk away with more.

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And so hence it's what you
shared in the beginning.

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And I do hope that we have time

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for some questions and
answers after this as well.

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Some of this is similar

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to the talks that you just mentioned,

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but I really was asked
to talk about screening,

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assessing and treating

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pregnant women with
substance use disorder.

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I have no disclosures.

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And I want to begin by really
framing this conversation

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as if on a three-legged stool,

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like one leg being epidemiology,
the other being a history

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and the third really being
ethics in human rights.

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So first, this is a slide
from the good mocker

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that talks about the
reproductive health life course.

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The typical woman spends five
years pregnant postpartum

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or trying to get pregnant

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and 30 years trying to avoid pregnancy.

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So although we today are talking

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about the specific window
of time of pregnancy,

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I want to acknowledge

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we put most of our
public health programming

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into that period,

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oftentimes at the neglect of the rest

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of the reproductive health life course.

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Second, when we talk
about drugs and pregnancy,

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we are really in the shadow
of the crack baby hysteria.

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And I think it's important to remember

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this time as well as remember
the science of the time.

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And this was a period of time

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in which there was like
a cross public media

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catastrophic stories

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that were echoed to a large
extent in the early science,

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science that was in retrospect

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conducted without adequate masking,

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without adequate control groups

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with poor sorts of measurements

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and this narrative of harm.

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This idea that these infants
were irreparably damaged

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and were going to consequentially bankrupt

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the public educational system,

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that narrative was also highly racialized.

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And in many ways when people talk

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about "the cracked baby,"

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we're really talking about
where the war on drugs

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intersected with the war on abortion.

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And those sort of racialized

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and sort of punitive
reproductive health policies

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are still very much active today.

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And the third leg of the stool

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really follows the very influential work

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of primarily black feminists

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in particular that formulated the movement

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and the perspective of
reproductive justice.

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Sort of moving from reproductive
health is a human right,

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which is understood as
the right to have a child

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or not have a child,

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but recognizing that human rights

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somewhere are aspirational

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and if you lack access to the right,

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it's not meaningless, but
it's not what we think it is.

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So everyone has the right to vote,

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but restrictions at the ballot box

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make that right unrealizable.

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Reproductive health is a human right,

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but without access

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to the means of expressing
your reproductive autonomy,

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that's problematic.

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And so the space of social justice

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is where you make, you
bring the right to reality

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and hence the third part of
the reproductive justice value.

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Not just the right to have
a child or not have a child,

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but the right to parent children in safe

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and healthy environments

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that is radical key and transformational.

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So I want to hold these
reproductive justice values

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as we walk sort of through
the rest of this talk.

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So I wanna begin with this question,

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why would someone who's
pregnant use drugs?

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And I wanna briefly discuss
the science of addiction

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and the science of treatment

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in order to in a way problematize this

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as not being the proper question to ask.

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Because in the United States
for the last 100 years,

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drug use is common.

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Most people use drugs.

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These are the most recent data

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from the national survey
of drug use and health.

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The bottom one on the right

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is looking at illicit substance use only,

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and this is past year.

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And on the top, this is past
month substance use in general,

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which includes alcohol,
tobacco products and vaping.

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And you can see how
many millions of people

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like use substances
either monthly or yearly

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in the United States.

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And most people who use drugs

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do not become addicted to them.

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On the left these are data from the 1990s

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also national level data.

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What they showed in that analysis

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has been seen over and over again since.

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And you might have heard people talk

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about how "addictive a substance is."

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And that oftentimes is from data like this

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where you calculate a proportion.

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In the denominators the number of people

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who've used a drug in the past year

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and the numerators, the number

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who meet criteria for a use disorder.

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And when you do that,

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you see about 30% of people
who've used a tobacco product,

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meet criteria for a nicotine use disorder.

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About 25% of people who used heroin

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meet criteria for an opioid use disorder.

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And somewhere around 10% of people

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who've used cannabis in the past year

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meet criteria for a cannabis use disorder.

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And this surprises people.

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Most people think that
anyone who's used an opioid

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has an addiction to it.

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And some people think that
nobody who uses cannabis

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has an addiction to it.

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So there's a large science

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around vulnerabilities to addiction

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that's illustrated very simplistically

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with this cartoon from NIDA.

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There's a biological or genetic substrate

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obviously for all organisms.

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And there are some associations

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with the development of addiction

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perhaps capture at best 30% of addiction.

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And then there's this larger
bucket of environment,

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which means things like we know

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the earlier somebody uses a substance,

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the more likely they are
to develop an addiction.

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And in particular environment also means

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the experience of adverse
childhood experiences

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as well as other forms of childhood

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or adolescent or adult trauma.

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And there is an association

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between the experiences of trauma

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and the development and using drugs

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and the development of a use disorder.

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So the American Society
of Addiction Medicine

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several years ago, reconceptualized

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the definition for addiction.

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And they state that it's a
treatable chronic medical disease

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involving complex interactions

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among brain circuits,
genetics, the environment

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and in individual's life experiences.

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People with addiction use substances

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or engage in behaviors
that become compulsive

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and often continue despite
harmful consequences.

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Prevention efforts and
treatment approaches

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are generally as successful

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as those for other chronic conditions.

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And clinically we use the DSM criteria

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to diagnose use disorder.

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And you'll see these are
the 11 items that are used.

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They are primarily
grouped under behaviors,

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loss of control or use
despite negative consequences.

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So taken really simply,

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the simplest way that I define addiction,

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it's a brain centered condition.

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It affects the whole body,

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but the visible symptoms are behaviors.

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So one of the reasons we say

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addiction is a chronic condition

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is because it behaves like
other chronic conditions.

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This article was
published in 2001 I think,

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and it was highly influential.

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And in this they sort of
grouped what they called relapse

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a year following diagnosis
for different conditions.

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And you can see here so for asthma relapse

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would be you get diagnosed with asthma,

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you're given an inhaler and you
end up in the emergency room

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with an exacerbation.

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Or for hypertension,

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you're diagnosed with high blood pressure,

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started on medication

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and your blood pressure either
stays the same or increases.

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And for addiction

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it would be you're
diagnosed with use disorder,

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you're initiating non-treatment
and you return to use

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or you continue to use.

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And the rates of this "relapse"

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are similar across illness states.

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In other words, addiction's
a chronic condition

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because it behaves like
other chronic conditions.

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But the goal of addiction
treatment is not more treatment.

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The goal is recovery.

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And this is SAMHSA's working
definition of recovery.

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It's holistic, it crosses
a multiplicity of domains,

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it's much more than abstinence.

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It's about integrity,
connection, purpose, serenity,

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and it's perfectly compatible
with the use of medications.

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So let's return to that initial question.

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The question isn't why would somebody use

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drugs in pregnancy?

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The question, because
most people use drugs,

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some of whom get pregnant.

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The question is, what happens
when people who use drugs

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get pregnant and stay pregnant?

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These are data from the national survey

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of drug use in health
looking at past month use,

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contrasting people who are not pregnant

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versus those that are
stratified by trimester

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and separated by substance.

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And you can see people
who are not pregnant

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are far more likely to
report use of any substance.

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Use decreases across pregnancy
and it differs by substance.

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People cut back alcohol the
most, cigarettes the least,

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and elicit substances
somewhere in between.

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So I look at these data and to
me they support the statement

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that all pregnant people are motivated

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to maximize their health and
that of their baby to be.

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Some people can stop using
substances, others can't,

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those that can't likely
have a use disorder.

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In many ways continuation of
substance use in pregnancy

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is pathognomonic for
having a use disorder.

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So when we're talking
about this topical area,

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we're not talking about
people who start using drugs

265
00:13:55,800 --> 00:13:58,410
in pregnancy, I've never seen that.

266
00:13:58,410 --> 00:14:00,750
We're talking about where
the reproductive health life

267
00:14:00,750 --> 00:14:03,210
course, getting pregnant,
staying pregnant,

268
00:14:03,210 --> 00:14:04,680
delivering an infant

269
00:14:04,680 --> 00:14:07,380
intersects with an addiction life course.

270
00:14:07,380 --> 00:14:09,660
Use proceeding to misuse,

271
00:14:09,660 --> 00:14:11,640
and then the development of addiction

272
00:14:11,640 --> 00:14:12,960
and all of this happening

273
00:14:12,960 --> 00:14:16,593
in a specific period of time of pregnancy.

274
00:14:18,690 --> 00:14:22,020
So we're gonna walk
through what's assessment,

275
00:14:22,020 --> 00:14:25,200
what's treatment, talk
about the fourth trimester

276
00:14:25,200 --> 00:14:30,200
and focus at the end on
stigma and discrimination.

277
00:14:30,900 --> 00:14:34,410
So I want to mark a distinction in terms.

278
00:14:34,410 --> 00:14:36,120
When I talk about screening,

279
00:14:36,120 --> 00:14:38,880
I'm talking about a verbal assessment

280
00:14:38,880 --> 00:14:42,090
oftentimes using a validated instrument.

281
00:14:42,090 --> 00:14:43,980
And when I'm talking about testing,

282
00:14:43,980 --> 00:14:47,760
I'm talking about looking
at a biological matrix

283
00:14:47,760 --> 00:14:50,880
i.e urine or blood or meconium or whatever

284
00:14:50,880 --> 00:14:54,840
for the presence or
absence of drug metabolites

285
00:14:54,840 --> 00:14:57,570
or parent compounds.

286
00:14:57,570 --> 00:15:01,020
So there are two types of drug tests.

287
00:15:01,020 --> 00:15:03,690
One is what we call presumptive.

288
00:15:03,690 --> 00:15:08,040
This is like based upon
like an ELISA immunoassay,

289
00:15:08,040 --> 00:15:13,040
the technology, this is
like the rapid COVID test.

290
00:15:13,260 --> 00:15:17,700
It's often used, the results
are rapidly obtained,

291
00:15:17,700 --> 00:15:20,400
the results are reported in binary fashion

292
00:15:20,400 --> 00:15:22,560
and it's inexpensive.

293
00:15:22,560 --> 00:15:26,730
Definitive tests are
more like the COVID PCR.

294
00:15:26,730 --> 00:15:30,750
They use a different technology
that actually quantifies

295
00:15:30,750 --> 00:15:34,710
the exact compound and the
quantity of the compound

296
00:15:34,710 --> 00:15:36,060
oftentimes expressed

297
00:15:36,060 --> 00:15:38,823
as something like nanograms per deciliter.

298
00:15:40,350 --> 00:15:43,410
Presumptive tests the point oftentimes

299
00:15:43,410 --> 00:15:46,320
but not exclusively point of care tests

300
00:15:46,320 --> 00:15:50,790
yield a poor quality piece of information.

