Good evening, everyone, and thank you for joining us this evening for the American Psychiatric Association's Looking Beyond webinar series for our third session for our summer webinar series focused on maternal mental health. My name is Madonna Delfish, and I'm a senior program manager in the Division of Diversity and Health Equity here at the APA. Now before we get started this evening, I would like to take a moment to acknowledge the land on which my home sits. This is the ancestral lands of the Piscataway Indian Nation. Please join me in paying respects to the elders, past and present, and acknowledge that it is our collective responsibility to support and pursue policies and practices that respect this land and its First Peoples. Thank you. I would also like to take this moment to thank the American Psychiatric Association CEO and Medical Director, Dr. Saul Levin, our APA President, Dr. Petra Stavonis, the APA Board of Trustees, our councils, our committees, caucuses, and our administration for their contributions and continuous support for the work that advances mental health equity. I would like to especially thank Dr. Regina James, Deputy Medical Director and Chief of the Division of Diversity and Health Equity, for being a champion for change and for support for this critically important webinar series. And now, I would like to introduce our esteemed moderator for this evening, Dr. Lane Gritti. Dr. Gritti is an adult in addiction and perinatal psychiatrist who completed her psychiatry training in Cleveland, Ohio, at University Hospitals Cleveland Medical Center and Case Western Reserve University. She served as Chief Resident amid the unprecedented changes caused by the COVID pandemic and went on to complete fellowships in women's reproductive mental health, community and public psychiatry, and addiction psychiatry. Dr. Gritti is also a tobacco treatment specialist through the Mayo Clinic and an acupuncture detoxification specialist through the National Acupuncture Detoxification Association. She currently serves as the Director of Substance Use Disorders and Perinatal Psychiatry Divisions for Sweetgrass Psychiatry in Mount Pleasant, South Carolina. Dr. Gritti, welcome. Thank you. I'd like to welcome everybody to tonight's panel discussion on this topic of utmost importance, addressing gaps in comprehensive treatment for birthing people of color with comorbid substance use disorders, implementing a targeted approach. I'd also like to thank the APA and Madonna Delfish for making this important educational activity possible. Tonight, we gather to shed light on a pressing issue, the disparities in healthcare faced by Hispanic and African American women when it comes to mental health and substance use treatment. The CDC's Maternal Mortality Review Committee found that 80% of pregnancy-related deaths were determined to be preventable. They also found that the leading cause of death varied by race and ethnicity. For Black women, cardiac and coronary complications were the leading cause of pregnancy-related death. For Hispanic and white persons, mental health conditions were the leading cause of death. And for Asian persons, hemorrhage was the leading cause of death. We all know Black women are three times more likely to die from a pregnancy-related cause than white women, which is the most significant factor contributing to our maternal mortality crisis. And you may hear things like, these communities often experience lower utilization of mental health and substance use services. However, the truth of it is that mental health and substance use services have not found ways to reach the people in these communities. Even more concerning is the fact that pregnant Hispanic and Black women entering substance use disorder treatment frequently report unmet mental health support at higher rates than their white counterparts. This disparity is exacerbated by the persistent barriers of misogyny, structural racism, discrimination, and stigma within our healthcare systems, making it even more challenging for minoritized women with substance use disorders to get the care they need. As healthcare providers and professionals, it is our responsibility to explore targeted approaches that are culturally appropriate and can bridge the gap in comprehensive treatment for birthing people of color with comorbid substance use disorders. Our goal tonight is to discuss the challenges surrounding the provision of care to pregnant individuals dealing with both substance use disorders and mental illness. We will also delve into evidence-based harm reduction strategies and best practices for treating pregnant and nursing patients. Throughout this webinar, our esteemed panelists will share their expertise, experiences, and insights. Together, we will explore the complex interaction between pregnancy, addiction, and mental illness in treatment planning. We will examine the importance of culturally appropriate approaches to care, highlighting the need for tailored strategies that consider the unique backgrounds and experiences of individuals seeking treatment. Additionally, we will discuss gender-responsive approaches to treatment and recovery and understanding the distinct needs and perspectives of birthing people. Our shared objective tonight is to assess current treatment recommendations and pave the way for change. By engaging in this conversation, we aim to bridge gaps in comprehensive treatment, dismantle barriers, and promote equitable access to care for all individuals, regardless of their race or ethnicity. Without further ado, let's embark on this enlightening journey together. Our panel is prepared to offer our insights and expertise as we work towards a future where every birthing person receives the care and support they deserve. Tonight we will start with Dr. Ponce-Martinez. She is an assistant professor in psychiatry at the UMass Chan Medical School and an assistant professor adjunct in the Department of Psychiatry at Yale School of Medicine. Dr. Ponce-Martinez is a graduate of Tufts University and UCI Med in Costa Rica. She completed her psychiatry residency training at the University of Virginia, where she served as chief resident and addiction psychiatry fellowship training at Yale School of Medicine. At UMass Chan Medical School, Dr. Ponce-Martinez's clinical and research interests include expanding access to treatment for substance use disorders in a variety of clinical settings, including inpatient psychiatric units, inpatient medical surgical units, emergency mental health unit, and state psychiatric hospitals. She is the addiction psychiatry section chief, director of telepsychiatry, and the program director of the addiction psychiatry fellowship at UMass. Thank you, Dr. Ponce-Martinez, and you can take it from here. Thank you so much, everyone, for having me here, and thank you for the invitation. I have a few slides to share as part of my presentation. Okay, and I think my slide is open. Great. So I'll be talking during this first part of the presentation about pregnancy, addiction, and mental illness. I don't have any conflicts of interest to disclose in relation to this presentation, and we'll focus on two of the objectives that you saw as part of this webinar, exploring the complex interaction of pregnancy, addiction, and mental illness in treatment planning, as well as assessing current treatment recommendations as they relate to pregnant women with substance use disorders. Why is this important? Why is this topic important? The first is that the rates of substance use and substance use disorders among women who are pregnant are increasing, and