Good evening, and welcome to APA's Looking Beyond webinar series. My name is Dr. Regina James, and I'm the Chief for the Division of Diversity and Health Equity and Deputy Medical Director here at the American Psychiatric Association. As the name of the webinar states, these webinars are an opportunity to really look beyond a single perspective or discipline to discuss inequities. And so we bring together various disciplines to hear and learn about approaches to address mental health inequities. This summer, APA is hosting a series of discussions focused on maternal mental health. And so tonight, we will address the intersection of justice involvement and the treatment of substance use disorders in pregnant individuals in marginalized and minoritized communities. But before we start, I'd like to open with acknowledgements. I would like to humbly acknowledge that the land on which the APA sits is where the Piscataway, Pamunkey, Nanticoke, Mattapani, Chickahominy, Mannequin, and the Powhatan cultures thrived. Together, we acknowledge the extraction of brilliance, energy, and life for labor force upon people of African descent for more than 400 years. We recognize the immigrant and American-born workers of African, Asian, Central, and South American descent whose labor still contributes to the well-being of our collective community. We celebrate resilience and strength and commit to being part of a comprehensive solution to the intergenerational trauma for members of these groups. Thank you. Now, I'd like to introduce our moderator this evening, Dr. Dionne Hart. Dr. Hart is board certified in psychiatry and addiction medicine. She is an adjunct assistant professor of psychiatry at Mayo Clinic School of Medicine, and she provides clinical services in multiple community settings, including an emergency department, a state-operated community behavioral health hospital, a correctional medical facility, and a short-stay withdrawal management center. Dr. Hart is nationally recognized as a patient advocate. She has served in numerous governance positions in her state of Minnesota and in both the American Psychiatric Association and the American Medical Association, and she currently serves on the APA Board of Trustees. She has received, again, numerous awards, including, and I wanted to highlight, Minnesota Psychiatrist of the Year. Please, let's welcome Dr. Hart. Thank you, Dr. James, for the introduction. Welcome to the American Psychiatric Association's Maternal Mental Health Program Series. This program, Substance Use Disorder Treatment for Marginalized Pregnant and Parenting People, Working Toward a Better Approach. The rise in substance-involved pregnancies has informed punitive policies for pregnant and parenting persons who engage in substance use or are living with untreated substance use disorders. This intersection of justice involvement often compounds the barriers to assessing substance use disorder treatment, particularly among minoritized pregnant and parenting people, and can have profound adverse implications for maternal and child health. This webinar will delve into the complexities of this issue and explore the multifaceted approach needed to address it. The panelists will discuss their work and give you strategies for improving access to evidence-based substance use disorder treatment, providing comprehensive support services, and advocating for policies that prioritize the health and well-being of marginalized pregnant and parenting persons. The learning objectives will be found in the chat. As your moderator and a fellow advocate for justice-involved individuals, I am excited to learn from our esteemed panelists. A longer bio for each of our panelists is available, but I will give you a few highlights. I'm going to start with Dr. Chinazo Cunningham. Dr. Cunningham is Commissioner of the New York State Office of Addiction Services and Supports, where she oversees one of the nation's largest systems of substance use and addiction services. She is a physician trained in internal medicine and addiction medicine, and has spent over 25 years providing care, developing programs, and conducting research with those who use alcohol and illicit drugs. For decades, she has collaborated with community-based reduction organizations and led one of the first programs in the U.S. to integrate addiction treatment into primary care. Dr. Joya Carrere-Perry is a physician, policy expert, thought leader, and advocate for transformational justice. As the founder and president of the National Birth Equity Collaborative, she identifies and challenges racism as a root cause of health inequities. Dr. Carrere-Perry has twice addressed the United Nations Office of the High Commissioner for Human Rights to elevate the cause of gender diversity and urge a human rights framework towards addressing maternal mortality. She is an adjunct professor of Tulane School of Public Health. Next is Dr. Myra Mathis. She is a faculty member and board-certified general adult and addiction psychiatrist at the University of Rochester Department of Psychiatry. She is currently the medical director for Strong Recovery, UR's medicine outpatient dual diagnosis clinic, which houses an opioid treatment program and provides a full range of addiction and psychiatric services. Next is Dr. Andre Jones. Dr. Jones is a psychologist and internationally recognized expert in the development