301
00:15:50,790 --> 00:15:53,610
One, there's a bias built into it,

302
00:15:53,610 --> 00:15:57,780
substances metabolize at different rates.

303
00:15:57,780 --> 00:16:00,420
Therefore things that
metabolize more quickly

304
00:16:00,420 --> 00:16:03,000
are less visible in drug tests.

305
00:16:03,000 --> 00:16:05,100
And things that stick around longer

306
00:16:05,100 --> 00:16:07,150
like cannabinoid metabolites

307
00:16:08,070 --> 00:16:10,440
are far more likely to be present.

308
00:16:10,440 --> 00:16:14,430
So there's a bias in substance metabolism

309
00:16:14,430 --> 00:16:18,093
that is reproduced in drug test results.

310
00:16:19,200 --> 00:16:21,750
Also, there's multiple substances.

311
00:16:21,750 --> 00:16:24,000
This is a partial list here on the left

312
00:16:24,000 --> 00:16:26,130
that can cause a false positive

313
00:16:26,130 --> 00:16:29,610
and presumptive test
due to cross-reactivity

314
00:16:29,610 --> 00:16:31,080
with the immunoassay.

315
00:16:31,080 --> 00:16:34,890
Many of these are substances
we prescribe during pregnancy

316
00:16:34,890 --> 00:16:37,143
or during the birthing hospitalization.

317
00:16:38,370 --> 00:16:42,390
These tests are also
subject to true positives

318
00:16:42,390 --> 00:16:45,060
that can be misinterpreted.

319
00:16:45,060 --> 00:16:48,150
These are three articles and
there's a fourth forthcoming

320
00:16:48,150 --> 00:16:53,150
that document positive newborn
drug tests for fentanyl

321
00:16:53,220 --> 00:16:55,140
when the fentanyl exposure

322
00:16:55,140 --> 00:16:58,890
was the epidural use during
the birthing hospitalization

323
00:16:58,890 --> 00:16:59,883
or during labor.

324
00:17:01,290 --> 00:17:02,490
So if we don't know this,

325
00:17:02,490 --> 00:17:06,570
we will misattribute the
positive fentanyl test

326
00:17:06,570 --> 00:17:08,523
to something that it is not.

327
00:17:10,470 --> 00:17:15,210
And finally, physicians do a very bad job

328
00:17:15,210 --> 00:17:18,570
at interpreting drug test results.

329
00:17:18,570 --> 00:17:21,630
This is one study that uses
on the right hand side,

330
00:17:21,630 --> 00:17:25,230
this is the test, there were seven items.

331
00:17:25,230 --> 00:17:26,640
I would sort of ping this

332
00:17:26,640 --> 00:17:30,550
at the sort of medical student
level and it was administered

333
00:17:31,620 --> 00:17:35,490
at the largest Canadian
medical conference.

334
00:17:35,490 --> 00:17:38,850
And no physician got 100%.

335
00:17:38,850 --> 00:17:41,130
In fact the average was about 50%

336
00:17:41,130 --> 00:17:43,830
in people who said they
used urine drug testing

337
00:17:43,830 --> 00:17:45,540
as part of their clinical practice

338
00:17:45,540 --> 00:17:48,993
scored one point lower
than people who did not.

339
00:17:52,410 --> 00:17:54,750
And every state is different.

340
00:17:54,750 --> 00:17:56,373
But at the federal level,

341
00:17:57,630 --> 00:18:02,630
CAPTA is clear that drug testing
is not required by CAPTA.

342
00:18:03,150 --> 00:18:04,710
Having a positive drug test

343
00:18:04,710 --> 00:18:08,490
is not the same as being
affected by substance exposure.

344
00:18:08,490 --> 00:18:11,370
And a demonstrable health impact is needed

345
00:18:11,370 --> 00:18:16,143
beyond a drug test is needed
for a report or a notification.

346
00:18:19,200 --> 00:18:23,430
So professional society
recommendations are similarly clear.

347
00:18:23,430 --> 00:18:27,510
Drug testing is not an appropriate
measurement of addiction.

348
00:18:27,510 --> 00:18:30,000
A drug test result, a positive result,

349
00:18:30,000 --> 00:18:33,390
is evidence of exposure,
not indication of health,

350
00:18:33,390 --> 00:18:35,160
ill health, injury or harm

351
00:18:35,160 --> 00:18:38,940
and not part of the
AAP discharge criteria.

352
00:18:38,940 --> 00:18:42,090
The American Society of
Addiction Medicine goes further

353
00:18:42,090 --> 00:18:45,390
and says that definitive
testing is required

354
00:18:45,390 --> 00:18:48,900
when the results informed
decisions with major clinical

355
00:18:48,900 --> 00:18:52,080
or non-clinical implications
for the patient.

356
00:18:52,080 --> 00:18:54,510
I would say that's any drug test

357
00:18:54,510 --> 00:18:57,150
during the birthing hospitalization.

358
00:18:57,150 --> 00:19:01,320
And everyone is clear that
if you are going to drug test

359
00:19:01,320 --> 00:19:03,450
consent is required.

360
00:19:03,450 --> 00:19:07,650
In contrast screening
is what's recommended.

361
00:19:07,650 --> 00:19:11,433
And it should be voluntary
and it should be universal.

362
00:19:12,780 --> 00:19:15,540
There are two studies that compare

363
00:19:15,540 --> 00:19:18,120
different screening instruments.

364
00:19:18,120 --> 00:19:22,680
And the big takeaway is
that all work decently

365
00:19:22,680 --> 00:19:24,240
and you should just utilize

366
00:19:24,240 --> 00:19:26,917
really what's ever already in the EHR.

367
00:19:28,320 --> 00:19:31,410
But I would add to this a little bit

368
00:19:31,410 --> 00:19:36,410
that we should preface screening
with permission asking.

369
00:19:37,860 --> 00:19:41,190
This reinforces the voluntaries.

370
00:19:41,190 --> 00:19:43,500
Is it okay if I ask you some questions

371
00:19:43,500 --> 00:19:46,230
about smoking, alcohol and other drugs?

372
00:19:46,230 --> 00:19:50,103
And if people say no, then we don't ask.

373
00:19:51,240 --> 00:19:53,160
One nice thing about prenatal care

374
00:19:53,160 --> 00:19:56,520
is that it happens at multiple episodes.

375
00:19:56,520 --> 00:19:58,980
And all of behavioral health work

376
00:19:58,980 --> 00:20:02,280
rests upon a strong therapeutic alliance.

377
00:20:02,280 --> 00:20:06,390
So asking for permission and
respecting what somebody says

378
00:20:06,390 --> 00:20:11,390
goes a long way in establishing
that therapeutic alliance.

379
00:20:11,760 --> 00:20:14,310
And the reason for
screening is that we can,

380
00:20:14,310 --> 00:20:16,680
from a population health perspective,

381
00:20:16,680 --> 00:20:21,153
put people, organize the
population into this risk pyramid.

382
00:20:22,110 --> 00:20:23,910
If below risk, right?

383
00:20:23,910 --> 00:20:25,950
Then we need to not ignore it

384
00:20:25,950 --> 00:20:28,560
but give positive reinforcement.

385
00:20:28,560 --> 00:20:31,830
Moderate risk is the place
of the brief intervention.

386
00:20:31,830 --> 00:20:34,770
And for people with the
disease of addiction,

387
00:20:34,770 --> 00:20:36,153
they need treatment.

388
00:20:40,110 --> 00:20:41,193
So treatment.

389
00:20:42,450 --> 00:20:46,050
The gold standard for substance
use disorder treatment

390
00:20:46,050 --> 00:20:50,940
in pregnancy is comprehensive
co-located service delivery,

391
00:20:50,940 --> 00:20:52,770
providing addiction treatment,

392
00:20:52,770 --> 00:20:56,010
which is medication plus
or minus behavioral care

393
00:20:56,010 --> 00:21:00,870
in the same time and
space as prenatal care.

394
00:21:00,870 --> 00:21:03,360
And the benefits of addiction treatment

395
00:21:03,360 --> 00:21:07,110
plus prenatal care date back,

396
00:21:07,110 --> 00:21:09,810
the evidence dates back to the 1970s.

397
00:21:09,810 --> 00:21:11,400
And this is not the first article,

398
00:21:11,400 --> 00:21:13,740
but this is my favorite article.

399
00:21:13,740 --> 00:21:15,900
And this is from Loretta Finnegan

400
00:21:15,900 --> 00:21:19,980
in what became the MATER
clinic in Philadelphia.

401
00:21:19,980 --> 00:21:23,250
And these are the five categories

402
00:21:23,250 --> 00:21:25,770
of analysis that she has here.

403
00:21:25,770 --> 00:21:29,160
And she looked at sort of a
composite obstetric complication

404
00:21:29,160 --> 00:21:31,680
and the far right is low birth weight.

405
00:21:31,680 --> 00:21:34,290
And some things stand out, right?

406
00:21:34,290 --> 00:21:36,600
People with untreated opioid use disorder

407
00:21:36,600 --> 00:21:40,260
who did not access prenatal
care had low birth weight,

408
00:21:40,260 --> 00:21:43,230
almost 50% had a low birth weight.

409
00:21:43,230 --> 00:21:47,040
But people who got
treatment and prenatal care

410
00:21:47,040 --> 00:21:49,530
had a low birth weight of almost 20%,

411
00:21:49,530 --> 00:21:51,660
which is much more similar

412
00:21:51,660 --> 00:21:55,530
to the population of people
without a use disorder

413
00:21:55,530 --> 00:21:58,323
than it is to the people
with untreated disease.

414
00:22:00,150 --> 00:22:02,940
And this sort of observation

415
00:22:02,940 --> 00:22:06,420
has been seen in a
multiplicity of other studies

416
00:22:06,420 --> 00:22:11,420
since the idea that healthy
mother equals healthy baby.

417
00:22:11,700 --> 00:22:16,080
Part of prenatal care is
to optimize maternal health

418
00:22:16,080 --> 00:22:18,900
via chronic disease management.

419
00:22:18,900 --> 00:22:21,600
These are data from Massachusetts

420
00:22:21,600 --> 00:22:23,910
separating people without addiction,

421
00:22:23,910 --> 00:22:26,460
treated addiction, untreated addiction.

422
00:22:26,460 --> 00:22:29,520
And you can see for every
single one of these categories,

423
00:22:29,520 --> 00:22:31,800
the population health burden

424
00:22:31,800 --> 00:22:36,300
is in the bucket of those
with untreated addiction.