I mentioned substance use and use disorders, because any substance use during pregnancy can be harmful, and can have a negative effect on both the mother and the neonate. Most pregnant women, despite this, go untreated, and they are not treated for substance use disorders. Most pregnant women, despite this, go untreated, leading to an increase in negative maternal and neonatal outcomes. The perinatal period is really an ideal time to both screen for and treat substance use disorders. For one, there's increased contact with health care professionals related to, ideally, prenatal treatment. There's increased access to health care insurance across most states, and there's often a motivation on finding out that they are pregnant. It is important to note, though, that due to the severity of their disorder, some women, despite the high motivation, may really find themselves unable to stop use, because of, again, the severity of their illness, as well as the access to treatment, as Dr. Grady had mentioned. Women, we know, face greater barriers to entering treatment for substance use disorders. This is in general. This is related to greater substance use-related stigma associated with being pregnant. It may also include family responsibilities. There can be fear of legal consequences, and I'll talk about this a little bit further, including child protection agencies, loss of custody of children. There's also a greater likelihood of co-occurring psychiatric disorders, particularly mood and anxiety disorders. So this is, again, some general information about women and substance use disorders. When we think about racial and ethnic minorities and women of color, these disadvantages or these factors are even more magnified, as I'll show you in some of the future slides. So how common is substance use in pregnancy? So this is data from the 2021 National Survey on Drug Use and Health, which is an annual survey that was conducted by the Substance Abuse and Mental Health Services Administration, or SAMHSA, of civilian population age 12 and older in the United States. So this one looks specifically at females of reproductive age, so between ages 15 to 44 and past month use, which is typically a proxy for current use, and found that about one in five use some type of tobacco product, alcohol, or illicit drugs with the legal substances, so alcohol and tobacco being the most common, but also significant numbers of illicit substance use. I have a few graphics later on to show you the prevalence of those. So it is not an uncommon problem in pregnancy. Furthermore, it seems like similar to other factors when we think about substance use disorders, the use of more than one substance is common. So patients, or so women that had used one substance, even if it were a legal substance during pregnancy, were more likely to report use of other substances. And all of this is sort of keeping in mind that drug and alcohol use, because of stigma during pregnancy, is very much underreported. So we believe that those numbers are much likely higher than what the survey finds. So this is information from the 2019 NSDUH, looking at women 18 or older. And again, the co-occurring substance use and mental illness is still quite high. So 4.6 million people, or a million women, age 12 or older, have both substance use and mental illness. I mentioned previously, alkaline tobacco remains the most common substances, and among illicit substances, it is cannabis, which is the highest. But there's still significant numbers of opioids and cocaine. And cocaine has a particular relevance, given the high rates of maternal mortality related to overdose deaths. We have seen an increase in cannabis use in women and pregnant women across the U.S. And this is in large part related to laws across many states legalizing recreational use of cannabis, and the perception that it is less harmful than many other substances. And so this sort of message gets passed on not only to adolescents, but also to young pregnant women, so thinking, well, it's not as bad as drinking alcohol. And what we find, as I mentioned previously, is that with the use of cannabis, not even the cannabis disorder, but use of cannabis, really increases the risk for co-occurring substance use and mental health issues. The other part of the story is that, and probably the most relevant as it relates to the The other part of the story is that, and probably the most relevant as it relates to this webinar and to our practice, is that the treatment gap is huge. So if we look particularly at co-occurring, so AMI is any mental illness, so the presence of any psychiatric disorder or mental illness, and substance use disorder and co-occurrence in patients and women 18 or older, the treatment gap is 89.9%. So these are women who would be eligible for treatment, but do not have access to treatment. And despite how scary that number is, when we look at what treatment constitutes, we find that the largest majority of women are actually receiving care, when they say that receiving care, it's through self-help groups, which play an important role in addiction treatment, but it is not part of the medical model when we think about other disorders that have such high impact on morbidity and mortality. So we're not providing evidence-based care, it's not as available. And even among the women that make it to specialty care, so this is specialty facility for mental health services in the past year, we find that for women that have co-occurring disorders, about 74% got treatment for one condition, a quarter got no treatment at all, and a tiny fraction, 12.9%, got treatment for co-occurring disorders. So there's really a lot of difficulty accessing treatment for both, when patients have psychiatric and substance use disorders, which tends to be very high, quite frequent. Some general principles about treatment of substance use disorders in pregnancy. One is that routine universal screening is recommended, and this is screening that is recommended in routine obstetric care as part of prenatal care, but certainly as psychiatrists, we are called to be able to do this upon finding patients that we come across who are pregnant. And routine screening means not only for substance use disorders, but also for other things like mood disorders, PTSD, trauma, violence, other health issues, other social determinants of health. So really people to understand what that individual's environment is like, and what other things she's at risk for. Understanding and not only assessing for, but also treating co-occurring psychiatric disorders when they are present, trying to identify any psychosocial conditions or trauma, other social determinants of health that might impact their ability to participate in treatment or to accept treatment. And trauma is a particularly relevant topic because we know that sometimes people are relevant topic because we know that substance use disorders in women, the presence of SUDs in women is highly correlated with both the trauma history and victimization. Trauma is not only a risk factor, but also a consequence of substance use. And so we may be facing with the consequences of that, and it's important to address it. At the same time that we're providing trauma-informed care, so we're understanding that the patient in front of us has a history of trauma, might be a victim of trauma, perhaps even presently, and that we should adjust how we're practicing to be able to deal with that. In reality, the best outcomes are for combined treatment. So providing treatment for both the co-occurring psychiatric disorder as well as the substance use