So, as a brief overview of our discussion today, I wanted to begin with a discussion over epidemiology and current trends in substance use during pregnancy. I also wanted to review evidence, based practices regarding the clinical care. For this particular population, the impact that covid-19 has had on substance use clinical care and during pregnancy and then I wanted to end with a conversation around stigma. So, starting with epidemiology and current trends... ...in opioid and other substance use over the past. And actually, 20 years, this is an important slide from the CDC. Comparing drug overdose death rates to other public health, epidemics in the past. So here you see, in the red line, the rate of drug overdoses. Basically surpassed automobile, accidents, deaths from HIV and death from firearms in the early 90s making this with the most, Deadly Public Health epidemic in recent history. This is some work by Daniel Ciccarone that talks about how the opioid epidemic is really a series of sub-epidemics. that have changed over the last 20 years. So initially we started out with excessive prescription... ...opioid use in the early 2000s but then that transitioned. over about 10 years to the predominant use of heroin. And then we see a complete overtaking. of use with synthetic opioids, such as fentanyl, Here's another slide from the CDC, which has some really important information about comparing mortality rates between men, and women also in rural versus urban areas. So, you see over time, mortality rates increasing more significantly among women, compared to Men, We also see more significant, mortality rates in rural areas compared to urban areas especially among women. So, for, for our conversation about women of reproductive age that are more prevalent in rural areas. More CDC information related to the predominance of use among women. Which on the left hand, side of the screen, has now really overtake can use. among men, which we used heroin used to be much... ...more prevalent among men. look in the early 60s and early 70s. And then on the right hand side, you see the percent increase. of substance use being more significant among women compared to men. Now because we've seen a significant increase in the prevalence of substance use among women of reproductive age. We have seen a corresponding increase in the prevalence of opioid use disorder during pregnancy. This again is from the CDC. And when you look at treatment admissions for substance use during pregnancy, this has been overtaken by opioids. So, here you see in the orange line between 2001 and 2002 really start to see an escalation in treatment, admissions, really being primarily due to opioids. This is the most recent data on the rates of both... ...NAS or neonatal abstinence syndrome as well as the rates of maternal. Opioid diagnose, these at the time of delivery and national claims data. So the first row talks about neonatal abstinence... ...syndrome and what's important about this slide is the heterogeneity by region in the United States or by state. So you see rates per 100,000 births hospitalizations. That's the unit he here being much more significant in States, Virginia, which is that very very dark amber/red color, almost 53/1000 births population compared to some of these very light pale beige or yellow states, which have much much lower rates like Nebraska... ...1 in a 1000 birth hospitalization. So there's a lot of heterogeneity by state. with the overall prevalence of NAAS and then to the Outside of that row. That's the percent change over the last approximately, 10 years in the diagnosis of NAS you see overall... ...prevalence in a percent change or increases in the rate being similar, but those percent changes you do see as more significant on the right side. Now from maternal opioid use disorder diagnosis, those are going to mirror in a s rates. So down in the bottom row there you see those... ...Maps being somewhat similar. in the coding but again emphasizing the heterogeneity, not every state is the saying. Different states have differential burdens. of substance use opioid use specifically. So, because opioid use is so prevalent, We have seen a significant uptick in overdose as a cause of pregnancy associated mortality. So now whenever we have discussions about death during pregnancy and immediate postpartum, period, opioids and other substances or at the top of the list. So this is a trend in mortality due to all causes on the top. So the top half of this Graph here shows all causes such as just hypertensive, disorders, sepsis, thromboembolic events. And then in the bottom, or opioid related disorders caused causing mortality, which is shown a sharp increase, their between 2014 and 2016, and also noteworthy is the racial ethnic breakdown between these two charts. So if you look at the top aspect of this all-cause mortality, The associated mortality is very predominant non-hispanic, black person's where if you look at opioid-related, there's a predominance, among non-hispanic white individual so different, differential there by race. But still significant cause of mortality, So, a little bit about substance use and opioid, use the among women that it is unique and is important to mention. So. I would argue that the epidemic has had a disproportionate... ...impact on women and there are a couple of reasons for this. So, opioid prescribing, which was the primary driver of the beginning of the epidemic. As mentioned in one of those earlier, slides has been more common among women. Women are also more likely to use opioids, chronically, and at much higher doses than men. And you see a higher prevalence has of chronic pain disorders among women. Compared to men we have an awful off also often have higher levels of emotional distress, anxiety and psychosomatic, responses from Pain, leading to increased use of opioids. So a couple of different reasons why you see an... ...uptick and opioid use that is differential