425
00:22:36,300 --> 00:22:38,070
And people with treated disease

426
00:22:38,070 --> 00:22:40,290
have birth outcomes that are similar to

427
00:22:40,290 --> 00:22:44,913
or at times identical to
people without addiction.

428
00:22:46,800 --> 00:22:49,020
So what about medication?

429
00:22:49,020 --> 00:22:54,020
Why use an opioid to treat
an opioid use disorder?

430
00:22:55,860 --> 00:22:57,900
This is one of the first articles

431
00:22:57,900 --> 00:22:59,930
written about heroin addiction

432
00:22:59,930 --> 00:23:02,733
as the first article
to describe methadone.

433
00:23:04,050 --> 00:23:06,000
And it still stands to this day,

434
00:23:06,000 --> 00:23:09,960
I think as one of the best
articles written about addiction,

435
00:23:09,960 --> 00:23:13,410
not by people who had
themselves at addiction

436
00:23:13,410 --> 00:23:15,723
that describes the illness state.

437
00:23:16,590 --> 00:23:19,260
And you can see here
on the left hand side,

438
00:23:19,260 --> 00:23:21,810
we'd use slightly different words today,

439
00:23:21,810 --> 00:23:26,790
but initially when people
begin to use opioids,

440
00:23:26,790 --> 00:23:30,450
they feel high or we'd say euphoric now,

441
00:23:30,450 --> 00:23:32,850
but rapidly over time

442
00:23:32,850 --> 00:23:37,260
people no longer experience
euphoria or intoxication.

443
00:23:37,260 --> 00:23:40,770
They're spending more and more
of their time in a sick state

444
00:23:40,770 --> 00:23:42,660
or a withdrawal state.

445
00:23:42,660 --> 00:23:46,380
And when they're barely feeling normal.

446
00:23:46,380 --> 00:23:50,460
So in many ways you've
probably heard how addiction,

447
00:23:50,460 --> 00:23:55,460
is sort of hijacks the
reward pathway, not untrue,

448
00:23:55,500 --> 00:23:57,240
but really addiction

449
00:23:57,240 --> 00:24:01,710
kinda goes from being a
reward seeking behavior

450
00:24:01,710 --> 00:24:03,570
when it becomes a chronic condition,

451
00:24:03,570 --> 00:24:06,483
it's really a relief seeking behavior.

452
00:24:08,070 --> 00:24:11,970
And when somebody is
untreated opioid use disorder,

453
00:24:11,970 --> 00:24:14,650
they're using opioids multiple times a day

454
00:24:16,350 --> 00:24:20,400
and they're experiencing
withdrawal multiple times a day.

455
00:24:20,400 --> 00:24:23,460
And if they're pregnant, so is the fetus.

456
00:24:23,460 --> 00:24:26,760
And it's actually those
multiple episodes of withdrawal

457
00:24:26,760 --> 00:24:31,170
in the untreated state that cause stress

458
00:24:31,170 --> 00:24:33,720
that lead to sort of premature activation

459
00:24:33,720 --> 00:24:36,060
of the hypothalamic pituitary access

460
00:24:36,060 --> 00:24:39,900
and a cascade of events
culminating in free term birth

461
00:24:39,900 --> 00:24:42,630
and low birth weight.

462
00:24:42,630 --> 00:24:46,440
So when we stabilize the
pregnant person with medication

463
00:24:46,440 --> 00:24:48,630
is illustrated here on the right.

464
00:24:48,630 --> 00:24:51,540
When you dose methadone correctly,

465
00:24:51,540 --> 00:24:53,370
people don't feel intoxicated,

466
00:24:53,370 --> 00:24:56,370
they don't feel sick, they feel normal.

467
00:24:56,370 --> 00:25:00,150
When we stabilize the
intrauterine environment,

468
00:25:00,150 --> 00:25:01,830
we stabilize the pregnant person.

469
00:25:01,830 --> 00:25:04,650
We stabilize the intrauterine environment,

470
00:25:04,650 --> 00:25:06,180
allow the fetus to grow,

471
00:25:06,180 --> 00:25:10,173
normally deliver at term of a
normal healthy birth weight.

472
00:25:11,520 --> 00:25:15,270
So the goals of medication
pharmacologically

473
00:25:15,270 --> 00:25:18,600
first is to really control withdrawal

474
00:25:18,600 --> 00:25:20,190
and that happens at the lowest dose.

475
00:25:20,190 --> 00:25:22,830
Second is to eliminate cravings

476
00:25:22,830 --> 00:25:25,380
and that happens at a
slightly higher dose.

477
00:25:25,380 --> 00:25:28,560
And third is to sort of achieve

478
00:25:28,560 --> 00:25:31,110
what we call an opioid blockade

479
00:25:31,110 --> 00:25:35,790
to prevent the feeling when
somebody uses an opioid

480
00:25:35,790 --> 00:25:37,563
on top of their medication.

481
00:25:38,520 --> 00:25:40,350
And so I think of medication

482
00:25:40,350 --> 00:25:43,260
as like a platform for recovery.

483
00:25:43,260 --> 00:25:45,300
We know people who receive medication

484
00:25:45,300 --> 00:25:47,730
are more likely to engage
in behavioral care,

485
00:25:47,730 --> 00:25:49,530
engagement in prenatal care,

486
00:25:49,530 --> 00:25:54,530
decreased acquisition and
transmission of HIV and Hep C.

487
00:25:54,540 --> 00:25:57,840
And we know that medications
are very successful

488
00:25:57,840 --> 00:26:01,263
at preventing overdose and overdose death.

489
00:26:02,190 --> 00:26:07,190
And that is a brief summary
of what you know stands behind

490
00:26:07,290 --> 00:26:10,620
these SAMHSA clinical
guidance recommendations.

491
00:26:10,620 --> 00:26:11,910
And these were the three

492
00:26:11,910 --> 00:26:15,900
sort of highest level
recommendations from this process

493
00:26:15,900 --> 00:26:17,670
that buprenorphine and methadone

494
00:26:17,670 --> 00:26:20,430
are the safest medications for OUD.

495
00:26:20,430 --> 00:26:24,150
Medically supervised
withdrawal is not recommended

496
00:26:24,150 --> 00:26:27,903
and switching from one to
the other is not recommended.

497
00:26:29,250 --> 00:26:31,740
And all of this is great,

498
00:26:31,740 --> 00:26:36,180
but most people receive no treatment.

499
00:26:36,180 --> 00:26:41,180
In general, only 11% of US
adults with a use disorder

500
00:26:41,340 --> 00:26:44,700
report receipt of any
treatment in the past year.

501
00:26:44,700 --> 00:26:47,460
A number that is unchanged in decades.

502
00:26:47,460 --> 00:26:51,750
And contrast that to about 85%
of people with hypertension

503
00:26:51,750 --> 00:26:56,750
or depression or asthma
or diabetes receive care.

504
00:26:57,000 --> 00:26:59,520
So there's a market disconnect

505
00:26:59,520 --> 00:27:03,060
across chronic conditions
in the United States.

506
00:27:03,060 --> 00:27:07,110
In pregnancy, treatment
is slightly higher,

507
00:27:07,110 --> 00:27:10,200
but still these are data
from national level data

508
00:27:10,200 --> 00:27:14,640
only one third of people
who have opioid use disorder

509
00:27:14,640 --> 00:27:18,180
and are pregnant reported
receipt of any treatment

510
00:27:18,180 --> 00:27:19,503
in the past year.

511
00:27:20,820 --> 00:27:25,470
And there are marked racial
inequities in treatment receipt.

512
00:27:25,470 --> 00:27:28,950
The left hand side, these
are data from Massachusetts

513
00:27:28,950 --> 00:27:31,710
illustrating that black
non-Hispanic patients

514
00:27:31,710 --> 00:27:36,000
had 0.4 times the odds of
receiving any medication

515
00:27:36,000 --> 00:27:38,940
for opioid use in pregnancy

516
00:27:38,940 --> 00:27:42,030
compared to white non-Hispanic patients.

517
00:27:42,030 --> 00:27:42,960
And on the right,

518
00:27:42,960 --> 00:27:46,890
this is one program in Philadelphia

519
00:27:46,890 --> 00:27:49,770
and looking at the mean methadone dose.

520
00:27:49,770 --> 00:27:52,800
And whereas white non-Hispanic
patients on average

521
00:27:52,800 --> 00:27:56,170
had 145 milligrams of daily dose

522
00:27:57,030 --> 00:28:00,573
black patients had less
than 100 milligrams.

523
00:28:01,830 --> 00:28:04,110
So when we put this all together,

524
00:28:04,110 --> 00:28:06,120
you got the universe of pregnant people

525
00:28:06,120 --> 00:28:10,230
with a substance use disorder
of whom from national data,

526
00:28:10,230 --> 00:28:13,260
only one third receive any treatment

527
00:28:13,260 --> 00:28:15,180
of whom I didn't show you these data,

528
00:28:15,180 --> 00:28:18,720
but only half actually
are receiving medication

529
00:28:18,720 --> 00:28:21,570
of whom like a smaller proportion

530
00:28:21,570 --> 00:28:24,720
are receiving the comprehensive
co-located services,

531
00:28:24,720 --> 00:28:27,090
which we think of as the standard of care

532
00:28:27,090 --> 00:28:30,903
and have been described in
the literature for 50 years.

533
00:28:32,640 --> 00:28:34,170
So to summarize,

534
00:28:34,170 --> 00:28:37,530
most people quit or cut
back use in pregnancy.

535
00:28:37,530 --> 00:28:40,920
Those that don't likely
have a use disorder,

536
00:28:40,920 --> 00:28:43,860
people with addiction need
and benefit from treatment,

537
00:28:43,860 --> 00:28:46,770
but most people don't
receive any treatment

538
00:28:46,770 --> 00:28:48,990
because treatment doesn't always exist.

539
00:28:48,990 --> 00:28:52,440
And what exists may not
be welcoming or safe,

540
00:28:52,440 --> 00:28:55,713
especially for pregnant
or parenting people.

541
00:28:57,750 --> 00:29:02,750
I have to call out naloxone,
I'm sure you all do this,

542
00:29:03,090 --> 00:29:05,820
but naloxone is a critical component

543
00:29:05,820 --> 00:29:10,080
of the public health response
to the opioid crisis.

544
00:29:10,080 --> 00:29:13,080
It's high affinity, it
reverses an overdose,

545
00:29:13,080 --> 00:29:17,820
it's not scheduled, FDA just
made it over the counter.

546
00:29:17,820 --> 00:29:21,600
It only works in people who
have an opioid in their system.

547
00:29:21,600 --> 00:29:24,300
It is safe for pets, for children,

548
00:29:24,300 --> 00:29:27,360
for people who are pregnant, for anyone.