disorder in a single place, with really the goal that stopping use of substances at any point during pregnancy is beneficial. So we're not only focused about stopping use during the first trimester, but really at any point, there is a benefit. And I'll expand that to include the postnatal period. So after the baby is born, so in the postpartum period is also critically important. It's important that we think about any legal or systemic barriers that may make it difficult for women to seek and receive care. In many of our states, including Massachusetts, where I practice, unfortunately, women who are actually receiving treatment, including with our gold standard, for example, with medications for opioid use disorder, that might actually trigger child abuse and are mandated reporting policies in some of these states. So rather than improving the access to care, some of these policies have been associated with delayed initiation of care. There's reduced care utilization that, in fact, limits access to both timely substance use treatment as well as the benefits for both the patient and children. And so a woman might be really thinking about, you know, a woman that has a history of trauma that has co-occurring psychiatric disorders may be really thinking, is it in my best interest to pursue treatment with buprenorphine for my opioid use disorder if I'm likely to trigger, to generate the spotlight on me and have additional monitoring at a time that's already stressful in my life? It's also very important to think about the postpartum period, which we often forget about. We focus so much on pregnancy and the unborn child. And then where we're in reality, the postpartum period, particularly the 12 months after delivery, is actually the perinatal period with the highest risk of relapse to substance use and overdose. And when you think about the factors that influence these, we can understand why. There's often decreased access to care. So the visits drop from, you know, perhaps whatever frequency the prenatal care is to perhaps one postpartum visit for the mother. There's increased stress in caring for a newborn. For a lot of women of color, that might mean less support from extended family or a partner. So there isn't someone to care for the child as a woman tries to go into treatment. There's increased rates of postpartum depression and anxiety. There is loss of health insurance coverage in many states. And there's also increased rates of interpersonal violence, among other things. And so these are all things to be mindful of and assess during this period, during the postpartum period. We do have effective treatment for substance use disorder, for maternal substance use, and things that can increase treatment utilization. So motivational interviewing techniques that include or not behavioral incentives. Contingency management, which actually has the most extensive empirical data to support its use among pregnant patients. Community reinforcement approach, which is less common among pregnant women with substance use disorders, but has also demonstrated effectiveness. And then pharmacotherapy, which I'll talk about in relation to opioid use disorder. So these substances of abuse, tobacco, cannabis, alcohol, and stimulants, there are no pharmacotherapies that have definitively found to be safe for use in pregnancy. In part because we don't have a lot of data. And so the traditional pharmacotherapies that we might be able to use, like nicotine replacement therapy, and verenicline, bupropion for tobacco, for example, or naltrexone, acamprosate, for alcohol use disorder in adults are unavailable to us in pregnancy. They're not approved for use. And we have some very little data in terms of efficacy. We have some data about medications that we can't use at all, but little data on what can't or on what we can use. But despite that, some of the behavioral interventions and psychotherapies that I mentioned in the previous slide are effective, particularly when they're tailored to pregnant women or pregnant individuals. So it's not as if we just have to put up our hands and say that we don't have treatment. There is treatment available. But for opioids, there are more specific treatments. So pharmacotherapy is the recommended treatment for opioid use disorder during pregnancy. Overdose is one of the leading causes of maternal mortality in the US, again, primarily in the postpartum period. And MOUD is supported by multiple professional organizations in government ages, from SAMHSA to ASAM, the American Society of Addiction Medicine, to ACOG, which is the OB society as well. And we know that MOUD during pregnancy reduces the risk of recurrence of opioid use, reduces risk of overdose, morbidity from infectious diseases, both during the pregnancy and up to one year postpartum. The medications that we use for treatment of opioid use disorder during pregnancy are methadone and buprenorphine exclusively. Naltrexone is not recommended during pregnancy and medically assisted withdrawal or detoxification is not recommended at all due to high rates of recurrence and overdose, as well as the potential implications of having the fetus go through opioid withdrawal, which can be deadly as well. So we have proven efficacy for both buprenorphine and methadone in treating pregnant patients with opioid use disorder. Neither is clearly superior. We have longer experience with methadone and there's the article that I referenced here tried to provide a comparison between methadone and buprenorphine in terms of the neon, what was previously called neonatal abstinence syndrome is now referred to as neonatal opioid withdrawal syndrome and found that now is typically less severe neonates born to individuals treated with buprenorphine compared with methadone by a small amount, but there was a difference there. What is more important and I think that is critical that we talk about for this topic, for this webinar today is that appropriate dosing is very important when we think about MOUD is probably the most important, not only as a way to help reduce cravings and avoid opioid withdrawal, but also to be able to have patient remain in treatment. And this requires an understanding of the pharmacokinetic changes are related to pregnancy, particularly with methadone metabolism. And we know that, and we found that bias here can actually have an important role in treatment outcomes for OUD. So one study demonstrated that pregnant patients of color received 67% of the dose of methadone that white patients received at delivery. And so we're seeing even some disparities there. So patients are not only are finally making it to treatment, they're prescribed the medication, but they're not dosed in the same way. And so this might create some increased symptoms that might then lead to treatment failure. So the patients are leaving treatment because they're not finding it effective and it's because we may not be dosing it appropriately. So perhaps use of standardized objective treatment guidelines could help reduce some of the disparities in healthcare that in this type of treatment that patients of color experience. The other area that is important to mention is overdose prevention. So providing education consistently to patients who are, to individuals who are pregnant regarding use of naloxone as an overdose rescue medication and harm reduction practices, as well as encouraging lactation. Breastfeeding in general tends to be lower in, the rates tend to be lower in communities of color. And so certainly it would be important to recommend that and to provide guidance for that in the postpartum