Hello, my name is Tricia Wright. I am an obstetrician and addiction medicine specialist and a clinical professor at the University of California, San Francisco, where I run the Center for Addiction in the Perinatal Period. My disclosures, I receive consulting income from McKesson and receive royalties from our book, Opioid Use Disorders in Pregnancy, neither which will allow me to retire anytime soon, unfortunately. My objectives for the talk are to be able to screen and assess for substance use disorders in pregnancy, counsel patients on the appropriate treatment of opioid use disorders in pregnancy with either methadone or buprenorphine, manage post-operative pain appropriately in the pregnant person dependent on opioids, and work within the systems to minimize stigma, increase access to care, and prevent maternal mortality. Okay, I'm dating myself in this one, but I remember these ads. Addiction used to be thought of as a man's disease, but even in the opioid epidemic in the 19th century, women were addicted in large numbers, usually by the prescription from male doctors for the various complaints such as headache, hysteria, and other... Start the slide over. Okay, I'm dating myself on this one, but I remember these ads very well. You come a long way, baby. Addiction used to be thought of as a man's disease, but even in the opium epidemic in the 19th century, women were addicted in large numbers, usually under the prescription from male doctors for various complaints such as hysteria. The truth is, women are unfortunately gaining parity in a lot of these addictive processes. So, how do we screen for substance use disorders in pregnancy? The main important thing is to use a validated screen and have it used to start a conversation. Some examples of validated screens that are used in pregnancy include the NIDA-4, the 4Ps, the SIRT-P, and all of these, again, are followed by an assessment if they're positive. The NIDA-4 is, in the last year, have you smoked tobacco or vaped, had more than three drinks of alcohol in one day or more than seven in one week, used a prescription for something other than prescribed, used an illegal or illicit drug, or used marijuana or cannabis. If the answer to this is, any of this is above is yes, then the screen is positive and the assessment should be done. The 4Ps Plus is another validated screening tool that was made at the copyright is with the additional, I'll start this slide over. The 4Ps Plus is one of the validated screening instruments specifically designed to quickly identify obstetrics patients at the risk of, for the use of tobacco, alcohol, or illicit drugs. For the past several years, NTI Upstream has been involved in developing and validating a screening methodology that will, it's just, sorry, this problematic slide. Start over. The 4Ps Plus is another screening instrument that talks about the use by the parents, the partner, the past, and the pregnancy, all in an attempt to de-stigmatize and get more appropriate answers. The SRP starts with, have you ever used marijuana? How many alcohol drinks have you consumed in the month before you were knowing you're pregnant? And do you feel the need to cut down on your alcohol or drug use? Again, if the answer to any of this is positive, the screen is yes, the screen is positive and the assessment should be done. What does this look like in the practical realm? So this is a risk pyramid for the assessment of substance use during pregnancy. All pregnant people should undergo a universal screening, which is generally a brief questionnaire. It can be a computer-assisted or an in-person assessment. And what that does is stratify patients into the pyramid in the middle. The majority of your patients are going to be in the low-risk category. And by that, they mean no history of substance use disorder, no at-risk use, stopped using substances as soon as they knew they were pregnant or before. And approximately 70% of patients will end up in that category. Those in the yellow or the moderate-risk category are those with a history of high use in the past, including recent treatment for substance use disorder, stop use late in pregnancy, or a continued low level of use. And these are the patients that really benefit the most from our counseling and our brief interventions using motivational interviewing techniques and frequent follow-up. The 4 to 5% in the red group at the top, the high-risk category, are those that likely make criteria for substance use disorder and likely require specialized substance use disorder screening. Just things to remember that not all use is problematic use, though we will talk about alcohol later on in pregnancy and how that can be problematic even at low-level use. What about urine toxicology? I get asked this all the time because some hospitals have made it a way to be inclusive of everybody. What I've found, it's really not a useful screening test for the reasons that it has a high number of false positives and also does not really assess whether a patient has a substance use disorder. It may be unhelpful in cases of intoxication, multiple drug use, guiding treatment length in cases with neonatal abstinence syndrome or neonatal opioid withdrawal syndrome. However, really all of this is individualized treatment anyway. It can be useful in follow-up and counseling and treatment. It should only be done with the patient's consent because it has been used to incarcerate women and remove children, especially in the Black and other communities of color. It really says nothing about parenting skills, as I mentioned earlier, and there's a high number of false positives. How do we assess substance use? This is really a conversation. When you have someone coming into labor and delivery and you want to find out when was your last