549
00:29:27,360 --> 00:29:30,720
But the thing to know is
that it's short acting.

550
00:29:30,720 --> 00:29:33,720
And in particular in this age of fentanyl,

551
00:29:33,720 --> 00:29:37,320
people oftentimes need multiple doses.

552
00:29:37,320 --> 00:29:41,610
There's no limit to how
much you can give somebody.

553
00:29:41,610 --> 00:29:44,790
And I really like this
Missouri opioid state

554
00:29:44,790 --> 00:29:48,780
targeted response,
scratching out more heroin,

555
00:29:48,780 --> 00:29:51,003
we need Mo' Heroes.

556
00:29:54,120 --> 00:29:57,870
So let's turn now and talk a little bit

557
00:29:57,870 --> 00:30:00,300
about the fourth trimester.

558
00:30:00,300 --> 00:30:05,300
This is the term to describe
the year following birth.

559
00:30:06,510 --> 00:30:09,660
And I like the language
of fourth trimester.

560
00:30:09,660 --> 00:30:11,490
It may not be mathematical,

561
00:30:11,490 --> 00:30:15,870
but it's inclusive of sort
of the rest of pregnancy.

562
00:30:15,870 --> 00:30:20,400
And this is a time of
increased vulnerabilities.

563
00:30:20,400 --> 00:30:24,480
People go from weekly
visits with their physician

564
00:30:24,480 --> 00:30:28,290
to maybe one or two visits
in the postpartum period.

565
00:30:28,290 --> 00:30:31,320
Care shifts from being
focused on the pregnant person

566
00:30:31,320 --> 00:30:33,270
to being focused on the newborn.

567
00:30:33,270 --> 00:30:34,470
And generally speaking,

568
00:30:34,470 --> 00:30:37,980
care shifts away from healthcare settings

569
00:30:37,980 --> 00:30:41,520
and to other services in
the public health space

570
00:30:41,520 --> 00:30:44,250
such as WIC, home visiting and et cetera,

571
00:30:44,250 --> 00:30:47,190
things that are actually disconnected

572
00:30:47,190 --> 00:30:49,443
from formal health treatment.

573
00:30:50,790 --> 00:30:53,910
This is a time of insurance churn,

574
00:30:53,910 --> 00:30:57,120
a time of welfare realignment,

575
00:30:57,120 --> 00:31:00,480
and a time of that we
kind of withdraw care

576
00:31:00,480 --> 00:31:04,620
in many ways at the most critical
time when people need it.

577
00:31:04,620 --> 00:31:09,330
Hence this is a time of
a return to use overdose

578
00:31:09,330 --> 00:31:10,833
and overdose death.

579
00:31:12,480 --> 00:31:15,420
This is one of the biggest success stories

580
00:31:15,420 --> 00:31:18,570
I think of 20th century medicine,

581
00:31:18,570 --> 00:31:22,353
which is the market decrease
in maternal mortality.

582
00:31:23,190 --> 00:31:28,190
Death rates in the late 1800s
approached 5% during birth

583
00:31:28,560 --> 00:31:33,560
and plummeted following
the advent of anesthesia,

584
00:31:34,080 --> 00:31:37,890
blood products and
antibiotics in particular.

585
00:31:37,890 --> 00:31:40,590
And when I started my training,

586
00:31:40,590 --> 00:31:43,110
the rates of maternal
deaths in the United States

587
00:31:43,110 --> 00:31:45,393
was about one in 10,000.

588
00:31:46,380 --> 00:31:49,680
But since then, through the
whole course of my career,

589
00:31:49,680 --> 00:31:51,060
rates of maternal death

590
00:31:51,060 --> 00:31:53,880
have only been increasing
in the United States.

591
00:31:53,880 --> 00:31:55,260
And this is in contrast

592
00:31:55,260 --> 00:31:59,547
to every other "northern or
developed economy nation."

593
00:32:00,840 --> 00:32:03,990
And there are market racial inequities

594
00:32:03,990 --> 00:32:06,390
in maternal deaths in the United States.

595
00:32:06,390 --> 00:32:08,850
Black women are four to five times

596
00:32:08,850 --> 00:32:13,300
more likely to die during
birth than white women are

597
00:32:14,850 --> 00:32:18,450
and so are people with
opioid use disorder.

598
00:32:18,450 --> 00:32:22,230
There are two studies that
look at the odds of death

599
00:32:22,230 --> 00:32:24,240
during the birthing hospitalization

600
00:32:24,240 --> 00:32:27,330
comparing people with
OUD to those without,

601
00:32:27,330 --> 00:32:29,610
and they report similar results

602
00:32:29,610 --> 00:32:33,180
somewhere between three and a
half to four and a half times

603
00:32:33,180 --> 00:32:36,900
the odds of death during
the birthing hospitalization

604
00:32:36,900 --> 00:32:40,563
compared to people without
opioid use disorder.

605
00:32:42,870 --> 00:32:44,910
And this risk of death

606
00:32:44,910 --> 00:32:48,000
is really like the tip
of the iceberg, right?

607
00:32:48,000 --> 00:32:50,460
When we think about all overdose events,

608
00:32:50,460 --> 00:32:53,430
many overdose events don't end in death.

609
00:32:53,430 --> 00:32:55,320
These are data from Massachusetts

610
00:32:55,320 --> 00:32:57,810
looking at overdose events

611
00:32:57,810 --> 00:33:01,373
prior to delivery through
pregnancy and after.

612
00:33:02,370 --> 00:33:05,940
And you can see whereas the
overdose events decreased

613
00:33:05,940 --> 00:33:10,940
through the course of pregnancy,
they increase postpartum.

614
00:33:11,040 --> 00:33:14,760
In fact their highest at the
end of the postpartum period.

615
00:33:14,760 --> 00:33:16,110
And I'm not showing you data,

616
00:33:16,110 --> 00:33:18,240
I've looked at this in a different state

617
00:33:18,240 --> 00:33:21,930
in this second year after birth

618
00:33:21,930 --> 00:33:24,690
and overdose rates remain elevated

619
00:33:24,690 --> 00:33:27,483
compared to pregnancy two years out.

620
00:33:28,470 --> 00:33:30,000
And on the bottom this shows you

621
00:33:30,000 --> 00:33:33,270
sort of the protective
benefit of medication

622
00:33:33,270 --> 00:33:37,563
to prevent overdose and
also overdose death.

623
00:33:39,750 --> 00:33:42,117
But the unique vulnerabilities postpartum

624
00:33:42,117 --> 00:33:47,117
are not only limited to
overdose and overdose death.

625
00:33:48,210 --> 00:33:52,323
Other important things to think
about include hepatitis C.

626
00:33:53,250 --> 00:33:58,250
These are data from Ohio
looking at rates of hepatitis C

627
00:33:58,320 --> 00:34:01,740
at birth, comparing 2006 to 2015.

628
00:34:04,650 --> 00:34:06,810
And you can see a market increase.

629
00:34:06,810 --> 00:34:11,810
In parts of the state having
in 2016 greater than 5%

630
00:34:12,000 --> 00:34:15,213
of all births that are
positive for hepatitis C.

631
00:34:16,800 --> 00:34:21,480
Yet we do a really bad job of assessing,

632
00:34:21,480 --> 00:34:26,163
educating and treating
people for hepatitis C.

633
00:34:27,180 --> 00:34:28,800
These are two nice studies

634
00:34:28,800 --> 00:34:32,340
by Liz Krantz and others in Pittsburgh

635
00:34:32,340 --> 00:34:35,280
that first look at like sort
of hepatitis C knowledge

636
00:34:35,280 --> 00:34:37,890
amongst pregnant people low.

637
00:34:37,890 --> 00:34:39,900
And second, looking at what happens

638
00:34:39,900 --> 00:34:42,150
in our screening pathway.

639
00:34:42,150 --> 00:34:45,660
They had about 400 people
that had opioid use disorder

640
00:34:45,660 --> 00:34:48,900
of whom only half got
tested for hepatitis C

641
00:34:48,900 --> 00:34:50,760
amongst those who were positive

642
00:34:50,760 --> 00:34:54,540
all got referred for definitive testing,

643
00:34:54,540 --> 00:34:56,130
but not everybody got it.

644
00:34:56,130 --> 00:35:00,000
And then postpartum the referral to an ID

645
00:35:00,000 --> 00:35:02,610
or hepatology doc to begin medication,

646
00:35:02,610 --> 00:35:07,230
only one person actually
completed that referral

647
00:35:07,230 --> 00:35:11,040
and that person did not
initiate medication.

648
00:35:11,040 --> 00:35:12,570
So we have this sort of like,

649
00:35:12,570 --> 00:35:14,850
this is saying nothing
of the newborn testing,

650
00:35:14,850 --> 00:35:16,800
which is equally poor,

651
00:35:16,800 --> 00:35:19,560
but we have this sort of
pending sort of tsunami

652
00:35:19,560 --> 00:35:24,090
of liver disease that's
related to the opioid crisis

653
00:35:24,090 --> 00:35:27,780
and to our sort of not taking
the moment of pregnancy

654
00:35:27,780 --> 00:35:31,683
well enough to engage in prevention.

655
00:35:33,390 --> 00:35:35,880
And the final thing
relates to contraception.

656
00:35:35,880 --> 00:35:38,790
We know from the Colorado experiment

657
00:35:38,790 --> 00:35:41,880
that if we can provide
people access to larks,

658
00:35:41,880 --> 00:35:45,123
many people will uptake them.

659
00:35:46,080 --> 00:35:50,550
But, and this is also
work from Liz Krantz.

660
00:35:50,550 --> 00:35:52,350
In pregnancy when we talk,

661
00:35:52,350 --> 00:35:54,480
this is the sort of cascade of care

662
00:35:54,480 --> 00:35:59,480
of people who had wanted a lark

663
00:35:59,730 --> 00:36:02,763
or expressed interest in a
lark during prenatal care.

664
00:36:05,070 --> 00:36:06,660
As you go through this,

665
00:36:06,660 --> 00:36:09,630
like very few people actually ended up

666
00:36:09,630 --> 00:36:13,053
getting the contraceptive
option that they wanted.

667
00:36:15,930 --> 00:36:20,433
So finally, let's talk about
stigma and discrimination.

668
00:36:21,690 --> 00:36:24,360
So stigma is a term
that comes from Goffman

669
00:36:24,360 --> 00:36:28,680
who is a sociologist in the
latter half of the 20th century.

670
00:36:28,680 --> 00:36:31,080
It's really sort of the experience

671
00:36:31,080 --> 00:36:33,990
of being deeply discredited or marked

672
00:36:33,990 --> 00:36:37,170
due to one's undesired differentness.