period. There is some benefits in the absence of any other contraindications of breastfeeding, including maternal infant detachment and perhaps unfavorable effects in terms of the neonatal opioid withdrawal syndrome. And the expectation that the recommendation is certainly for pharmacotherapy to continue in the postpartum period, not to stop. Once the baby's born. So just some final conclusions for this section, substance use and use disorders during pregnancy and in the postpartum period is common. The use of one substance increases the risk for another one. The co-occurring psychiatric disorders are also common, particularly as a relief to trauma. And for successful treatment, it's important that we address both barriers to treatment and provide treatment for co-occurring disorders, ideally in the same place. And finally, MOUD is the standard of care for opioid use disorder in pregnant and postpartum women. And there are effective behavioral treatments that exist for other substance use disorders. Thank you. Thank you, Dr. Ponce-Martinez. I was nodding a lot. I didn't have my camera on, but I was like nodding the whole time. Especially I like the parts about cannabis use because that is so, the excitement about it in terms of everyday life is just so far ahead of the actual research. And it's just a daily frustration for me. And the stuff about trauma and addiction, and especially pregnancy and women in addiction, trauma is such a big thing. And then the legal battles and worries about losing custody is so detrimental for the long-term care of these patients. So I just thank you for talking about those things. I loved every second of it. Next, I'm going to introduce Dr. Dennis Anthony. Dr. Anthony obtained his BS in psychology from Duke University and his medical degree from Howard University School of Medicine and went on to Johns Hopkins for an internship in internal medicine and then residency in psychiatry. He completed an NIH-sponsored postdoctoral fellowship in addiction research at the Behavioral Pharmacology Research Unit at Johns Hopkins and is duly board certified in psychiatry and addiction medicine. He is the director of the Cornerstone Clinic at Helping Up Mission, Addiction Treatment Services, and the Center for Addiction and Pregnancy at the Johns Hopkins Bayview Medical Center. These programs treat individuals with substance use disorders and co-occurring psychiatric disorders who often have encountered with stigma and other social disparities. He serves as a core faculty member at Johns Hopkins Center for Health Equity and is the co-director of the Congregational Depression Awareness Program, which aims to equip select members of the Baltimore area congregation to recognize and empower individuals within their networks. All right, take it away. Thanks so much. I'm really glad to be here with this group and looking forward to hearing questions from the participants. So the title that I have for the talk is Perinatal Health Equity with Considerations for Persons with Substance Use Disorders and Other Mental Illnesses. I have no disclosures relevant to this talk. And as we already know, there's a pertinent outcome that we always keep in mind, which is the newborn. And we do wanna keep in mind the different types of outcomes that can occur when there's substance use in the picture, especially opioid use disorder. And that has been reviewed previously by Dr. Ponce-Martinez. And there are other complications that can occur that we well know. So I won't repeat those here. Where I come from is at Bayview Medical Center in Baltimore. And we have had a program called the Center for Addiction and Pregnancy for over 30 years now in different iterations that has always striven to improve perinatal outcomes of women with substance use disorders and their children through a comprehensive care model, which includes clinical research and education. Where that has landed more recently is really looking at an intensive outpatient program that looks at a multidisciplinary approach to how we advance care. So making sure we have good guidelines at the beginning, almost like the contingency-based model that was mentioned before to advance care when certain goals are met. And then have, at the same time, psychiatric evaluations and mental health counseling, also case management in addition to obstetric and pediatric healthcare coordinated on the campus. And this includes antepartum and postpartum because as mentioned before, there is still tremendous risk after the newborn comes to fruition. And up to a year, there's still a lot of risk that we need to account for. What I'll talk about a little bit more is the housing component, and I'll bring that up towards the end. But we've always provided housing because there's been an established need often for persons needing some type of recovery-oriented housing and a structured monitoring environment is what we provide. So the center was established in 1991, like I said, over 20 years. And it's always included a combination of psychiatry with substance use disorder and comorbid conditions for evaluations and treatment, including medications, and also pediatric folks to make sure they're helping out with neonatology and primary pediatric visits. And then we have our obstetricians with our maternal fetal medicine expertise, especially because there's some more complexity to persons with substance use disorders when they are pregnant. And the reason that it's really important to focus on this is we think that the kind of bringing together of all these expertise would be enough. But what we did find at some point is that there's some discrepancies that we need to think about. And we found that by looking at multiple pregnancy outcomes over the course of a few years within Johns Hopkins, that there were certain psychosocial factors that stuck out the most, substance use disorders, mental illness, and also interpersonal violence. And we asked the question, what combination of these factors would be most likely to lead to adverse perinatal outcomes, the ones that we mentioned before? And we found that there would be a 21% increase of perinatal outcomes, adverse perinatal outcomes, if there were no psychosocial factor involved. But however, we did find that there would be a 35.3% increase if there were all three psychosocial factors involved. Now, beneath that is still the point that Black women were 2.5 times as likely to have adverse perinatal outcomes as other groups. And that goes to the point that we probably need to consider not only the psychosocial factors, but look at considerations of ethnicity, race, gender involved into this as well. And that goes to one of the core biomedical ethical principles that gets considered often, but is definitely getting more spotlight, justice. We also think about things like autonomy, beneficence, non-malfeasance, or do no harm. But when it comes to justice, there are different ways of looking at it. One way we can look at justice is by saying that people receive that which they deserve. But another way which gets towards this topic more is that resources really, if you look at the principles of the medical practice, the resources should be equitably distributed. And that is at the core of health equity to figure out what we should be doing to make sure everyone gets what they need. And within the Center for Health Equity, led by Lisa Cooper, we have a quote here that she's put out there that there should be a vision to have a community, a nation, or even a world, if you will, which every person can achieve their best, their best health, especially. Because that's where