between women and men. Similarly, for substance use. There are different Pathways to substance use for women compared to men. So women have higher rates of co-occurring psychiatric disorders, trauma is incredibly prevalent. Among women who have substance use disorders memory. Women have a lifetime history of abuse and psychological distress. And you see when you talk to women about their use of substances, they often discussed using substances to cope with a mood disorder or history of trauma, PTSD or violence. That's incredibly common among the population. And women often develop physical dependence is more quickly than men, which is a concept referred to as telescoping. So the, the the escalation or the transformation to having a physiologic dependence, appears to be quicker in some women compared to men. And then women have a higher risk of overdose than men even when prescribed lower Doses. And some of this is related to BMI and body mass in those types of things. So we all know as Obstetricians that pregnancy is incredibly important time for all women and... ...especially for women who have substance use... ...disorders with for a variety of reasons. So we know that pregnancy changes all women's behavior. Again this is ubiquitous across all women. We see it all the time in our clinical practices. This is a really nice picture from an article by a four-way, which I really think demonstrates visually. The time to absence of pregnancy for a variety of substances and then in the, on the right hand side, that's the time to relapse or recurrence of use in the postpartum period. So time to absence if you look at the left side of this slide, we soften the first thing to drop off for women as alcohol. And this is important, most women, you do see a stop, if they are not dependent or have a used to sort of related to alcohol. Do stop alcohol. That culturally Has been really an undated in in our, in our culture. That being said, if somebody continues to use an alcohol and pregnancy, the odds that they have a use disorder is incredibly high. So, every woman should be screening evaluated for alcohol, use in pregnancy at the initial contact with either their obstetric or primary care provider. Whoever they're in counting when they get a diagnosis of pregnancy. Because as we know, alcohol is a teratogen. and You use in pregnancy is incredibly harmful for the baby. So alcohol, usually a stopped first and then you see a drop off cocaine marijuana. And then you see the the the least likely thing to stop a cigarette use or tobacco use. And I think we also know that empirically with our clinical practice. and the right hand side again, that's time to... ...resumption after delivery and I think we also are aware of this that most women resume or We increase tobacco use, even if they've just decrease the number of cigarettes smoked per day and other substances are also resumed after delivery. Pregnancy is also incredibly important because it increases health care access for many, many women. So the vast majority of pregnant women with opioid use disorder and other substance use disorder are enrolled in Medicaid. So what happens is if a woman has not been engaged in health care or doesn't have a health care coverage due to a variety of reasons. They get automatic eligibility due to their pregnancy. So regardless of income so that's a huge. gateway to get women necessary services. At they haven't been eligible before and like I said they have new access now to medications for opioid use disorder have access to prenatal care, psychosocial services, and additional supports. Which so it's really this very much window of opportunity. to engage women and health care because they have they have coverage ubiquitous leading. It's also an important opportunity to evaluate women who have substance use disorders for co-occurring... ...disorders that can also be managed and during... ...pregnancy and hopefully treatment engagement occurs that continues after delivery. So that such as infectious disease, processes and psychiatric disorders. Etc. So it's important, especially for Obstetricians to understand that addiction is not a disease of pregnancy. So very few women develop a use disorder during pregnancy. What happens is pregnancy huh? When women who have I used to sorter happen to get pregnant so in why I say this is it's really important to stress. That is a chronic medical process that existed... ...prior to pregnancy and will exist well beyond a pregnancy episode. So our goal is as obstetric providers is to try to engage and try to get as much women as many supports engaged in treatment, try to to connect her to as many resources as... ...possible while this window of opportunity exists... ...because the use disorder will persist for the rest of her life. And our job is to help help her really engage in the management of that disorder. So, I also wanted to read you a little couple ways we think about addiction and where all clinical... ...providers should be thinking about this. Initially. was talked about as a brain disorder. in the early 90s through the NIH. and it was described as a chronic disease. Brain reward motivation, memory related circuitry. So the brain is essentially rewired when somebody has prolonged use of substances that leads to dependence. So there are physical and and receptor change. Has that occur that that cannot be undone with with the flick of a switch. So dysfunction in this neurocircuitry leads to the characteristic manifestations that were used to seeing with somebody who has a substance use disorder. and then which is typically pathologically pursuing... ...reward or relief or other typical behaviors. This is a more I would say an addendum to that definition, which is preferred by the American Society of Addiction Medicine, which is the biopsychosocial model. So you have biological factors, genetic factors have predisposing factors family, history of somebody who may have