673
00:36:37,170 --> 00:36:40,230
To be stigmatized, to be
held in contempt, shunned,

674
00:36:40,230 --> 00:36:42,300
or rendered socially invisible

675
00:36:42,300 --> 00:36:45,750
because of a socially disapproved status.

676
00:36:45,750 --> 00:36:49,320
Stigma is a mark of otherness

677
00:36:49,320 --> 00:36:52,980
due to deviation from social norms.

678
00:36:52,980 --> 00:36:55,980
And people who are pregnant who use drugs

679
00:36:55,980 --> 00:36:59,040
experience sort of like compounded stigmas

680
00:36:59,040 --> 00:37:01,140
around drug use, around addiction

681
00:37:01,140 --> 00:37:04,380
and around motherhood and reproduction.

682
00:37:04,380 --> 00:37:08,280
But in many ways stigma is
like a them problem, right?

683
00:37:08,280 --> 00:37:11,220
It's a label, a mark of otherness.

684
00:37:11,220 --> 00:37:14,013
It comes from the word stigmata,

685
00:37:14,940 --> 00:37:17,103
from the crucifixion of Christ.

686
00:37:18,870 --> 00:37:21,750
I prefer the term discrimination

687
00:37:21,750 --> 00:37:26,310
because discrimination is
how we treat other people.

688
00:37:26,310 --> 00:37:31,050
And we can do something, it's
hard to change social norms,

689
00:37:31,050 --> 00:37:35,043
but it is possible to
change our own behaviors.

690
00:37:35,910 --> 00:37:39,540
And one of the ways that we
can sort of respond to stigma

691
00:37:39,540 --> 00:37:44,540
and discrimination is by attention
to the words that we use.

692
00:37:44,550 --> 00:37:47,310
This is a reference
called the "Addictionary"

693
00:37:47,310 --> 00:37:51,330
that's wonderful and worth exploring.

694
00:37:51,330 --> 00:37:53,430
And the general principles

695
00:37:53,430 --> 00:37:57,840
are that we can reflect the
worth of dignity of all persons

696
00:37:57,840 --> 00:38:00,480
by using people first language.

697
00:38:00,480 --> 00:38:04,410
When we talk about addiction,
treatment and recovery,

698
00:38:04,410 --> 00:38:06,693
we should focus on the
medical nature of SUD,

699
00:38:07,770 --> 00:38:11,010
focus on treatment and
promote the recovery process

700
00:38:11,010 --> 00:38:13,440
in the words that we use.

701
00:38:13,440 --> 00:38:17,130
We should also avoid
perpetuating negative stereotypes

702
00:38:17,130 --> 00:38:20,823
and biases through slang and idioms.

703
00:38:23,310 --> 00:38:28,310
Addiction treatment is a
unique space clinically.

704
00:38:29,700 --> 00:38:33,330
It's a space really of mutual mistrust.

705
00:38:33,330 --> 00:38:35,913
And I wanna unpack that a little bit.

706
00:38:37,380 --> 00:38:39,780
I had almost no education

707
00:38:39,780 --> 00:38:41,580
around addiction as a medical student,

708
00:38:41,580 --> 00:38:44,010
but I was taught two things.

709
00:38:44,010 --> 00:38:47,130
One, I was taught when I
took an alcohol history

710
00:38:47,130 --> 00:38:50,220
to at least double what
the patient told me

711
00:38:50,220 --> 00:38:52,440
to get to the true result.

712
00:38:52,440 --> 00:38:55,860
And the other thing that was
thrown around was this phrase,

713
00:38:55,860 --> 00:38:59,340
denial is a symptom of addiction.

714
00:38:59,340 --> 00:39:03,450
Both of those are examples of mistrust

715
00:39:03,450 --> 00:39:05,010
from providers, right?

716
00:39:05,010 --> 00:39:06,240
We're not trusting

717
00:39:06,240 --> 00:39:09,183
what the person in front
of us is telling us.

718
00:39:10,590 --> 00:39:13,320
And I would say that our
mistrust as providers

719
00:39:13,320 --> 00:39:16,800
is often misplaced, it's
rooted in discrimination

720
00:39:16,800 --> 00:39:18,780
and in prejudice.

721
00:39:18,780 --> 00:39:21,300
Patients mistrust us.

722
00:39:21,300 --> 00:39:25,560
And that mistrust in contrast
to our mistrust is warranted

723
00:39:25,560 --> 00:39:29,070
in particular by those who've
experienced oppression,

724
00:39:29,070 --> 00:39:32,970
in particular by those that
have experienced discrimination

725
00:39:32,970 --> 00:39:34,980
in healthcare settings.

726
00:39:34,980 --> 00:39:38,400
In other words, patient
mistrust is legitimate

727
00:39:38,400 --> 00:39:41,793
due to historic memory and
everyday discrimination.

728
00:39:42,660 --> 00:39:47,660
Now what if I trust a patient
I should not have trusted.

729
00:39:47,730 --> 00:39:51,753
The consequences of that
misplaced trust are minor.

730
00:39:52,620 --> 00:39:55,290
But what if a patient trusts me

731
00:39:55,290 --> 00:39:57,780
and they shouldn't have trusted me?

732
00:39:57,780 --> 00:40:02,640
The consequences of that
misplaced trust can be severe.

733
00:40:02,640 --> 00:40:03,930
And this difference

734
00:40:03,930 --> 00:40:08,040
reflects the power
differential of care, right?

735
00:40:08,040 --> 00:40:12,960
The risk and vulnerability
of the interaction

736
00:40:12,960 --> 00:40:15,510
it differs incredibly.

737
00:40:15,510 --> 00:40:19,080
And this means that the responsibility

738
00:40:19,080 --> 00:40:23,010
for overcoming mistrust does
not rest with the patient,

739
00:40:23,010 --> 00:40:24,963
it rests with us.

740
00:40:26,070 --> 00:40:29,760
And we can address like that mistrust,

741
00:40:29,760 --> 00:40:33,840
we can build trust through
clinical discussion.

742
00:40:33,840 --> 00:40:37,050
And these are just some
examples of questions

743
00:40:37,050 --> 00:40:41,700
that there's thousands that
you can ask that are open-ended

744
00:40:41,700 --> 00:40:44,910
and that give people back
the dignity and respect

745
00:40:44,910 --> 00:40:49,773
that they deserve and create
space to overcome mistrust.

746
00:40:50,610 --> 00:40:52,410
What's the most important thing to you

747
00:40:52,410 --> 00:40:53,640
about treatment or recovery?

748
00:40:53,640 --> 00:40:56,670
What do you know about
different medications?

749
00:40:56,670 --> 00:41:00,210
Do you have fears or concerns
from previous experiences?

750
00:41:00,210 --> 00:41:01,890
What do you need to feel safe?

751
00:41:01,890 --> 00:41:04,350
What are you looking for in a provider?

752
00:41:04,350 --> 00:41:06,483
How do you feel your care is going?

753
00:41:07,830 --> 00:41:12,830
Because I think we have to
recognize that birth is not safe

754
00:41:13,200 --> 00:41:16,260
in particular for people who use drugs.

755
00:41:16,260 --> 00:41:21,240
And the work that you do that
is focused on patient safety,

756
00:41:21,240 --> 00:41:24,900
I would urge you to think
about discrimination

757
00:41:24,900 --> 00:41:27,210
as a patient safety issue.

758
00:41:27,210 --> 00:41:31,950
Because we have pathways driver diagrams,

759
00:41:31,950 --> 00:41:35,730
stuff like this that we
can address patient safety,

760
00:41:35,730 --> 00:41:39,903
that we can actually tackle
discrimination through.

761
00:41:40,980 --> 00:41:43,080
And these are sort of like the two,

762
00:41:43,080 --> 00:41:48,080
I would say most appropriate
professional society statements

763
00:41:49,470 --> 00:41:52,770
recently that relate to this space.

764
00:41:52,770 --> 00:41:54,900
And the first is from ASAM

765
00:41:54,900 --> 00:41:57,900
that states that equating
a positive toxicology test

766
00:41:57,900 --> 00:41:59,280
with child abuse or neglect

767
00:41:59,280 --> 00:42:02,310
is scientifically
inaccurate, inappropriate,

768
00:42:02,310 --> 00:42:05,010
and can lead to an
unnecessarily punitive approach,

769
00:42:05,010 --> 00:42:07,260
which harms clinician patient trust

770
00:42:07,260 --> 00:42:10,860
and person engagements
in healthcare systems.

771
00:42:10,860 --> 00:42:13,620
An ACOG now a couple of years ago

772
00:42:13,620 --> 00:42:17,910
called out in particular
the practice of drug testing

773
00:42:17,910 --> 00:42:20,850
and reflex reporting to child welfare.

774
00:42:20,850 --> 00:42:23,610
And they said that the laws,
regulations and policies

775
00:42:23,610 --> 00:42:25,710
that require healthcare practitioners

776
00:42:25,710 --> 00:42:28,680
and human service workers
to respond to substance use

777
00:42:28,680 --> 00:42:31,950
and use disorder in a
primarily punitive way

778
00:42:31,950 --> 00:42:33,540
require healthcare providers

779
00:42:33,540 --> 00:42:37,410
to function as agents of law enforcement.

780
00:42:37,410 --> 00:42:41,340
In other words, the proximity of policing

781
00:42:41,340 --> 00:42:44,040
is nowhere closer than it is

782
00:42:44,040 --> 00:42:46,590
during the birthing hospitalization.

783
00:42:46,590 --> 00:42:49,230
And these practices,
they don't go this far,

784
00:42:49,230 --> 00:42:54,230
but I would say are contrary
to the professional ethics

785
00:42:55,080 --> 00:42:57,750
of the healing professions.

786
00:42:57,750 --> 00:43:00,420
So in contrast to that punitive model,

787
00:43:00,420 --> 00:43:04,620
really we need to stand
on the dyad, right?

788
00:43:04,620 --> 00:43:07,110
And this is Dr. Winnicott,

789
00:43:07,110 --> 00:43:11,190
he was a pediatrician who then
retrained as a psychiatrist.

790
00:43:11,190 --> 00:43:14,070
He's the person who first
described the blankie.

791
00:43:14,070 --> 00:43:17,190
The attachment a child has to an object.

792
00:43:17,190 --> 00:43:20,100
And he described really the dyad this way.

793
00:43:20,100 --> 00:43:22,230
There's no such thing as a baby.

794
00:43:22,230 --> 00:43:24,270
If you set out to describe a baby,

795
00:43:24,270 --> 00:43:27,840
you will find you are
describing a baby and someone,

796
00:43:27,840 --> 00:43:29,940
a baby cannot exist alone,

797
00:43:29,940 --> 00:43:32,973
but is essentially part of a relationship.