things should be if you're looking at this from a biomedical ethical perspective. And there have been difficulties with that. Over the pandemic, especially, and just before the pandemic, there was a spotlight that certain individuals did have a higher rate of opioid overdose deaths, as it's showed here in this data. And further data actually escalated from here. Even though if you were to look at the overall rate of opioid overdose deaths between 2018 and 2019, that overall rate looked like it had plagued during that period of time. But if you looked underneath that, it did appear that non-Hispanic Black individuals had an increase in opioid overdose deaths by 38%. And this is prior to the pandemic. The rates have gone up since then. And yes, the overall rates of opioid overdose deaths have gone up, but there still is that discrepancy in that Hispanic Black individuals and others have an increase that surpassed the overall rate of opioid overdose deaths, and an increase that surpasses those of White individuals. Now, if you pair this with other information that we all know, where there is a discrepancy in not only maternal mortality, but infant mortality up threefold on both sides, that really leads to a storm to say that we need to look at what we could call a perinatal opioid epidemic to see how that could be taken into account and how we should consider treatment differently and how we should look at it to zero. SAMHSA has taken their approach from a treatment standpoint, and they've talked about ways to address the needs of persons who are pregnant and women with substance use disorders to get better outcomes for the gender and also ethnic differences. What they talk about at a broad level is that assessments should be conducted in the person's preferred language. And often that can be a barrier to making sure that the assessments are sensitive to the ethnic identity, including acculturation level. Also looking at things like the approach and making sure there's a cultural lens, which I'll talk about a little bit more. And of course, making sure the staff are trained and where possible, proficient in the cultural competencies. And so that's a point to say cultural competency is very important, but there are ways of going deeper into that approach. One thing that they suggest, which I think is unique and something that should get more consideration is the assessments at the beginning. We're all used to certain standardized assessments, but there are also assessments to ask, where is the person on their identity? Things like the cross-ethnic scale, identity scale for adults, or the Bertin Brevet questionnaire, or even the FICA spiritual assessment tool to see where a person's spirituality is. It may not be the exact question about how much they're using, but it gives you a sense of who the person is. And that part is very important because it can also give them a sense of maybe belonging to the treatment process. If a person feels out of place or doesn't feel understood, that can lead to difficulty engaging into the process. That's been shown at many educational levels, high schools, colleges, but thinking about that and applying that need for a sense of belonging to treatment for substance use disorders is something that could be considered as well. SAMHSA goes on, and I won't read all of these, this slide and the next slide, but it goes on to also point out different considerations for different ethnicities. This slide here shows considerations for Latino women. This slide here also shows considerations for Black and African-American women. And again, I won't read the slides, but there's also information within their treatment improvement protocols to show tips and also considerations for Asian women and also Native American and indigenous women. So there are opportunities to think this information through to make sure that there is accounting for the identity of the person and make sure they feel that they belong in the treatment process. And it all goes to a bigger idea, not just cultural competency, but the versioning term structural competency in which the structure or the institution itself actually becomes competent and strives to include, as it says here, the ability to recognize and to respond to the larger social context, not just respond or be prepared, but respond with self-reflexive humility and engagement. And that's a bigger piece where it goes beyond just the training or having the assessments. It's how does the person respond and how does the institution account for that in the whole process? Part of that is also looking at the systems around the treatment. Engaging with child protective services is very important, making sure that there's preservation of the newborn and the family, because that is one place where the cycle of addiction and community disruption could be broken down. There's also consideration of how to consider the family unit, depending on what that looks like within the treatment process. Yes, there is a very important opportunity to look at the parent and also the newborn, but looking at the rest of the family that might be involved for social support could help break that disruption. And there's always a need for legislature and making sure that we are putting forth legislature where possible that accounts for this equity and keeping the unit of the family together to break the cycle. One other piece that I will put out there is that depending on where the treatment occurs can make a difference. So oftentimes we are met with the phrase, the person or the patient will come to the doctor and go see the doctor. One thing that we've done differently at the Center for Addiction and Pregnancy in the past year is we partnered with a program in the community. Again, trying to change how we view ourselves and try to be demonstrators of that self-reflexive humility, we took our folks and took our treatment into the community and partnered with a place called Helping Up Mission. That opened up a facility that houses 250 individuals, 200 of those being women and 50 of them being their children. It's been a partnership that's taken a lot of understanding on both sides, a lot of empathy on both sides, but it's really broken the model to say, how can we be more culturally adept? How can the institution be more culturally responsive to literally where the people need the help? And that's a way that I think could be also possible to meet people where they are literally and find a way to be more attuned with the needs of what they have. And finally, I'll put out there that there's always the need for more research. We know what we know, which is a good amount about the medications and the utility for them, but we always could use more, especially when it comes to substance use disorders and pregnancy. At the center of this slide is the patient involvement, as they say here, and there's always implementation to think about public health research, preclinical and also the clinical, but it is really important to make sure not only do we keep the patient at the center of what we do, but make sure that we are equitable in who we involve in that research, the different ethnicities, different backgrounds, making sure that the research outcomes are representative of all the people that it is needed for. So that's something that should be taken into consideration and oftentimes that might go underneath in that search for equity. So I'll stop there, but just putting out there, people want to learn more information about the Center for Addiction and Pregnancy. I have some here, but I look forward again to hearing what the