had a substance use disorder, psychological factors to somebody who maybe have a psychiatric disorder, that's untreated or something that is needs to be addressed. That the substance is helping with. Then there's the social or environmental context, that will contribute to. the development of an addictive Sorter. And then you have to have the substance. So you can't have a used to sort of, without any substance exposure. So adding that on is a critical component and... ...then a Sam describes this as almost like a switch. And when all of those things come together, I used to sort of develops. And the symptoms of an addictive process, our... ...behaviors and like most disease processes that were the symptoms are behaviors. I think that often makes providers at times. Uncomfortable. obesity is an example where the symptoms are often characterized. But with behaviors, those are often considered very kind of refractory or difficult to manage chronic disease. Process sees versus managing some numbers or like... ...hypertension or somebody's. a glycemic control. You're monitoring the behavior incentive numbers. So these behaviors are the inability to abstain from a substance, or craving a substance impairment and behavioral control. and diminish recognitions of the problems with one's Behavior. So Allah loss of insight, it is supposed to involve cycles of relapse and remission. Just like any other chronic disorder and without treatment, it is Progressive and can lead to significant mortality. We're aware of. So I wanted to transition a little bit into evidence based practice because I think it's important for all obstetric providers to be aware of some... ...very fundamental premises of how we should be caring for this particular population. So, I think it's important to think about the... ...opioid epidemic as a patient safety issue, because opioid related deaths are preventable, and we saw how they contributed to mortality. So, therefore, the mentality rot. The rise is immortality that we've seen due to opioid use are highly preventable. Doable. So I put this up here so that people understand that it's a really important reference that is available. online through ACOG and AIM. So ACOG's partnership with AIM to produce a patient safety bundle. This one is about obstetric care for women with opioid to suit used to sort of, which was published a couple of years ago. Really is designed to help systems and providers... ...adapt evidence-based practices into their clinical... ...settings to really group outcomes for this population. So this is essentially a plug to look at the bundle. Utilize the bundle as a way to optimize your clinical care Pathways and how you perceive. the picket patient care process for this population. But I'll go over some highlights so screening, which is the beginning of the process. So, Universal... ...screening is recommended for all pregnant women period. using a Dated instrument. So every single woman who walks through the door... ...with a new diagnosis of pregnancy should be... ...evaluated for licit and illicit substance use, but that evaluation is a conversation. that can be helped with the use of a validated tool. And I've listed those here on the slide, these tools are all been doubt validated, or evaluated and pregnancy. So, again, the screening process is universal for all women and should be a patient provider communication or patient-provider conversation. Selective screen here risk-based. Screening is a problem and inappropriate because it misses women with problematic. Use a perceptual, 8 stigma and discrimination and no one knows who is using substances, so it's completely inappropriate. So is universal urine, toxicology screening. There's a variety of reason that this is not recommended and should not be used as a sole assessment of substance. Use urine drug screens, have a variety of issues with them. They've been Very short detection window and they don't capture binge or it continues. They do not look at alcohol at all and they don't... ...capture depending on the essay a variety of... ...synthetic opioids like fentanyl car fentanyl. So you'll have somebody quote-unquote screen positive on a urine drug screen when the fact they may be using highly. highly dangerous opioids, synthetic, opioids. So when do we do, do urine drug screening? You. should establish in your clinical setting specific... ...criteria for when this could occur to avoid profiling discrimination bias, which is rampant frankly before performing a urine drug screen, you have to paint consent. There are serious problems that will occur. If somebody's any biological sample is sent without their permission because there's significant consequences to that with somebody who comes back with. Sort of biological tests. There are certain exceptions for certain situations, clearly possible criteria, for biologic testing. I've listed some here. There is no standard for when this must be done. But here are some things that certain Health Care Systems. You serve. Somebody has been absent for care or there's a concern about a certain Behavior, then potentially a conversation about substance use could occur somebody a signs or symptoms of substance use. Somebody has a Issue like cellulitis or endocarditis. That seems like it could occur from injection or intravenous drug use than it may be warranted, often patients, who are in treatment programs, get urine drug screens. and there may be an obstetric complication that is concerning for ongoing substance use, but it's there should be criteria, that is established so that we're not doing selective testing. Now, going to transition just briefly to kind of clinical care Pathways and things that are... ...absolutely necessary to provide care for this... ...population because it's important for... ...all providers to be aware of these components of a comprehensive care package. The first component to this care package is medication, absolutely necessary