798
00:43:34,350 --> 00:43:36,990
And in the most recent sort of update

799
00:43:36,990 --> 00:43:39,540
the standardization of
the clinical definition

800
00:43:39,540 --> 00:43:44,070
of opioid withdrawal in the
neonate, the citation is here.

801
00:43:44,070 --> 00:43:49,070
We really tried to embed
some foundational principles

802
00:43:49,110 --> 00:43:51,750
into this document and
into this definition.

803
00:43:51,750 --> 00:43:54,810
Really these are to serve as guardrails.

804
00:43:54,810 --> 00:43:57,540
And I think as you do the work you do,

805
00:43:57,540 --> 00:44:00,420
centering it around
foundational principles

806
00:44:00,420 --> 00:44:03,060
and thinking about guardrails to the work

807
00:44:03,060 --> 00:44:07,023
is critical in keeping
things at least in lane.

808
00:44:07,890 --> 00:44:10,980
And these were the four
foundational principles

809
00:44:10,980 --> 00:44:12,750
that we agreed upon.

810
00:44:12,750 --> 00:44:16,290
Use disorders a disease required
requiring compassionate,

811
00:44:16,290 --> 00:44:18,570
ethical and evidence-based care.

812
00:44:18,570 --> 00:44:21,810
The dyad is the appropriate
subject of care.

813
00:44:21,810 --> 00:44:25,200
A diagnosis of withdrawal
does not imply harm,

814
00:44:25,200 --> 00:44:28,590
nor should it be used to assess
child's social welfare risk

815
00:44:28,590 --> 00:44:31,410
or status, should not be used to prosecute

816
00:44:31,410 --> 00:44:33,600
or punish the mother as evidence

817
00:44:33,600 --> 00:44:36,360
or as evidence to remove and neonate.

818
00:44:36,360 --> 00:44:37,950
And that environmental factors,

819
00:44:37,950 --> 00:44:40,470
family influences and social structures

820
00:44:40,470 --> 00:44:43,710
strongly influence neonatal outcomes

821
00:44:43,710 --> 00:44:46,050
and should be recognized.

822
00:44:46,050 --> 00:44:49,740
And so when I think about
the work that we do, right?

823
00:44:49,740 --> 00:44:52,920
Both from a public health
and a medical perspective,

824
00:44:52,920 --> 00:44:54,960
the work we want to do

825
00:44:54,960 --> 00:44:58,230
is something that is both evidence-based

826
00:44:58,230 --> 00:45:00,780
and person-centered.

827
00:45:00,780 --> 00:45:03,600
And what this means is evidence-based care

828
00:45:03,600 --> 00:45:06,150
is something that's grounded in science.

829
00:45:06,150 --> 00:45:09,090
And generally speaking,
in this topical area,

830
00:45:09,090 --> 00:45:12,810
we exaggerate the harms
of illegal substances

831
00:45:12,810 --> 00:45:15,570
and we minimize those of legal ones.

832
00:45:15,570 --> 00:45:16,830
More importantly,

833
00:45:16,830 --> 00:45:21,030
we overstate the importance of
the intrauterine environment

834
00:45:21,030 --> 00:45:25,050
and neglect the role of
the caregiving environment.

835
00:45:25,050 --> 00:45:28,560
By person-centered care, this
means care that's ethical,

836
00:45:28,560 --> 00:45:30,540
that's grounded in human rights,

837
00:45:30,540 --> 00:45:33,450
that's ground that recognizes
reproductive health

838
00:45:33,450 --> 00:45:34,500
as a human right.

839
00:45:34,500 --> 00:45:37,320
And in particular acknowledges

840
00:45:37,320 --> 00:45:39,750
those reproductive justice values,

841
00:45:39,750 --> 00:45:42,840
specifically the right to raise children

842
00:45:42,840 --> 00:45:46,200
in safe and sustainable environments.

843
00:45:46,200 --> 00:45:50,160
Person-centered care also
means supporting autonomy

844
00:45:50,160 --> 00:45:51,900
and maternal subjectivity

845
00:45:51,900 --> 00:45:55,050
and decision making surrounding pregnancy.

846
00:45:55,050 --> 00:45:58,680
Which means as providers
we must remain attuned

847
00:45:58,680 --> 00:46:00,660
to the unique demands that we,

848
00:46:00,660 --> 00:46:04,830
that society places on
pregnant and parenting people

849
00:46:04,830 --> 00:46:08,070
on their bodies and on their minds.

850
00:46:08,070 --> 00:46:10,740
And with that, thank you.

851
00:46:10,740 --> 00:46:14,880
This is the information here
for the substance use form line

852
00:46:14,880 --> 00:46:16,560
that I share in the...

853
00:46:16,560 --> 00:46:19,960
It's an underutilized
service, it's rant funded

854
00:46:20,940 --> 00:46:23,370
and it's free to any provider

855
00:46:23,370 --> 00:46:25,980
anywhere in the United States to call

856
00:46:25,980 --> 00:46:29,940
and get help with
anything related to drugs.

857
00:46:29,940 --> 00:46:30,780
So thank you.

858
00:46:30,780 --> 00:46:33,090
With that, I'm gonna stop sharing

859
00:46:33,090 --> 00:46:34,680
and I hope that there's some time

860
00:46:34,680 --> 00:46:37,203
for questions and et cetera.

861
00:46:55,500 --> 00:46:56,430
All right.

862
00:46:56,430 --> 00:46:58,860
-[Marge] Well, I'll start.
-[Woman] Me too, thank you.

863
00:46:58,860 --> 00:47:00,660
So hopefully Marge is gonna jump in.

864
00:47:00,660 --> 00:47:02,163
I see her, she's ready to go.

865
00:47:03,870 --> 00:47:04,823
[Dr. Terplan] Oh, hey Marge.

866
00:47:05,940 --> 00:47:06,840
[Marge] Thank you so much.

867
00:47:06,840 --> 00:47:09,720
I wish you could have come here in person

868
00:47:09,720 --> 00:47:13,950
and I just know somebody's asking

869
00:47:13,950 --> 00:47:15,660
for the warm line information,

870
00:47:15,660 --> 00:47:17,100
so maybe I can put that...

871
00:47:17,100 --> 00:47:20,661
I have a copy and I'll put it in the chat.

872
00:47:20,661 --> 00:47:25,661
And just as I was so happy
that you could come and talk

873
00:47:26,400 --> 00:47:31,400
because we've been treating
people for a very long time

874
00:47:31,740 --> 00:47:36,740
and as we've moved people
into community-based care,

875
00:47:37,830 --> 00:47:41,040
we've tried to keep
people in their community

876
00:47:41,040 --> 00:47:42,750
and it's a relatively low volume.

877
00:47:42,750 --> 00:47:44,133
You saw those pieces,

878
00:47:44,970 --> 00:47:48,760
the numbers that Michelle
presented earlier

879
00:47:50,430 --> 00:47:53,640
between COVID and
everything, our turnover.

880
00:47:53,640 --> 00:47:56,880
And so we really lost a huge amount

881
00:47:56,880 --> 00:47:59,670
of this sort of statewide knowledge.

882
00:47:59,670 --> 00:48:02,370
And then at the same time,
sort of CAPTA came in

883
00:48:02,370 --> 00:48:03,810
and these other reporting things

884
00:48:03,810 --> 00:48:06,390
that made it very difficult

885
00:48:06,390 --> 00:48:10,050
to like kind of level
set a lot of the things

886
00:48:10,050 --> 00:48:11,460
that you talked about.

887
00:48:11,460 --> 00:48:14,520
And I'm curious about whether or not

888
00:48:14,520 --> 00:48:16,560
that's something that's unique to hear

889
00:48:16,560 --> 00:48:21,270
or if we've seen a change
over relatively recently.

890
00:48:21,270 --> 00:48:24,360
I feel like we had made a
lot of inroads about stigma

891
00:48:24,360 --> 00:48:26,730
and how we talked to people
that sort of backslid

892
00:48:26,730 --> 00:48:30,180
and I'm just curious
about if that was just us

893
00:48:30,180 --> 00:48:32,940
or if that was nationally

894
00:48:32,940 --> 00:48:36,483
and strategies people have
used to recover from that.

895
00:48:38,370 --> 00:48:40,333
[Dr. Terplan] Yeah, thank you.

896
00:48:40,333 --> 00:48:42,930
I mean, overwhelmingly,

897
00:48:42,930 --> 00:48:47,930
I think like Vermont is
functioning at a higher level

898
00:48:48,780 --> 00:48:52,620
in this space than other states are.

899
00:48:52,620 --> 00:48:56,050
But we observed sort of the same thing

900
00:48:57,060 --> 00:49:00,090
in Maryland following CAPTA CARA,

901
00:49:00,090 --> 00:49:02,970
that we had an anonymous
reporting mechanism

902
00:49:02,970 --> 00:49:06,150
in child welfare before
that it actually opened.

903
00:49:06,150 --> 00:49:07,710
I was really skeptical of it,

904
00:49:07,710 --> 00:49:09,930
but I was delighted it opened up

905
00:49:09,930 --> 00:49:12,540
all these resources for people

906
00:49:12,540 --> 00:49:16,350
that were unrelated to addiction,
housing, transportation,

907
00:49:16,350 --> 00:49:19,260
stuff like this that I felt
was somewhere was even unfair

908
00:49:19,260 --> 00:49:22,290
that only people who use drugs
got access to those things

909
00:49:22,290 --> 00:49:24,390
and they should have
been more universalized.

910
00:49:24,390 --> 00:49:29,370
And then with the most
recent captor reauthorization

911
00:49:29,370 --> 00:49:32,160
really shut that down
and shunted everybody.

912
00:49:32,160 --> 00:49:34,620
There was no longer that
sort of alternative reporting

913
00:49:34,620 --> 00:49:36,780
mechanism and access.

914
00:49:36,780 --> 00:49:40,590
CAPTA was supposed to
have been reauthorized

915
00:49:40,590 --> 00:49:42,840
in the last congressional session.

916
00:49:42,840 --> 00:49:47,790
And it was held up at the last
minute really by a couple of,

917
00:49:47,790 --> 00:49:50,940
well, one Texas senator in particular

918
00:49:50,940 --> 00:49:55,290
who wanted that transgender care

919
00:49:55,290 --> 00:49:56,943
be labeled as child abuse.

920
00:49:59,100 --> 00:50:04,100
So one is hopeful that it's
overdue for reauthorization.