participants have to ask on this webinar. Thank you. Thank you so much. That quote about envisioning a place where we can all achieve our best health gave me chills. What a beautiful dream, you know, that we're doing our best to work with what we have, you know, but that is the dream. And the housing part, oh my gosh, so important. And preserving the newborn, being with the family. I've had so many patients who, when they had a positive test at the birth of the baby, it was taken away and then they relapsed right away. That's just what happens. So we have to preserve that, such a strong motivating factor for sobriety and having an environment like you guys have done where people can do that is just amazing. I'm just so excited to hear about that work that you're doing. So next is time for the question and answer portion. And our first question from the audience is, what changes in the state or federal policy would make the greatest impact, both in the short-term and the long-term? I think the first thing that comes to mind for me are some of these policies regarding mandatory reporting for positive urine drug screens at time of birth. And the fact that it automatically triggers a DCF involvement and it doesn't discriminate whether the positive urine drug screen is related to medications that are prescribed and appropriate in the treatment of a substance use disorder or substances that are used. There isn't sort of a distinction. And I think that just creates so much anxiety for the new mother at a time when she's already experiencing a lot. And it's almost like setting her up for failure really. And so what I've seen, for example, in my institution and the clinic that we have is called the Green Clinic, really assessing, trying to providing treatment for substance use disorders for pregnant women by the OB group and there's psychiatry involved as well, is that so much of the work, instead of focusing on things that really matter as part of their treatment, goes into documentation and kind of creating a file for when, it's not if, for when DCF becomes involved or the Child Protective Agency. So I think that's very unfortunate and it's a missed opportunity. And that would have a very clear impact on the lives of women, on additional women that are considering treatment but are not open to it because of their fear of legal involvement. I think that's a very important point. And the legal involvement is such a big thing that I see that hesitancy to engage in treatment comes from that. I would say from my standpoint, just another aspect, not to say it's more or less important, it would be the availability of insurance for persons that are not only pregnant but postpartum. I know in Maryland, we had a change maybe a couple of years ago, such that individuals up to one year postpartum can have coverage still. And I recently found out there's going to be a change in Maryland that undocumented citizens will also have a coverage up until four months postpartum. I think those types of considerations, not just during pregnancy, but after the baby is born are very important to ensure that these services can last and be engaged in a meaningful manner. My pipe dream to add to that is that we can have, you know, people don't have to go to work so soon. People can have, you know, some sort of income postpartum because that is so important. And yeah, just anything that tears a newborn baby and their mother apart is like the most cruel thing I could ever imagine to do to someone. And it's going to affect that child for the rest of their life too. And we really don't need more trauma in the world. I had some questions as you guys were talking. I was hoping I could ask what consideration should providers be conscious of on an individual level when working with minoritized pregnant patients in substance use disorder treatment? I would say making sure there are assumptions about what type of environment you're coming from. Making sure you have a good understanding of why did they show up to your door versus the door down the street in terms of treatment. Because there are a lot of options sometimes and sometimes you have to get a good understanding of why did they show up? It could be something that is cultural in their background and they didn't want their family to know or their partner to know. And understanding those values upfront are going to be very important because for minoritized individuals, oftentimes those values get ignored. And that would be a reason why they are less likely to engage or stay in treatment. So the other thing I would put out there would be asking them what type of modality of treatment they prefer. And I'm not just talking about medications but just thinking about how would they like to engage? There are even some articles out there saying some types of psychotherapy are more or less receptive depending on cultural background including group psychotherapy. So it's very important to understand those values to make sure that talking about certain things at the beginning are important or do they want that deferred to later on because of some of their values? So I think values and understanding are a key portion of that. I absolutely agree. And I would add to that. One of the things that comes to mind is autonomy. So frequently it seems like for women who are pregnant that's something that may be lost as part of their treatment, including in terms of urine drug screen. So doing drug screened as a screening tool rather than as a tool as part of their treatment and sometimes without their consent and the repercussions that it has. And so I think that's one area. I think that for a lot of minoritized women certainly being able to address the fact that they may be reluctant to engage with an individual treatment provider because of their perception when they're pregnant and if they're using substances. So kind of stating that out openly I think can be one way to engage the person and saying, even if the individual provider might not have exact knowledge about everything that needs to be done right but even acknowledging you may be reluctant to trust me and I'm here to try to help you. Let's figure this out together. Also providing education I think is critical in a way that's understandable for our patients. Many of our patients might come with preconceived notions about, for example, methadone dosing. The lower my methadone dosing the better I'm doing the less harm for the baby. So doing it in a way that enhances their autonomy but provides critical information saying actually what we're really trying to prevent is cravings and you going into opioid withdrawal because that affects the baby. So providing that kind of critical information in a way that is respectful of their autonomy and then really just fighting patient-centered care and creating a partnership. And this is the information that I can provide and I think motivational interviewing has wonderful ways in which we can provide information in a way that respects the patient's autonomy and then being able to have a plan together whether it's harm reduction or abstinence-based or introducing pharmacotherapy but sort of that collaboration I think is key because the truth is the model that Dr. Antoine described is wonderful and I think some institutions across the country have that but that is still the minority. So unless you're in these hubs where academic medicine is available most of our patients in the population do not have access to it. So it's important that we bring some of these factors into the individual practice. Those are great, amazing points and something that sparked