drink, your second to last drink, your third to last drink, et cetera, have you ever gone through withdrawal before? Have you ever been through treatment? Just really remember, if you take nothing else away, the only ways to kill people in addiction medicine is not to recognize and treat alcohol or benzodiazepine withdrawal or to increase methadone doses too quickly. However, that could be a new thing in the latest fentanyl epidemic. In pregnancy, really remembering that medications for opioid use disorder remain the standard of care. That means opioid agonist pharmacotherapy, either with methadone or buprenorphine, endorsed by the American College of Obstetrics and Gynecologists as the optimal treatment for opioid use disorders in pregnancy. Just really remembering that methadone and buprenorphine are safe and effective treatment options in pregnancy. The benefits of medications for opioid use disorder are manifold, including the maternal benefits of a 70% reduction in overdose-related deaths. If we recognize that the United States leads the developed world in maternal mortality and that opioid use disorders are a leading cause of this from overdose, that this is very important to keep people on their medications for opioid use disorder. It decreases their infectious disease mortality, including HIV, hepatitis B, and hepatitis C, and really increases engagement in prenatal care and recovery treatment. The fetal benefits are also profound. You reduce fluctuations in the maternal opioid levels, which reduces fetal stress. You get a decrease in interuterine fetal demise, a decrease in interuterine growth restriction, and a decrease in preterm delivery, so all very important benefits for the fetus as well as the mother or the pregnant person. What about managing pain in opioid-dependent pregnant women? Women who are on opioids for chronic pain is one subset. Women on pharmacotherapy for medications for opioid use disorders, methadone or buprenorphine, or women with untreated opioid use disorders. All of these are separate categories of pregnant people that might come in on opioids. Their treatment is slightly different, and the principles are slightly different. Some of the risks of treating pain is really the number one risk is undertreatment of pain. And this can, you know, undertreatment of pain actually trigger relapse in women with opioid use disorder, as well as treating the pain inappropriately with the opioid agonists or full opioid agonists, if not done in a thoughtful way. So why is pain so hard to treat in a person who is dependent on opioids? Patients have a high tolerance to opioid medications because they have an increased density of their mu receptors. So those are the opioid receptors that are responsible for pain, and they also are the opioid receptors that are responsible for respiratory depression. So with this, you get opioid-induced hyperalgesia. So patients require more opioids to treat their pain. In addition, a great percentage of patients with opioid use disorders have a history of trauma or interpersonal violence, which can make the emotional component of their pain even more. An additional component of the emotions is a worry about child welfare involvement, a guilt about a baby having neonatal withdrawal, and a fear of relapse. So we really have to address all of the components of pain before we can appropriately treat. Prenatal care management, one of the most important caveats of this, women really should be, or pregnant people should be encouraged to stay on their pharmacotherapy for opioid use disorder. If you need to speak with their treatment provider to get information on their last dosage and things like that, obtaining a CFR 42 compliant consent form to talk with them. It's just kind of HIPAA on steroids. We're really saying this is protected information. We know that weaning and detoxification strategies increases the risk of relapse and adverse outcomes without significantly decreases the rates of neonatal abstinence. So there was a push a few years ago to have women who were dependent on opioids or had an opioid use disorder to go off their opioids through medically assisted withdrawal in order to prevent neonatal abstinence syndrome. What we found is this is a really bad idea for many reasons, including maternal relapse of rates of up to 75% just during the pregnancy itself, not to mention the high relapse rates after delivery. Women on opioids for chronic pain can consider weaning down during the pregnancy, but just remembering that there's few other options available for pain. There's other ways to appropriately manage and treat neonatal withdrawal other than weaning the pregnant person off of opioids. Patients who are dependent on opioids for whatever reason can benefit from an anesthesia consult and the cognitive behavioral therapy to balance their expectations and aid with pain control. So labor management for pregnant people on medications for opioid use disorders or opioids for pain. Again, maintaining a daily dose of their medication, either their buprenorphine or their methadone or the chronic opioids that they're on to really prevent withdrawal and treat the underlying pain condition. Remember that this is a baseline. This is not meant to control their labor pain. This is just solely to prevent withdrawal and to treat their baseline pain. Then neuroaxial analgesia, epidural or combined spinal epidural as soon as desired can be important. There's really no evidence of pregnant people maintain on medications, tolerate labor poorly if their medications are maintained. There's some thought to avoid nitrous oxide, though other people, and we have used it successfully, there can be variable absorption and can be dissociative. So some patients can find it problematic. So just use with