and examination of both behavioral and pharmacologic treatments for pregnant women and their children in risky life situations. She serves as the senior advisor role for UNC's Horizon, where she leads and participates in national policy and international policy projects. Dr. Jones has co-authored multiple national and international guidelines on the topic of caring for pregnant and post-pregnant people with substance use disorders and their children. We will have social media handles in the chat, but I'm going to start with just a couple of housekeeping items. Each of our guests has permitted us to use their first names. We welcome your questions, and we appreciate you putting them in the chat, and we will be monitoring the chat. After each of our panelists begins with their opening comments, we'll start with the questions in the chat. Any questions we are unable to answer during the webinar may be included in our podcast. So let's get started. I'm going to go in the order that I introduced you, so Cherazzo, would you please begin? Great. Thank you, and I'm really happy to be here. Thank you for inviting me to participate in tonight's webinar. So I'm Cherazzo Cunningham, and I'm the Commissioner of the New York State Office of Addiction Services and Supports, and I just want to sort of set the stage for what we do in New York and our role here. So our office oversees all of the addiction services across New York State. We are a separate office from our Department of Health, and there's a separate office for mental health, and so I report directly to the governor of New York. Within our office, we oversee and work with approximately 1,700 programs that provide addiction services. We touch about 730,000 people. We run, we have state-run addiction treatment centers. We have 12 of those, and then we have a budget of about $1.3 billion and about 1,000 employees. So our goal is really to, you know, have New Yorkers really lead the healthiest lives as possible, and we oversee a continuum of services that include prevention, treatment, harm reduction, and recovery services, so really the full continuum of services. And we certify, we regulate, and support all of the services within that continuum. Specific, so for today, and the topic that we're talking about, so I've been Commissioner for over two and a half years. When I came to government, I really used my work in academic medicine to inform, and my work on the ground, providing care to people who use drugs, to inform our guiding principles. And so we really have three guiding principles in our office. The first is embracing harm reduction in everything we do. Really focusing on keeping people alive, especially as we know that the drug supply is more deadly than ever before, and we're in the worst crisis in terms of overdose deaths than ever before. So that's both a philosophy, a philosophical approach to providing services, and it's also providing harm reduction supplies, you know, so naloxone, fentanyl test strips, xylosine test strips. The second guiding principle is to use a data-driven approach, and use evidence-based strategies. So in everything that we do, we're focused on the data to help guide where we invest our time, our money, our energy, and really focus on using strategies that we know work. So going to the true and tried, well-researched ways that we know improves people's lives. And then the third guiding principle is to use an equity lens in everything we do. And so we know that drug policies in this country have been racist. We have to say those words out loud. We have to acknowledge that, and we have to think about how we can move forward differently to not repeat the same mistakes. So while equity, a lot of equity, has to do with race, it's not the only thing. In New York, you know, I certainly think about geography and rural and urban areas and making sure there's equitable distribution of resources. We think about special populations like pregnant people, like LGBTQ population who are at higher risk of having harms related to substance use. And so we really think about everything we do in terms of who we fund, what data we collect, what data we analyze, you know, what program we support, all the way through in terms of using an equity lens. So that's the sort of big picture when it comes to our Office of Addiction Services and Supports. And then just focusing in a little bit more on this subject, so I think what's really important to know is that we, I'm very proud of the work that we're doing in the criminal justice system in New York. So we have a law that requires medication treatment for opioid use disorder, all forms of medication treatment, in every prison and every jail in New York State. So that's 44 prisons and 58 jails that offer buprenorphine, methadone, and naltrexone to every person that has opioid use disorder. It's a heavy, heavy, heavy lift to make that happen, and we are the only state in the nation really requiring all of our jails, all of our prisons to do this, and, you know, and really at this scale. So that, you know, so that, with the regulatory framework around how we're doing that, how we're requiring that, how we're working with the prisons and the jails to really implement this is one really important piece to this discussion. So I'll stop there and let the other speakers speak. Thank you. So I know from the video, I can see a lot of like head nods, and