921
00:50:04,500 --> 00:50:07,260
So one's hopeful that
it will be this time,

922
00:50:07,260 --> 00:50:12,120
but I think some of those
kinda anti-trans motivations

923
00:50:12,120 --> 00:50:16,260
might come into play again.

924
00:50:16,260 --> 00:50:21,030
But the proposed new CAPTA

925
00:50:21,030 --> 00:50:23,220
actually mirrors what
you're already doing.

926
00:50:23,220 --> 00:50:27,360
One is that notifications are anonymous

927
00:50:27,360 --> 00:50:31,800
and not to child welfare but
to public health agencies

928
00:50:31,800 --> 00:50:35,020
who is changing the language
of plans of safe care

929
00:50:35,940 --> 00:50:37,650
to family care plans.

930
00:50:37,650 --> 00:50:38,970
So acknowledging a family,

931
00:50:38,970 --> 00:50:40,680
which is a big thing language-wise.

932
00:50:40,680 --> 00:50:42,120
And two, removing

933
00:50:42,120 --> 00:50:45,843
sort of this oftentimes
misleading language around safety.

934
00:50:46,740 --> 00:50:51,060
Right now there's market
heterogeneity across states.

935
00:50:51,060 --> 00:50:53,280
There are some states that
are doing some really,

936
00:50:53,280 --> 00:50:56,160
I think incredible work legislatively.

937
00:50:56,160 --> 00:50:58,470
One would be the State of Washington.

938
00:50:58,470 --> 00:51:00,840
There's something called House Bill 1227,

939
00:51:00,840 --> 00:51:03,510
which is going into effect
in a couple of months,

940
00:51:03,510 --> 00:51:06,210
which really this is about the standards

941
00:51:06,210 --> 00:51:08,610
around child removal uses ICWA,

942
00:51:08,610 --> 00:51:11,910
the Indian Child Welfare Act standard

943
00:51:11,910 --> 00:51:13,710
and applying it to all children.

944
00:51:13,710 --> 00:51:18,710
So removals only happen if
there's a threat of imminent arm.

945
00:51:19,530 --> 00:51:23,010
And for drugs it's
unclear what the drug use

946
00:51:23,010 --> 00:51:23,910
leading to the threat

947
00:51:23,910 --> 00:51:26,340
so that there has to
be a causal connection

948
00:51:26,340 --> 00:51:28,230
between something and the threat.

949
00:51:28,230 --> 00:51:31,230
Second piece is that
the court must consider

950
00:51:31,230 --> 00:51:35,520
the risks of removal to the
child and to the parent,

951
00:51:35,520 --> 00:51:38,430
not just the risks of remaining together.

952
00:51:38,430 --> 00:51:40,380
And the third is that they're parents

953
00:51:40,380 --> 00:51:43,170
have to be given preventative services

954
00:51:43,170 --> 00:51:45,450
prior to removals happening.

955
00:51:45,450 --> 00:51:48,150
So that's actually to some
extent like this incredibly,

956
00:51:48,150 --> 00:51:51,690
I think like a model that
other states could follow.

957
00:51:51,690 --> 00:51:54,360
We'll see what happens with
ICWA in the Supreme Court

958
00:51:54,360 --> 00:51:56,160
'cause there was a hearing around that.

959
00:51:56,160 --> 00:51:59,943
But at least anyway, that
standard was kind of mapped out.

960
00:52:01,110 --> 00:52:01,943
The other thing,

961
00:52:01,943 --> 00:52:05,220
and is I urge anyone on
this call to do this,

962
00:52:05,220 --> 00:52:08,940
we have I think a posity
in the published literature

963
00:52:08,940 --> 00:52:12,360
on how useful plans of safe care can be,

964
00:52:12,360 --> 00:52:14,490
not just in preventing removals,

965
00:52:14,490 --> 00:52:19,020
but in supporting recovery
and parenting and communities.

966
00:52:19,020 --> 00:52:22,413
I know, I mean, it's a
tool just like anything.

967
00:52:23,348 --> 00:52:26,610
It's not categorically good
or bad, depends how we use it.

968
00:52:26,610 --> 00:52:29,670
Some people are using it really well

969
00:52:29,670 --> 00:52:34,320
and some people are using
it superficially and poorly.

970
00:52:34,320 --> 00:52:36,660
But those people that are using it well,

971
00:52:36,660 --> 00:52:39,630
which it sounded like, I mean
for the little bit I know

972
00:52:39,630 --> 00:52:42,000
like in Vermont it's being used well.

973
00:52:42,000 --> 00:52:44,250
It can be a super helpful tool.

974
00:52:44,250 --> 00:52:45,990
So I would encourage you

975
00:52:45,990 --> 00:52:48,210
and those of you that
have access to those data

976
00:52:48,210 --> 00:52:50,040
to share how it's used well,

977
00:52:50,040 --> 00:52:51,720
how it helps keep families together,

978
00:52:51,720 --> 00:52:53,610
how it helps support recovery,

979
00:52:53,610 --> 00:52:57,240
how it helps kind of
communities remain intact.

980
00:52:57,240 --> 00:52:59,760
So it's not exactly
answering your question,

981
00:52:59,760 --> 00:53:03,753
but I share with you like at
some degree a backsliding,

982
00:53:06,361 --> 00:53:08,490
but it's contrasted with
like on the one hand

983
00:53:08,490 --> 00:53:12,780
some excellent legislation
in the State of Washington

984
00:53:12,780 --> 00:53:14,220
and some other things here and there.

985
00:53:14,220 --> 00:53:16,470
And also as we see

986
00:53:16,470 --> 00:53:19,260
like an increasingly punitive environment,

987
00:53:19,260 --> 00:53:23,070
state environment in particular
for reproductive health

988
00:53:23,070 --> 00:53:25,350
in particular in certain places.

989
00:53:25,350 --> 00:53:27,960
And many of us are very concerned

990
00:53:27,960 --> 00:53:31,770
about what those abortion
restrictions and criminalization

991
00:53:31,770 --> 00:53:33,810
are going to mean in general,

992
00:53:33,810 --> 00:53:38,133
but also for pregnant and
parenting people who use drugs.

993
00:53:40,680 --> 00:53:43,710
[Marge] Thanks, always a
pleasure to hear your thoughts

994
00:53:43,710 --> 00:53:47,340
and yeah, I think looking
up that legislation

995
00:53:47,340 --> 00:53:50,850
would probably help us
a lot as a guidepost.

996
00:53:50,850 --> 00:53:52,383
So thanks.

997
00:53:53,490 --> 00:53:55,230
[Dr. Terplan] And I'm
happy to put you in touch

998
00:53:55,230 --> 00:53:57,780
with the advocates who
really were behind that bill

999
00:53:57,780 --> 00:54:02,122
in Washington State because
it came from lawyers.

1000
00:54:02,122 --> 00:54:04,470
(Dr. Terplan laughs)

1001
00:54:04,470 --> 00:54:05,749
Not from doctors.

1002
00:54:05,749 --> 00:54:08,832
(Dr. Terplan laughs)

1003
00:54:11,310 --> 00:54:12,930
Other questions?

1004
00:54:12,930 --> 00:54:14,525
Oh, somebody has their hand up.

1005
00:54:14,525 --> 00:54:16,290
Yeah.

1006
00:54:16,290 --> 00:54:17,700
[Woman] Thanks so much.

1007
00:54:17,700 --> 00:54:18,870
I don't usually put my hand up,

1008
00:54:18,870 --> 00:54:21,720
but I wasn't sure if that was
the procedure this morning.

1009
00:54:22,620 --> 00:54:24,543
Thank you so much for this talk.

1010
00:54:25,426 --> 00:54:27,303
I have a lot of thoughts.

1011
00:54:29,430 --> 00:54:32,860
The whole frame is so lovely and helpful

1012
00:54:33,930 --> 00:54:36,510
and also just thanks for
acknowledging Vermont's work

1013
00:54:36,510 --> 00:54:38,160
in this space.

1014
00:54:38,160 --> 00:54:42,120
We do have some pretty
remarkable heroes on this call,

1015
00:54:42,120 --> 00:54:44,670
on this Zoom.

1016
00:54:44,670 --> 00:54:45,690
So my question for you,

1017
00:54:45,690 --> 00:54:47,790
I loved when you said very powerfully

1018
00:54:47,790 --> 00:54:49,980
that postpartum supports
are sort of uncoupled

1019
00:54:49,980 --> 00:54:51,780
from medical care.

1020
00:54:51,780 --> 00:54:53,550
And what I thought about in that setting,

1021
00:54:53,550 --> 00:54:57,180
I'm a pediatrician, I
think the pediatric piece

1022
00:54:57,180 --> 00:54:59,370
is pretty connected to
those public health programs

1023
00:54:59,370 --> 00:55:02,250
you mentioned like WIC home visiting,

1024
00:55:02,250 --> 00:55:04,020
but you framed it in the context

1025
00:55:04,020 --> 00:55:05,850
of the substance use disorder.

1026
00:55:05,850 --> 00:55:09,420
And what that sparked for me is challenges

1027
00:55:09,420 --> 00:55:11,880
with treatment providers

1028
00:55:11,880 --> 00:55:16,880
not working in the public
health prevention newborn space.

1029
00:55:18,990 --> 00:55:21,600
And that's nothing about
our obstetrical care,

1030
00:55:21,600 --> 00:55:24,270
it's about the community-based
treatment providers.

1031
00:55:24,270 --> 00:55:26,670
I'm curious if you have any advice for us

1032
00:55:26,670 --> 00:55:31,020
about how do we get those tried
and true treatment providers

1033
00:55:31,020 --> 00:55:32,850
who are really passionate about their work

1034
00:55:32,850 --> 00:55:35,730
to understand the broader context

1035
00:55:35,730 --> 00:55:38,490
of public health postpartum supports

1036
00:55:38,490 --> 00:55:41,040
that are like really solid in Vermont

1037
00:55:41,040 --> 00:55:44,820
and have a nice uptake.

1038
00:55:44,820 --> 00:55:46,923
We have a bit of a chasm there.

1039
00:55:48,210 --> 00:55:49,660
[Dr. Terplan] Yeah, I mean,

1040
00:55:52,500 --> 00:55:55,710
I would also add though
that before I answer that,

1041
00:55:55,710 --> 00:56:00,710
that obstetricians and people,

1042
00:56:01,320 --> 00:56:04,290
the whole like universe
of people who work,

1043
00:56:04,290 --> 00:56:09,290
who intersect with birth are less aware

1044
00:56:09,660 --> 00:56:13,290
than most pediatricians
that these services

1045
00:56:13,290 --> 00:56:17,370
such as home visiting
early headstart exist,

1046
00:56:17,370 --> 00:56:20,220
much less how to access that care.