caution. And possibly increase sedation when combined with opioids. What's really important is really avoiding partial agonists while patients are in labor if they are dependent on opioids because they can precipitate withdrawal and cause some fetal intolerance of labor pretty severely. For postpartum pain management, if they've had a vaginal delivery, just with all pain management, we're really getting to a multimodal approach. And as osteopaths, you are very familiar with some of the ways that we can treat pain without medications. And we have a lot as allopaths to learn about that from you. But really remember, schedule the acetaminophen, you know, one gram scheduled every six to eight hours. Ibuprofen or other NSAIDs scheduled every six hours. And then if they need a stronger NSAIDs, then ibuprofen, then using Catorlac IV or IM. And then, as I just mentioned, non-analgesic adjunct approaches, ice pack, heating pads, hydrocortisone, local anesthetic applications to perineum, acupuncture, massage, all of these things can help. And remember that, you know, keeping the birthing parent and their child together is really important in this process to help take care of the pain. And it helps the newborn also to prevent neonatal withdrawal. For a patient who has, you know, C-section or a more complicated delivery, you can consider epidural morphine or hydromorphone prior to the catheter removal. You know, if they have a significant laceration repair or complicated delivery. And then when you give additional opioids as needed, just really remember to order as needed, not ordered routinely. So being very mindful of this. Remember that buprenorphine, given that it's a partial opioid agonist, it acts on the mu receptors. It can, its activity despite being partially blocking the mu receptor can be overcome with high affinity for agonists such as fentanyl or hydromorphone. And then, so if they do need additional pain medications, it can be given. Doing split daily buprenorphine or methadone doses. You know, we've done methadone up to four times a day as needed to help, you know, treat their pain. But remember, when going from daily dosing to four times a day dosing, sometimes that can make it more difficult in the short term. So just remember that you need to treat their pain. And remember that buprenorphine and methadone, their half-life to treat pain is much shorter than their half-life for withdrawal. So if you're using buprenorphine or methadone to treat pain, it needs to be dosed much more frequently. So laboring persons with an untreated opioid use disorder can be very challenging. It can be hard to get a careful history, but as much as possible, you know, get a history including all substance use. In these cases, especially if they're non-responsive or altered, this is one case that you're in toxicology. It can be considered to know exactly what the patient is intoxicated from or withdrawing from. Doing cow scoring can be very important so that you're treating withdrawal. So the cows is the clinical opioid withdrawal scale. And this is a scale done to know when to treat withdrawal. And prior to the fentanyl age, I would say, you know, you're not wrong starting buprenorphine because it's much easier to switch from buprenorphine to methadone than vice versa. However, sometimes this can be very challenging for patients who are using fentanyl because fentanyl can really build up into the maternal circulation or into the maternal fat store, sorry, and cause precipitated withdrawal when you start buprenorphine even up to two and three days later. So it can be very challenging. So, and sometimes in that case is, you know, using a full agonist such as methadone or treating them, you know, with hydromorphone until you can get them into enough withdrawal that you can safely start buprenorphine with the aid of an addiction medicine provider. Anesthesia can be challenging, mostly given other substances used such as benzodiazepines or stimulants, because they can, you know, kind of confound the effects of the anesthesia. So if they have an unscheduled or emergency cesarean delivery, if they have a labor epidural, that's ideal. You can add long-acting morphine. Some anesthesiologists were concerned because you can't then treat their itching, but most women I know that would much rather deal with itching than uncontrolled pain. You know, obviously spinal if there's time. And then, you know, if they do need a general, depending on the urgency or their clinical situation, it can be done. But then afterwards, remember that your pain control is going to be even more challenging because you're dealing with withdrawal on top of a pain. And so considering like tap blocks and things like that can be very helpful. A low dose of ketamine, and this is, I'm talking very low dose of 10 milligrams, can be very helpful around the time of the emergency cesarean and the general anesthesia, which is interesting because opioid-induced hyperalgesia is really due to the phosphorylation of the NMDA receptors and ketamine reverses this. So when they did a study on this, they randomized patients to get ketamine at the time of cesarean and those that did have less pain at two weeks postoperative. So just really considering that. And, you know, as part of your ERAS protocols, considering gabapentin as a single dose. Long-term gabapentin can sometimes increase the risk of having a baby with neonatal withdrawal. However, a one-time dose is not really going to influence that. For postoperative pain management after a cesarean section, just as with a vaginal delivery, scheduled acetaminophen, PO or IV, they are actually equivalent. So if the patient is tolerating PO, then it can be given, scheduled, and is a lot less expensive. Ibuprofen, again, as scheduled, and then if