for all women period and the two medications we use most commonly from pregnancy or methadone and buprenorphine. I want to briefly review the historical context of this because I think it Helps with the perspective of where we have been where we are now. So actually in the early 70s, is when we started to see published literature on steel, birth rates among women who had opioid use disorder, they would come in at the usually third trimester, or peri-delivery and they're still birth rates were four times greater than those in the general population. And women were presenting, because there was no... ...standard and treatment at that time from a medication perspective, in repeated cycles of detox, and real app. Which is what happens when you're illicitly using and they noted, the fetal distress again. Like, I mentioned stillbirth and then it was a concern for fetal withdrawal in utero that was unmonitored. And then when the infants were delivered, they noticed a withdrawal syndrome that has been termed NAS or sometimes referred to as NOWS, our neonatal opioid withdrawal syndrome. So, this is one of the very first published papers on this issue when they engage women in methadone. So these are women, who came in, who are listed Lee using opioids, and they were able to engage both of them and methadone treatment. Now, the baby's still had withdrawal symptoms after... ...delivery but those moms and babies went home together. So that's really what we're looking for. Is Preservation of the maternal infant diet and this is one of the first studies that showed that... ...power of medication to help in some way. Recovery process and keep moms and babies together. So this is a great slide, it's simple, but it has a huge impact. So the red line is overdose rates and then the green dashed line is, people orphan the use of buprenorphine and the blue is the use of methadone. So there you see the rise in the rates of both of those pharmacotherapy options, and you see a corresponding decrease in overdose. So medication works, it is the key component to anyone's treatment program, who has an opioid use disorder. Or I'm not going to go in depth to the two medications, but I will just mention the concept of which one should a patient Beyond. Now, that's an individual Choice by a patient. So there's no perfect person for either and the, the treatment should be tailored to the needs of each patient. It's important to talk to women when they come in to, for to initiate treatment. What are their experiences with treatment? Many women have been on treatment in the past or have used these treatments illicitly and have a preference. So, we need to be talking to him. In about what their exposures have been in the past, what they would like to go on for a treatment. Just like, with diabetes, we have different treatment options. We want to have different treatment options for women who have substance use disorders. We should not be transferring women who are successfully engaged in a treatment program prior to pregnancy to another treatment program during pregnancy. Because if they were successful using a particular medication, we want to keep them on that medication during pregnancy. Even some early data on Vivitrol demonstrates, a success with keeping women. Although that is currently not standard of care. candidates for buprenorphine, we do offer this as first line for patients, who are treatment naive. It's easy to start, it's easy to transition to methadone. If you're not successful that with that particular medication. versus or somebody with methadone, unless they have a preference for that up front. Also for buprenorphine, you want to make sure they they could Sure, their medication without concern for diversion. And again, there's many places that don't have access to methadone, so that may be your only treatment option. Brief slide here about Subutex versus Suboxone. Just because that may be something that providers have been exposed to. So, buprenorphine was the only product available when the early pregnancy safety studies were being conducted. So that really did dictate early clinical, practice patterns, but there's a lot of advantages to the Suboxone of a combination buprenorphine/naloxone product, there is a decreased risk of a diversion and Medicaid covers Suboxone in all 50 states versus in some states, there is restricted, access to the mono product, or buprenorphine. So, Suboxone is universally available and so, a lot of treatment programs, including ours, here in Pittsburgh, have transition predominantly to Suboxone with a few exceptions, the another concern related. To the combination product initially, which is not borne out, is, is related, was related to naloxone, so it does cross the placenta, but there's very low levels of absorption or transplacental passageways, orally ingested, which is how it's designed to be taken, and neonatal levels, are significantly lower than required for therapeutic effects because there was a theoretical concern about potential induced neonatal withdrawal process and illicitly using a full agonist, like heroin and then introducing the combination. Like, such as buprenorphine naloxone, but that has not borne out to be a significant issue. So Suboxone is just as acceptable, treatment auction as subutex, and in many cases preferable. I. wanted to briefly talk about detox or medically... ...assisted withdraw because that it tends to come up. This was a systematic review. We put together on all of the detox studies that... ...have been published related to the process and pregnancy. Many of the studies were of incredibly poor quality. There was not an RCT for obvious reasons and most of them did not have a comparison arm. There was a huge loss to follow-up and participating patient. It's and then a lot of risk of bias in the women that were enrolled in these studies. So you saw among those studies huge ranges in completion rates for the process. So many women