to mind as well is with that lack of access oftentimes especially for psychiatric care these are gonna meet individuals that have never seen a psychiatrist before. So something that I've started doing is explaining what do I do? What is my goal over the course of the visit? Because as we know, there are definitely histories of what has happened to minoritized populations and minoritized women especially. So I think starting out the process by saying this is what I do, I actually use a Bob Ross picture and say, I'm just gonna paint a picture of your life so I can understand you better and make recommendations. Something that is welcoming but really grounds the process so you don't make them think that they're gonna be moving too fast or moving into an unsafe conversation. I love those points so much. Another thing I was wondering and I kind of in my intro touched on it is and we touched on it in that graph that has that abysmal engagement rate, right? But how do we need to change what we're doing now to reach these patients? How can we meet them where they're at in the true spirit of harm reduction? I think that probably goes back to the first question about legislature. There is often reinforcement of the care being siloed to where the people aren't and there's an opportunity there to do things like mobile trucks or put treatment into housing facilities, residential facilities. I think we need to get away from our ivory towers for lack of a better term and move out into the places where people are. That would send a big signal as well to say, it makes it easier on a person who's pregnant to not have to go across town, just go down the street or go down the hall as we do it at our facility, making it easier for them. I think we've sent a big signal and go a long way. Yeah, there have been some models that have been described. Massachusetts has one of them, for example, the McPack for Moms, where the care is provided at the usual place of care. So it's at the OB clinics, at the OB appointments for routine prenatal care, but is informed by OBs having access to this hotline where they're able to get information or additional support for substance use and psychiatric disorders. So I think anywhere that is addiction, psychiatrists or psychiatrists, we're able to collaborate with additional providers in our community, OB providers in our community to be able to provide this care. I think that also would provide treatment. It almost makes you think about the possibilities with virtual care, just meeting people literally wherever they're at, wherever they're at with their phone. And I'm hopeful that that can make a difference. And something, Dr. Ponce-Martinez, that you reminded me of is that kind of bit of mantra through my training, which is that the relationship between the doctor and the patient can be healing within itself and focusing on that. And that actually is kind of supported by some research being done here. And you made me think of it with talking about going in the community, is that's what they're doing in Cleveland. And what they've learned is instead of making it patient-centered, they're talking about making it relationship-centered. Because what they're saying is, you have the patient and you throw all this stuff around them, but if they don't utilize it, why aren't they utilizing it? Well, it's because they have to have a relationship and some trust first. And I think that trust is so broken with the medical institution and minoritized communities that we have to do the work of rebuilding that. I agree. And I think in large part, that also means that the healthcare force and the people that are providing the care look a lot and reflect the patient population that we are treating. There's more like, it's greater likelihood of buy-in there, not only the physician there, but any other member of the treatment team as a way to really be able to kind of get your foot in the door and build a relationship, build some trust. You mentioned virtual applications. Certainly, I think one possibility, and there are some people, in fact, I presented on pregnant women and SUDs at the APNO meeting. And one of the panelists was talking about an application, a smartphone application that doesn't involve seeing someone in the face and describing their frequency of substance use. And just looking at the higher rates of response. And so things like that, where you remove the shame and the stigma of substance use during pregnancy, I think might be something that we can use in the future that will be helpful. I fully agree with that. Technology, I think, would be a big way to go about it. And I think there could be, before we even get into the treatment paradigms, there could be ways to bring these conversations into the community in different places, whether it's salons, could be even barbershops for potential fathers in these situations as well, and spreading the conversation so we can increase the comfort by the time they get to the treatment facilities. I love the thoughts you guys are having here with removing the shame and stigma. It's just beautiful. It's amazing. This is the dream. I feel like we could just kind of go back and forth all day like, we should do this, we should do that. Okay, more questions that I had on my list is, so we know that mental health challenges have been linked to higher rates of like drug use in the postpartum period and use during pregnancy. What should providers and treatment facilities do to ensure mental health treatment is also a goal in the substance use disorder treatment population? I think it needs to be screening. That starts at a widespread goal. At our hospital, we started a great campaign for interpersonal violence screening, which we all should be doing. The mental health screening for pregnant or non-pregnant persons, I think needs to be a little bit more prevalent in all the different specialties, internal medicine, OB, wherever it may come up. And then as that gets applied to these types of areas for substance use disorders and OB where likely our patients would come to our treatment, it'll just be part of the water. So just making that a regular conversation, how are you feeling, whether it's something that's just a two question screener or something a little bit more in depth, like an audit C. The SAMHSA treatment improvement protocol that I mentioned has a wide variety of options, but I think it really should be something that should be part of the initial conversation, but not burdensome on the person coming in the door. You don't want a 100 page questionnaire, something that just gets the essence of how are you feeling today? And if it's not that great, then you keep going, but those should be just as important, if you will, as the interpersonal violence, the trauma questions and now mental health. I agree. I think if we wait to identify symptoms, I think we're likely going to miss some of them. And it's helpful to think about this, thinking about this as almost like the norm, co-occurring psychiatric and substance use disorders as a norm rather than the exception. And moving away from, I think, how many of us have trained in psychiatry and thinking of them as in certain silos. So is it one or the other? To get one better, we need to treat the substance use disorder before we're willing to address the depression or the anxiety, because it's likely substance-induced. Doesn't matter. It's affecting their quality of life. It's affecting retention and treatment. It's affecting adherence, medication adherence even. So both have to be treated simultaneously. And the semantics can come after. The stuff