needed, Ketorolac. Continuing the methadone or buprenorphine is really important in the postpartum period, as well as during labor again, just stressing methadone and buprenorphine won't provide adequate pain control. But it's really necessary to keep these on board to maintain the baseline and treat the opioid debt. So you're keeping patients out of withdrawal. You're treating their baseline pain or. Opioid use disorder, and then adding additional opioids and multimodal pain control measures on top of that, if you can get a PCA, that can be very helpful. Some of my anesthesia friends don't like it and some do some say it limits ambulation and so it's, it's up to your anesthesiologist in the, in the decision making process to make sure that you're doing the right thing. Discussions with the patient, you know, limited a patient controlled analgesia, fentanyl or hydromorphone for 24 hours is not unheard of and can be very helpful. And again, looking at a more functional pain scale, as we're trying to decrease the amount of opioids so that we give as a baseline, because it's no. Secret that we did give too many opioids now, we may not be giving enough. So we tend to have this pendulum that swings, but 1 of the things we can really do is is using something like a universal pain assessment tool, which also kind of takes into not just the subjective from the patient, but some more objective science to appropriately treat pain. If patients are going for a scheduled cesarean section, and they're dependent on opioids, this is something having a pre op consultations with anesthesia to help allay their the patient's fears about getting adequate pain control. Because this is 1 of the great greatest fears they have coming into the hospital is that their pain won't be treated appropriately their labor pain. And then this also gives you the. Opportunity to really counsel about expectations and improve coping strategies to deal with their pain and really reminding them to continue the pharmacotherapy, including the morning of the surgery. So, if they're scheduled for a cesarean section at 1030, make sure they take their buprenorphine before they come into the hospital or get their methadone dose before they come into the hospital. What about naltrexone? Because that is the 3rd option for treatment of opioid use disorder. It's really not recommended in pregnancy for the treatment of opioid use disorder, because buprenorphine and methadone are so much more effective at preventing relapse. And we know that the oral naltrexone is. Which is 1 of the formulations available. Is not recommended for treatment of opioid use disorder, because it actually can increase the risk of overdose death. So it's not the standard of care, but if you have a patient who is on it prior to pregnancy and desires to continue, it can be continued. And it is a 1st, line medication for alcohol use disorder in pregnancy, which I'll talk about later. The naltrexone is available in both oral and a long acting intermuscular form these. Um, like I mentioned, oral is not recommended for treatment of opioid use disorder. The long acting is however, during pregnancy, because we know there's going to be a time during labor where there's a high chance of needing opioids. And this is so this is a full antagonist. So opioids at traditional doses will not work for pain. And so, um. It can be overcome at very high doses, but, um. The recommendation really is to switch if they're on the form to switch to the form, which can then be stopped a few days before labor. Um. Again, realizing that labor delivery, the postpartum period is very fraught time for relapse. Um, and so really being mindful of this and counseling patients appropriately, um, to make sure this will destabilize them. This is just a really busy slide, but if you do have a patient who is on naltrexone and has emergent acute pain, some things you can do, um, including admitting to the ICU under very, um. High doses of full opioid agonist. Um, so switching a little bit to so the post operative. Discharge when you're sending a patient home who is dependent on opioids, um, after cesarean section, and even in the opioid naive. Um, patient really discussing how much, uh, patients. Uh, need opioids, um, when they're discharged home, we know that shared decision, making decreased opioid prescribing by 15% and really didn't affect post operative pain control. Really, when back in the day, when I trained, everybody got. 30, 30 tablets of 5 milligrams of oxycodone and acetaminophen a discharge and, um. For a C section, and really, you know, I trained a long time ago. Um. Of those a really small subset used all of the opioids prescribed. So, getting back to the homogeneous or 1 size fits all opioid prescribing risks under prescribes to an important subsets of the population, but. Really over prescribes to the great majority of the population. So 1 of the things you can do as look at the. Um, medication record, and, you know, see how much they've really been requiring in the hospital and what we found when we're using a multimodal approach, um, and scheduling there and said in their acetaminophen that they're really using much less opioids in general. And sometimes, um, they don't want any opioids to go home with. And so really looking at that and prescribing an appropriate amount. For opioid dependent patients. Um. You need to be mindful that again, their chronic opioids are not going to cover their acute postoperative pain. So, prescribing them their baseline pain medication, or making sure that they have enough baseline medication, plus pain medications to cover for the surgery, which is in general is not more than usually a week. Um, and usually a lot less and again, it's just a patient centered approach and asking how much patients need can be very