weren't able to even complete the... ...withdrawal process and when you see completion rates around 100%, those were typically in incarceration or jail settings. where women didn't have a choice and then, in addition to not completing the withdrawal process, you see illicit drug use for currents being incredibly prevalent. Two women who were withdrawn. Now, the initial issues with stillbirth we found not to be different between women who were withdrawn and women who stayed on medication for oud. So that initial concern and when you aggregate all the studies together with not an issue but the real concern is illicit use recurrence as well as the inability to complete the withdrawal process. So in summary, when you look at retention rates... ...by medication or route of treatment. You see some difference here, which I think is important to mention. so methadone, you see retention rates between... ...50 and 80 percent. the Suboxone or the buprenorphine product to see between 40 and 50%. And then it really starts to drop off with Naltrexone, abstinence based approaches or non-medication approaches, and then a medically, assisted withdraw, you see much lower rate. So again, like I mentioned earlier medication management is really the standard of care for the treatment of opioid use disorder. Who is prescribing during pregnancy. This is an analysis we did looking at prescribing providers, other people an orphan for pregnant women than Pennsylvania. Medicaid. And here we see that Primary Care Providers are by far the most common. prescribers of buprenorphine and pregnancy in code. And then there you see in the middle of this table OBGYN. which really is much much too low in my opinion. And we need to encourage all of our upstairs colleagues to become, wavered to provide beeping orphans so that we... ...can serve as a gap filler or even be able to initiate. an orphan in pregnancy. for patients, who come in, who need medical, who need medication during pregnancy. So the importance of obstetric providers in the care continuum for this population is incredibly important. So we're going to briefly go over a couple of... ...additional components to kind of what I mentioned a comprehensive care approach. So trauma is incredibly important in this population to address as well as the ability to provide Behavioral Health interventions. So all pregnant women with opioid use disorder should be evaluated for Behavioral Health needs over half of pregnant women with opioid use disorder, have a co-occurring psychiatric disorder. So that has to be identified. and treated appropriately and most psychiatric medications are safe in pregnancy. This is this is I think an incredibly important slide about understanding where woman has come from and the journey that she has had that has led up to. where she is in pregnancy and where she is in her recovery process. So part of understanding that is listening to women and asking them what has gone on in their life. So so it's essentially changing the conversation from what's wrong with you too? What has happened to you? So engaging in patients about their personal experiences understanding. what has happened in their life and that can be a key to helping treat their recovery process. So, a little bit more information about trauma experiences among many women. So many women experience trauma in childhood. So feelings of neglect, verbal abuse, physical, abuse, observed ipv, all of these. Childhood. And then we also have to understand the social context. So many women have a current or former partner, who is used substances, or is currently using a substance. This can really impact the recovery process and... ...ability for that patient to remain engaged in treatment. So you see a variety of friends, family members acquaintances. If somebody is using around you, it's very difficult for you to maintain. your recovery process. So, co-occurring disorders are briefly, want to mention co-occurring disorders, because they're incredibly important, especially when women are getting engaged in Medicaid and prenatal care. We need to be talking to them about hepatitis. We need to be screening all women for hepatitis and HIV, and linking them to care after delivery because that often does not occur. So intravenous drug use or injection drug use has now overtaken. previous cause has to be really the reason most individuals are getting hepatitis C. And over 80% of women who have opioid use disorder, have a history of intravenous drug use at one period of time. So many are Hep C antibody positive. We need to do a viral load to see if their chronic carriers antibody. Positively, just the first step in the in the evaluation process. to understand. If they do have chronic the chronic disease process, and many women are newly diagnosed and pregnancy because again, it's a new time for care engagement. So we need to see if they have chronic hepatitis. We also need to be evaluating all women for HIV and then vertical transmission of hep C is leading cause of childhood hep C at this time. So a couple slides, about social services and resource support, because this is incredibly important to care for this population. because these needs are significant for many women. Social workers are by far my favorite individuals because they provide so many resources and Care Pathways for patients that. Nobody else can. So social workers and Social Service organizations are critical to the care process for this population. So many women need housing Transportation assistance. They may have legal issues. That each job support of training. They need help with childcare or. To understand the mechanisms for childcare that is supported by federal funds. Many women in need help with insurance to get enrolled even though you're eligible, doesn't mean that you're automatically enrolled unless you go through the paperwork process. So social workers, and Social Service organizations have to be part of the Care Delivery