1047
00:56:20,220 --> 00:56:22,980
And I say this 'cause
one of the motivations

1048
00:56:22,980 --> 00:56:25,800
that health professionals have to report

1049
00:56:25,800 --> 00:56:29,280
a family to child welfare
is from the recognition

1050
00:56:29,280 --> 00:56:32,460
that this is a family that has needs,

1051
00:56:32,460 --> 00:56:34,950
I don't know how to get
those needs to them,

1052
00:56:34,950 --> 00:56:37,980
but there's this agency that can.

1053
00:56:37,980 --> 00:56:40,170
Now that agency can or cannot,

1054
00:56:40,170 --> 00:56:42,330
like your agencies are
better than other states,

1055
00:56:42,330 --> 00:56:44,940
but there's many places
where child welfare agencies

1056
00:56:44,940 --> 00:56:47,340
are primarily agencies of surveillance.

1057
00:56:47,340 --> 00:56:48,840
They can mandate services,

1058
00:56:48,840 --> 00:56:52,320
but they don't themselves
provide those services.

1059
00:56:52,320 --> 00:56:55,230
And I contrast that around addiction

1060
00:56:55,230 --> 00:56:58,560
with like how we deal with
folks in the cancer center.

1061
00:56:58,560 --> 00:57:01,890
Somebody has cancer, they're
seeing in the cancer center,

1062
00:57:01,890 --> 00:57:04,830
they're having difficulty
with transportation.

1063
00:57:04,830 --> 00:57:06,630
The cancer center provides,

1064
00:57:06,630 --> 00:57:08,940
can help assist in
providing transportation.

1065
00:57:08,940 --> 00:57:10,500
The cancer center can even sometimes

1066
00:57:10,500 --> 00:57:13,680
provide counseling to children

1067
00:57:13,680 --> 00:57:18,570
whose one of two parents like
has a maybe a fatal diagnosis.

1068
00:57:18,570 --> 00:57:20,730
And so we take as a health system,

1069
00:57:20,730 --> 00:57:23,670
we take that sort of social responsibility

1070
00:57:23,670 --> 00:57:27,690
for certain illness states
such as cancer, well-resourced,

1071
00:57:27,690 --> 00:57:32,040
but we don't for other illness
states such as addiction.

1072
00:57:32,040 --> 00:57:35,343
And that reflects a value or a devalue.

1073
00:57:36,270 --> 00:57:40,350
So I think there are ways
to try to connect some...

1074
00:57:40,350 --> 00:57:41,700
We have social workers

1075
00:57:41,700 --> 00:57:44,310
who are embedded in birthing hospitals

1076
00:57:44,310 --> 00:57:47,340
who sometimes not always where you are,

1077
00:57:47,340 --> 00:57:50,160
but whose primary job is
actually reporting people

1078
00:57:50,160 --> 00:57:51,660
for social service receipt

1079
00:57:51,660 --> 00:57:54,000
rather than providing those services

1080
00:57:54,000 --> 00:57:55,470
themselves as they might

1081
00:57:55,470 --> 00:57:57,870
if they worked in a different
part of the hospital.

1082
00:57:57,870 --> 00:58:00,663
So that's worth sort of
reflecting back and unpacking.

1083
00:58:02,490 --> 00:58:05,310
In terms of the drug treatment system.

1084
00:58:05,310 --> 00:58:08,010
I mean, it's historical, right?

1085
00:58:08,010 --> 00:58:11,730
It's only recently and in completely

1086
00:58:11,730 --> 00:58:13,980
that addiction is incorporated

1087
00:58:13,980 --> 00:58:17,310
within formal traditional
healthcare systems.

1088
00:58:17,310 --> 00:58:19,950
So the system we have emerged

1089
00:58:19,950 --> 00:58:24,340
because of neglect from
normal dominant healthcare

1090
00:58:25,710 --> 00:58:28,572
and it's a funny system, right?

1091
00:58:28,572 --> 00:58:31,140
We've got OTPs, highly regulated methadone

1092
00:58:31,140 --> 00:58:33,810
with daily observed dosing.

1093
00:58:33,810 --> 00:58:35,670
You have residential programming,

1094
00:58:35,670 --> 00:58:37,380
you've got partial hospitalization,

1095
00:58:37,380 --> 00:58:38,370
you have intensive outpatient,

1096
00:58:38,370 --> 00:58:42,270
you've got stuff that's
organized that no other illness,

1097
00:58:42,270 --> 00:58:45,573
no other mental illness either
organizes things this way.

1098
00:58:46,680 --> 00:58:49,500
It's this historical structure
that generally speaking

1099
00:58:49,500 --> 00:58:52,290
has been disconnected from healthcare.

1100
00:58:52,290 --> 00:58:55,440
And so it has its own
culture, it has its own thing.

1101
00:58:55,440 --> 00:59:00,000
And on the hold it was really
built to take care of men,

1102
00:59:00,000 --> 00:59:01,620
not to take care of people,

1103
00:59:01,620 --> 00:59:05,130
women and other people who are
capable of becoming pregnant,

1104
00:59:05,130 --> 00:59:08,850
much less welcoming to people
who might be parenting.

1105
00:59:08,850 --> 00:59:13,660
So there's a lot of work
that kinda needs to be done

1106
00:59:15,360 --> 00:59:18,420
to make a more welcoming
environment in that space.

1107
00:59:18,420 --> 00:59:21,720
But I think some of it is to connect

1108
00:59:21,720 --> 00:59:24,063
like these things better.

1109
00:59:25,170 --> 00:59:26,850
What is it 7% of people

1110
00:59:26,850 --> 00:59:29,370
who are eligible for early
headstart in the United States

1111
00:59:29,370 --> 00:59:32,760
receive even a referral
to early headstart.

1112
00:59:32,760 --> 00:59:35,940
I would say there's got a
minority of obstetrician,

1113
00:59:35,940 --> 00:59:38,220
gynecologists even know
what early headstart is

1114
00:59:38,220 --> 00:59:41,490
much less that it starts in pregnancy.

1115
00:59:41,490 --> 00:59:44,460
There are some examples of
things that are more integrated.

1116
00:59:44,460 --> 00:59:46,620
I think some nurse family partnerships

1117
00:59:46,620 --> 00:59:48,750
or family nurse partnerships
and things like that.

1118
00:59:48,750 --> 00:59:51,060
But those that tend to have
a pretty high threshold

1119
00:59:51,060 --> 00:59:55,230
for engagement as opposed to
sort of like a low threshold,

1120
00:59:55,230 --> 00:59:58,110
which works a whole lot
better for most of the people.

1121
00:59:58,110 --> 01:00:01,470
So what do we do with the
addiction treatment services?

1122
01:00:01,470 --> 01:00:05,220
We engage with them, we bring
them into the conversations,

1123
01:00:05,220 --> 01:00:09,963
we invite them to the tables
such as this table here today.

1124
01:00:12,060 --> 01:00:14,490
We think about the services
that they're not providing

1125
01:00:14,490 --> 01:00:17,190
and how can we go there
to provide those services

1126
01:00:17,190 --> 01:00:20,040
in particular sort of
reproductive healthcare.

1127
01:00:20,040 --> 01:00:23,730
Is there a way to embed like or period,

1128
01:00:23,730 --> 01:00:27,570
like either go to the clinic
and provide like contraception

1129
01:00:27,570 --> 01:00:31,560
or like make the transfer back and forth.

1130
01:00:31,560 --> 01:00:33,240
So I think it's really through the lens

1131
01:00:33,240 --> 01:00:38,240
of sort of collaborative
public health work

1132
01:00:39,630 --> 01:00:44,630
and moving towards sort of
integrated service delivery.

1133
01:00:44,700 --> 01:00:46,560
And somewhere, I will say like this,

1134
01:00:46,560 --> 01:00:49,410
the addiction treatment system is absurd

1135
01:00:49,410 --> 01:00:53,823
and really the model
is primary care, right?

1136
01:00:54,660 --> 01:00:58,710
Integrated, comprehensive
co-located services.

1137
01:00:58,710 --> 01:01:02,070
Why every FQHC should provide,

1138
01:01:02,070 --> 01:01:03,720
pap smears should provide,

1139
01:01:03,720 --> 01:01:06,170
contraception should
provide addiction treatment.

1140
01:01:09,210 --> 01:01:11,280
[Woman] So, great we do
have one pediatric practice

1141
01:01:11,280 --> 01:01:16,280
in Vermont that provides
treatment services for parents,

1142
01:01:16,380 --> 01:01:18,960
which is also a model that really works,

1143
01:01:18,960 --> 01:01:23,960
but it takes an enormous
commitment and also a willingness

1144
01:01:23,970 --> 01:01:26,280
to go beyond your traditional role, right?

1145
01:01:26,280 --> 01:01:31,280
As a pediatric provider,
which has some trepidation.

1146
01:01:33,450 --> 01:01:34,353
Thank you so much.

1147
01:01:35,580 --> 01:01:36,832
[Dr. Terplan] Yeah, there's a real role

1148
01:01:36,832 --> 01:01:40,563
the federal agencies in this,
which they have not done.

1149
01:01:41,839 --> 01:01:44,613
Like to guidance from the top HRSA,

1150
01:01:45,626 --> 01:01:49,140
like laying out like sort of requirements

1151
01:01:49,140 --> 01:01:53,160
for continuation of the financial
benefit of being an FQHC

1152
01:01:53,160 --> 01:01:56,613
that's tied to really
holistic service delivery.

1153
01:01:58,140 --> 01:02:02,613
But reflects a devalue of
women's health that it isn't.

1154
01:02:03,810 --> 01:02:06,123
And we need to call it out as such.

1155
01:02:09,390 --> 01:02:10,223
[Woman] Oh, my goodness.

1156
01:02:10,223 --> 01:02:13,132
This was a wonderful
thought and discussion.

1157
01:02:13,132 --> 01:02:14,340
Yay.

1158
01:02:14,340 --> 01:02:15,780
[Dr. Terplan] Oh wait, we're out of time.

1159
01:02:15,780 --> 01:02:17,277
I'm sorry, so sorry.

1160
01:02:19,140 --> 01:02:21,570
[Woman] But if anyone has
any additional questions

1161
01:02:21,570 --> 01:02:24,540
or comments, certainly
reach out to our team,

1162
01:02:24,540 --> 01:02:26,160
send us an email.

1163
01:02:26,160 --> 01:02:30,630
We certainly can help get
some comments back and forth

1164
01:02:30,630 --> 01:02:32,850
and answer any questions that come up.

1165
01:02:32,850 --> 01:02:34,160
And we're really...