important. Um, with, especially with patients with opioid use disorder, because some patients are appropriately worried that this might cause a relapse to their opioid use disorder. If they have access to pain medications, especially if their opioid use disorder was brought on by, um, 1st, an addiction to pain relievers. And so with this, um. You know, you also want to appropriately treat their pain because, as I mentioned earlier, pain can be a trigger for relapse. Untreated pain can be a trigger for relapse also. So, um, you can have a stable family member who can manage their pain medications if that's available and really prescribing a small quantity of pain medications for 3 to 7 days and coordinate with the addiction medicine provider. So that they know that the patients on a prescribed medication, and when you have a pregnant patient that comes in, who has had no prenatal care and has an untreated opioid use disorder. They really are the patients that should have priority for admissions for treatment postpartum and giving a warm handoff to the treatment provider while they're in the hospitals really important. Switching gears, because I want to really talk about opioid use. I mean, alcohol use disorders, because I'll cause 1 of the more most common things that pregnant people use and 1 of the most harmful and it's. You know, hasn't gotten. In addition to the opioid use disorders, it's gotten much more common, especially since the pandemic, starting with a, this is a vignette that was in the news several years ago, this Diane Schuller was a 36 year old woman. She drove her minivan down the wrong way down the Taconic State Parkway for nearly 2 miles before striking SUV. She killed 10 people, including her 2 year old daughter and her 3 nieces at the time her blood alcohol concentration was 0.19 so more than twice the legal limit and her urine toxicology was positive for THC in her minivan there was a half empty 1.75 liter bottle so big bottle of alcohol in her minivan, and she was on her way to the hospital. So, big bottle of absolute vodka found hidden in the minivan despite all this evidence her husband and her lawyer came out saying that she couldn't have had an alcohol use disorder. She had to have something medically wrong with her. I go to bed every night knowing my heart is clear. She did not drink. She has not an alcoholic something medically had to happen in this really shows the. You know, that addiction is a family disease and that, you know, having had a close family member who was in a similar situation that I had no idea they were drinking as to the extent that they were if they can hide it very well. And so it's something that we, as providers need to talk to patients about, because they do actually want help in the majority of cases. They just don't know how to get it, you know, some of the advertising that's really promoted towards women, and especially parenting women men, traditionally outnumbered women with alcohol use disorders by 2 to 1 so that the old numbers were 11.9 versus 5.9% but really now it's reaching parity and advertisers are targeting women. As I just mentioned, mommy's time out and this is mommy juice on the bottom and we saw with that the rates of binge drinking increased by 17.5% among women and what we found is alcohol use is increasing among women while decreasing among men. Drinking mothers using it to cope with the 2nd shift. You don't have to you just have to Google alcohol and mom to get all these memes about the most expensive part of having kids is all the wine you need to drink. This is really this normalization that. I'll call is needed to parents and this really came to a head during the pandemic. Women were more likely than men to over drink during the pandemic, including among the non Hispanic black population. Those with children under the age of 18, drink more days and they drink as much as men, including total drinks per month and bit of the episodes of binge drinking. And we also know that women start drinking younger, their adolescent girls are as likely as adolescent boys to binge drink and there's really no escaping this targeting and I have to say, this came into my email box and, you know, it really does sound good to have a, a beer after a marathon. My disclosure, my addicts were 3, so I keep an eye on that. But why, this isn't a good thing when women are over represented with alcohol is there's a faster trajectory to problem drinking and addiction. They develop complications from alcohol, much lower levels of drinking than men and we're seeing alcohol associated liver disease appearing in the 20s and 30s, which is unheard of to have someone with an alcohol use disorder and come in with pregnancy when I trained and we see. A few of those a month, so I'm really remembering that they have pregnant people aren't immune to having alcohol use disorders, even with all of the targeted ads and everything out there we know that people with alcohol use disorder use disorder are more likely to engage in risky sexual behavior, not using contraception and for women with an alcohol use disorder, the relative risk of dying from alcohol use disorder is much lower than women with an alcohol use disorder, which is unheard of to have someone with an alcohol use disorder come in with pregnancy when I trained and came in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol 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come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is un unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is unheard of to have someone with alcohol use disorder come in with pregnancy, which is

substance use disorders

pregnancy

treatment options

maternal mortality

screening tools

opioid use disorder

pain management strategies

alcohol use disorder