Continuum. So this is just a long list and it's not meant to be read individually, but it just shows that all of the things that go into really trying to take a comprehensive approach to the care process. And what many of these women really need. to really engage and have a successful recovery... ...process for themselves and for their families. So a quick slide on postpartum care because care does not end in pregnancy and substance use is forever. So postpartum care. So one of the things about many women with substance use disorders is at times many women do not end, attend their postpartum visit. I think that's true for all for all women in general. But especially for women who may have more active substance use issue. We see decreased attendance with the postpartum visit. So if we want to provide certain things that we have historically, Provided during the postpartum visit we need to... ...find another way to do so. So thinking about the immediate postpartum period, what can we provide the hospital? What are ways that we can engage women to come back to see us, whether it be virtual visits or remote Outreach to might, to make sure that we're able to follow up with these patients. After they leave the hospital. So breastfeeding another important postpartum issue. So many women do initiate breastfeeding in the hospital. But you see significant declines in? He's feeding rates in the after the immediate postpartum period. So well, initiation is strong among many women and who have substance use disorders. We need to understand ways to more effective effectively, engage them at the postpartum period continues because there's a lot of benefits to that... ...you see Improvement NAS severity decreasing NAS treatment rates. Stress reduction, for Mom, increase maternal confidence is really important outcome to Look at increased bonding and often motivation to continue to. Avoid illicit, use always need to be thinking about contraception. Only for women who do not desire, another pregnancy, but in the postpartum period they just had a baby. So we want to make sure that we have talked to them about their contraceptive plans moving forward. And what is the type of or two to choose a method, postpartum depression, almost, half of women, with OUD screen positive for postpartum depression. So that's an incredibly High rate. We need to be understanding. how we can get women engaged in Behavioral, Health... ...interventions during pregnancy and screening... ...evaluate for spikes in pre-existing mood disorders and make sure we're aware when this can occur again, and then parenting is something often, not discussed, but as a critical component to taking him to baby and a lot of women who have a Substance use issue lack knowledge about being music infant care. So, parenting skills training classes, support groups, intense involvement. With the Pediatric Care Providers is critical for this particular population to ensure outstanding outcomes for moms and babies. So, I want to transition here to some data related to covid-19 and substance use. Because there is a lot of impact in covid-19 has had on substance used in calculations. So this is recent data from the CDC from December of this year that looked at drug overdose deaths in centrally the year prior to May 2020. So that was the highest number of overdose death rates ever recorded in a 12 month periods. And a lot of these overdose deaths occurred at the end of that period over the course of the very beginning of the pandemic. And so, that's a lot of this is attributed to covid synthetic, opioids, appear to be the driver as they have been with the last several years of overdose death rates, increasing over 30% and there's also been a significant rise in stimulant use, which is what's happening. Is there's Co-user contamination. So either known or unknown contamination of cocaine with fentanyl. And then somebody goes to use cocaine and there's fentanyl. embedded within the substance and they have either an unintentional overdose. So deaths involving psychostimulants, methamphetamines, etc., have also and increasing. So a lot of polysubstance, use a lot of mixing of substances. causing a spike in mortality rates, and with covid... ...what happened and is still potentially happen is patients, were using alone and one of the protective measures against overdose death, it when somebody is actively listening using is to use with somebody else. So that if there's an overdose does occur that you have naloxone or somebody to help get assistant assistance. But if patients are using alone, you see death... ...rates rise because there's nobody to assist. If somebody has used too much of the substance, they're also working incredibly increased barriers to treatment. So many treatment programs were not accepting new patients. It was more difficult to be seen in person. So those early months of the pandemic, we really saw a lockdown in the ability for patients, who receive care, which increase illicit, use an overdose rates and then all of us have had increased psychosocial stress. But when you have very little Support and reserve when significant stresses like have occurred with the pandemic occurred on a employment loss of child care, your child, may not be in school anymore. Again, loss of financial income. You those psychosocial, stressors have really caused a spike in substance, use in general and adverse outcomes for those with use disorders. This is a study out of Kentucky, that looked at that kind of immediate pre, and then in the heart of the endemic, January to April 2020, and they saw a bump in the number of EMS overdose runs the emergency department. They also sought a lot of refuse transportation to the ED after overdose, so it happens is emergency. Medical personnel will go out to a size 8. They will revive somebody who's at overdose with naloxone and then they'll refuse. transport back to the emergency department. So that was a significant increase