about the screening makes me wonder about, you know, AI is the newest and coolest thing that I've seen personally. Could we have some sort of AI program that would allow people to do like the two questions and it goes to a different tree of other questions, but in a really intelligent way where it's not just questions and it can give meaningful information, like that would be so cool. I know that's gonna be on the radar at some point. You know, that's gonna be a question of whether AI can match the empathetic skills, the MI skills. And if AI does that, I'd be happy to give that up. But I think we've all had challenging situations with persons we've worked with and the ability for AI to match that step for step, I don't think it's gonna be possible. I don't have the largest faith in this moment, but to maybe start the questions and then trigger someone else to come on who's more skilled, I think that's where we're gonna start. And certainly things like precision medicine, where we're looking for what's the most predictive outcome for this person so we can redirect, that's certainly where we need to go. All right, well, I have some more questions. If other people have questions, you're welcome to put them in the chat, but I'm just gonna keep going with my questions for a few more minutes. So can you guys talk about some of the barriers to care for pregnant people? And we've already touched on some of them, seeking substance use disorder treatment, but some of the other ones? I would say we have touched on some, insurance for sure has been one. If you look at the National Survey for Drug Use and Health, I think it does come down to some of the things they put in their surveys, which are where to find the treatment facilities that would be right, especially if there is a housing component. Sometimes it's very difficult to find a residential space for that. The stigma is very much a big piece of that. I'm not feeling comfortable to talk about the situation. Some people, unfortunately, don't also feel like their substance is a problem, depending on what the substance may be. And that comes up very often as well. Often those are the bigger ones, and then you have transportation, where to get to that facility, how to get to that facility. You wouldn't necessarily know where to find all those types of specialties in one space. As Dr. Ponce-Martinez mentioned, it is not always the norm that everything is co-located to make it easy. So some of the things are just baked into how the city and how the person's life is made up, but then you do get to a person's comfort, and the stigma is a big thing there. And I would add to that, I think even from more specialized treatment, if we are talking about a minoritized population, so how many facilities, are these facilities that a pregnant woman who is minoritized would feel comfortable in? Are there any residential facilities or inpatient facilities that would feel comfortable with a pregnant woman, or that might be more reluctant to provide treatment, or programs that provide treatment in anything other than English, or that would have any other culturally appropriate components? And so those are things that they might consider and make them more reluctant to participate in. And Dr. Ponce-Martinez, I don't know if you agree with me or not, sometimes the stigma is not just that a person has substance use disorder and is pregnant, but sometimes the providers, we may not be part of this, but sometimes providers are like, I don't know what to do in this situation, and we don't have that many options for treatment. So it's not as complex sometimes as it may seem, but I think that could be a barrier that providers are a bit premature in their hesitancy to jump into treating a person who is pregnant. Absolutely. Even in places that I think that can provide, that routinely provide substance use disorder treatment, the addition of pregnancy as part of the description of the reading of the patient makes them feel more reluctant. And even in providing medications, right? And so thinking about let's focus on self-help, let's focus on a number of things, but a lot of reluctance, even from the clinicians in offering what we know is effective. I totally, there's so much panic. When there's a pregnant person, oh my gosh, I don't deal with this every day. What do I do? What do I have to look up? There's a lot of that. So I feel like we have to continually educate people on pregnant people. And as we have scant research, so as any new thing comes out, we got to make a big deal about it and bring up all of it again. I'm presenting later this year, basically about that, just like the basics at our Ohio Society of Addiction Medicine Conference. And I'm really excited. Okay, so I have one more question. How, what practice, what steps have you guys taken in your practice to ensure culturally competent care? So we've done it at a couple layers actually. Myself and another person within Hopkins actually helped write Maryland State Legislature to ensure that all practitioners, not just psychiatrists, but all behavioral health practitioners need to get cultural competency training to renew their license. So that's tripled down to training that happens not only within our institution, but also within our clinic. But then we want to make sure we ask the person to come in the door for treatment. Do you feel our care is culturally competent? Trying to get that rating on a more regular basis. So those have been our attempts. The hardest part obviously is making sure we get those surveys out to the person to come for treatment on a regular basis. So we're trying to fine tune that, but getting the different layers, not only within our clinic, but really to keep your license. We've really been advocating at that level. That's wonderful. And I can't say that our practice or that my involvement is that extensive. I think for us, we have been, we've really, we're at a training clinic. And so providing education for medical students, psychiatry residents, addiction psychiatry fellows, and other trainees that rotate with us in how to provide culturally competent care and trying to really ensure access to a diverse population is important because you don't develop experience with it unless you address it. And then really being able to understand patients, at times trying to pair providers with patients, based on similar language and different and similar backgrounds as a way to be able to introduce care. That's also ways in which we've done it. Love that you both, you had like the top-down approach and then sort of the educating everybody approach. All right, well, thank you everybody so much. I'm gonna throw it back to Madonna to close us out here. Thank you all so much for joining us this evening and a very, very special thank you to our esteemed panel, Dr. Antoine, Dr. Ponce-Martinez, and Dr. Gritti. You shared some invaluable insight that I hope our audience can take back to their practice, to their respective practices. So thank you again for spending time with us this evening. And to our audience, please join us for our next Looking Beyond webinar, which will be a case study presentation on postpartum psychosis in August. So if you're interested, please visit www.psychiatry.org and register there. We look forward to seeing you there. Have a wonderful evening, everyone. Good night. ♪♪

maternal mental health

comprehensive treatment

birthing people of color

substance use disorders

disparities in healthcare

culturally appropriate care

routine screening

co-occurring psychiatric disorders

medication-assisted treatment

barriers to care