their and then an increase in runs for suspected overdoses with deaths at the scene meaning, when they arrived, somebody had already died in the cause was most certainly from overdose. So, a little bit about covid-19 and severity of... ...somebody with a substance use disorder and covid-19 risk and severity. So there's been no data that has demonstrated That covid-19 severity increases in somebody who has a substance use disorder but that that literature... ...and that research is ongoing some hypothetical reasons. Why somebody with a substance use disorder may have an increased risk for a severe covid-19 infection or hospitalization due to covid-19. So. we know that opioid use decreases respiratory... ...rates which already can lead to respiratory depression. And in somebody with a respiratory illness, that could be exact after baited and let use can. Cause a variety of abnormalities. that can be worsened with covid-19, smoking is a big issue, so many. individuals who use substances use tobacco, and they also smoked their substance of abuse. If it's, in addition to Tobacco. So many patients have underlying lung disease... ...like COPD and Asthma and just in general poor lung health and then you put a Covid-19 infection on top of that and then it's hypothesized that... ...that could have a much worse or severe outcome from a covid infection. Another thing to know that we've discussed is... ...many of these patients have maybe a immuno... ...compromised due to HIV, hepatitis, or liver disease... ...from viral hepatitis and that could affect their covid-19 outcomes as well. So speaking of the use of multiple substances, this is some of our research groups data from a national data set, talking about the use of additional substances in addition to opioids during pregnancy. So, on the left-hand, a, you see. a spike in the prevalence of tobacco use among pregnant women with the oud. So again other predisposing factors for chronic lung injury and chronic lung issues for this particular population. You also see a Is there on the right hand upper side - C for cannabis use. We also saw a rise in amphetamine use over time with decreases in cocaine, sedatives and alcohol. So but from a pulmonary perspective and along damage perspective, cannabis tobacco and amphetamine use could could contribute to worsening covid-19 infection. So covid-19 also cause significant changes in substance, use care. So just like all Healthcare was very much disrupted, especially at the beginning of the pandemic, a lot of substance use regulations were temporary... ...lifted because they were pretty stringent and... ...even more barriers would have been in place if we could not have temporarily lifted some of those regulations. So we saw a lot of increased spacing between visits and dispenses to allow for social distancing, and not having as many patients. As calm as frequently in person, we see a rise in telemedicine versus in-person visits a decrease in the amount of urine drug screen that was occurring because patients weren't coming and in person and he's restriction for take home at the dose of methadone dose is typically. Methadone is dispensed daily for patients who are early in their recovery process. And we saw with covid, a lot of patients taking home, multiple doses of methadone potentially, before they were stable enough in their recovery to do so. So, we did see a spike in street methadone use, or methadone diversion, which typically had not been as significant of problem, due to the tight regulations, pre covid related to take home doses. So, a couple of words about telemedicine. So telemedicine has really increased the flexibility of patients and providers to be able to have Healthcare encounter related to substance use, and we've been able to prescribe buprenorphine or other controlled substances. The medicine without conducting an in-person evaluation, which is really been great to reach patients. Who for a variety of reasons, can't make it in in person for a treatment appointment. However, that the converse side of that is, I'll show you a little bit of data decrease in person visit frequency, can lead to less accountability, and can lead to increases in illicit, use diversion and overdose. So a lot of substance use treatment is relationships. and patient-provider. Their interaction, which... ...is harder to do often via telemedicine or Telehealth approaches. So balancing. the flexibility of telemedicine with the need for high-quality care. That often needs to occur in person is still something that we're trying to figure out as a Treatment Community. So here's basically a non-inferiority kind of observational trial, where. approximately 100 pregnant women were either chose to receive in-person treatment or telemedicine... ...person after an initial in person visit and they didn't see in this trial with only 100 women, significant differences in retention and treatment... ...between women who chose telemedicine and those who chose in person. So we can be an option. For some women may be More stable in their recovery or have significant difficulties getting too impatient appointments, and it is an important part of treatment that will stay. It's just more evaluating, which patient is right for this particular modality. And how often is this modality used. The converse is, is this study which is in the Gray journal in November of last year about unintended consequences of this transition. So here on the left is the attendance at a group therapy. So the red is attendance when patients were in person which was over 60%. And then when things went virtual right in the heart of the pandemic, group therapy, attendance dropped off, significantly to only 20% and then post kind of the spring when they used a combination of in-person and virtual options, group therapy, attendance, jumped up. So exclusive virtual or exclusive telemedicine... ...care for Patients with substance use is probably not the right option and on the right hand side, another graph. Depicting that shows craving scores or the craving for opioids. when there wasn't, you see that spike in the Middle where there was virtual only care, it really does to me emphasize the importance... ...of touching base with your provider in person. The need for that relationship to develop that trust. Stead interaction to be in person for at least a significant percentage of time and for women who are early in their recovery. So, I want to end with a discussion on stigma because. we see stigma all the time in our everyday lives, for a variety of different persons in in our culture, in our country, in our world, and. nobody faces more stigma than women who have substance use disorders. So like I mentioned, they're really the most stigmatized of all chronic medical disorders. in stigma among Healthcare professionals can really... ...threaten their therapeutic commitment and prevent Amon from seeking care. And when women don't seek care, then we see a rise in adverse outcomes. So images really matter. So, these are some images that are particularly stigmatizing, so the use of needles, you won't see any needles throughout my presentations. Nobody needs to watch somebody injecting substance into their arm. It's just, it just creates. not a helpful image of substance using individuals. And. this up here in the upper left-hand corner of a crying baby. I mean all babies cry. So, Showing. images like that of children of women who may have a substance use or it's not helpful to anyone and should not be used to encourage you. If there's an interview or if you have a media. encounter to stress, the importance of, how to... ...communicate this in a non stigmatizing way in addition to images. Mattering language really matters to. So how we talk about patients who have a substance use disorder and how we talk to patients, really, Ali really matters on a daily basis. Women talk to me about the language and how they've been treated by Healthcare Providers and it's often a warming. So on the left-hand side here you see examples of stigmatizing language, so addict junkie alcoholic drug user. Instead, we need to talk about individuals with substance use disorder or somebody who's coping or dealing with a disorder. Again, using the word clean, the converse that is dirty is I know that these are kind of slang words but we really want to talk about somebody who's in... ...recovery or engaged in treatment. and medications for opioid use disorder are what they are their medications, they're not opioid Replacements. or anything different than any other medication for any other medical disorder so they should be called as such. The worst culprit is addicted baby. No one should ever be using that phrase. and Technically babies aren't even addicted. Addicted. Behaviors is a behavior where somebody expect has a behavior to use and babies, don't do that. They have a physiologic dependence on a substance. So that should never be used. And then detox, even though it is phrase used, we should we should be using medically monitor, supervised withdrawal, So this is my last couple of sides. We did survey a group of providers in our health... ...system regarding beliefs and attitudes towards pregnant, women who have substance use disorders. And what we did is we asked them 11. We show them 11 statements and ask them if they... ...agreed or disagreed with those statements. So some examples, these are the 11 statements here. So examples of, you know, most alcohol or drug dependent persons or unpleasant to work with pregnant women who use alcohol or other drugs should be I wish those... ...types of statements and what we did is we created a stigma score. So 1 through 11, if you had the right answer, well if you had the wrong answer, you had a stigma score of 14 that question. So your score could be a zero to 11. So, here are the stigma score by the types of providers, we asked. So we asked a PPS, nurses, Physicians, and social workers. And so, if you had a zero stigma score, you, you did not... ...agree with any of those stigmatizing statements. And if you had a set, well, nobody scored above a seven. But a let if you had 11, then you you felt like all those are appropriate statements. So here you see what's great. A lot of providers did not agree with most of the statements but you do see a trend with several patients. I mean several participants I'm agreeing with... ...some sizing statements so and then some differential by provider type. So the blue being a peepees orange, nursing gray, Physicians and yellow. Social workers social workers, kind of having least or the smallest stigma score. So it just provides an example of. There's a lot of stigma out there among providers and we need to do our best to try to change that. And this is just again, emphasizing how we are... ...responsible for this and understanding addiction as a medical. Water can really reduce stigma, and educating ourselves, and our colleagues is essential for improving outcomes for this population. And I want to end with this quote, because I think... ...it's just so wonderful and it grounds us as Obstetricians. So the dyad is what we're all interested in preserving and it's so important for all women to be with it babies. So what is the dyad? It's a structurally and functionally interconnected metabolic. You meant shared by the mother and fetus through the placenta. So there is no such thing as a baby. If you set out to describe a baby you will find you were describing a baby and someone be a beacon on Oh, exist alone, but is essentially part of a relationship. So as obstetric care providers is reading through, this always makes me just reaffirms what our goal and Mission is. as Obstetricians. Thank you so much.

substance use during pregnancy

opioids

clinical care practices

COVID-19 impact

stigma

evidence-based practices

comprehensive care

maternal and infant outcomes

stigma surrounding substance use