I'm sure at home there's a lot of head nods and maybe a few amens, because I think there's a lot of the work which we want to focus on today. So thank you for sharing that. Deanna? So thank you so much, Dr. Hart, Deanna, I'm sorry, I did the opposite of what I normally do, which is call you by your first name since I've known you so long. So the National Birth Equity Collaborative is now nine years old, which is kind of crazy to me, time is flying, and when we were founded, I had actually been a city medical director, so coming from being in private practice as an OBGYN, and then working in New Orleans during Hurricane Katrina and after Hurricane Katrina around things like evacuation, but also running the HIV clinics there, the maternal and child health, well, baby clinics, the typical city health department kind of strategies when it was time to create my own organization, really thinking through what is needed in the black community, an organization that is not tied to government, because once you leave government, or when you're in government, some things you can't say, right? So like when you're working for government, there's certain political positions that are tied to your positionality. So as an organization that works with community members, we get to work in the local, state, federal, and international level to really ensure that black moms and their babies can survive and thrive. So that means acknowledging the harms of racism, classism, and gender oppression. Or another way to put it is that we no longer want to believe in a hierarchy of human value based upon skin color, based upon geography, based upon gender, all of these things, based upon religion. Like this belief that we are somehow better or worse based upon these identities has caused a lot of harm. And it causes people to not take care of patients who have substance use as part of their profile. I know for us, we have worked with local hospitals to think through their strategies and policies everywhere from hospitals in rural Louisiana, to hospitals in New York City, to state and local health departments about policies and advocacy, to think through things like when you have a patient, like with ACOG, when we were focused on substance use disorder, we were really focused mostly on fentanyl as if people don't have a poly substance use disorder. And we can become hyper-focused on one and forget that people are still, alcohol, fetal abstinence syndrome is still real and it's still happening quite a bit. And so to not get hyper-focused on one, but really think about the full breadth of all humanity and all the things that they need, because if we, we are all scientists. So the premise of our work is that our if statement is that we are not broken. The United States was built on a belief that people were broken and we're here to fix them. So if you have substance use disorder, if you are not fitting into the typical narrative of the typical white supremacist narrative in the United States, then you should be fixed. Well, we don't think you should be, that you're broken. We believe that you are, that systems and structures have been trying to break you. So it's our job through psychology, through psychiatry, through being an OBGYN, our role is not to say you're broken, let me tell you how to fix you. Our job is to say, Hey, we see you. We see that you have been being harmed by systems and our job is to support you to make sure you can thrive. So it makes you look at substance use disorder in a very different way, instead of problematizing the patient and blaming and shaming them, thinking about how we can create systems, structures and policies that meet people where they are and values them for their full humanity, no matter if they're housing insecure or if they're living in a fancy big house in Manhattan, that they're all equally valuable and that's our role. So that's what we get to do. Hope that answers the question. Thank you for that. I really appreciate that idea of hierarchy of human value. I've never heard it said that way, but that is, that's a powerful image. Thank you for that, Myra. Thank you. And good evening, everyone. I'm Myra Mathis. I am an addiction psychiatrist and the clinical chief for the division of addiction psychiatry at the University of Rochester Medical Center. And I oversee all of our clinical services, which includes an opioid treatment program, as well as a breadth of outpatient substance use disorder treatments. We also have a consultation program called SUDPC, which stands for substance use disorder in primary care. We don't just work with primary care physicians, but we collaborate across a variety of disciplines with our OBGYN colleagues to really create sort of onsite and more on-demand treatment resources for pregnant and parenting individuals with a substance use disorder and those who are interfacing with the medical system in other ways that also have a substance use disorder and can be supported by our services. As a program that is in New York State and as one of the programs that is overseen and certified by the Office of Addiction Services and Supports led by CHNAZO, we also do collaborate with our local jails to provide methadone for patients. So our patients that are already enrolled in our opioid treatment program continue on their methadone that's provided directly by our program. And we also collaborate in order to provide inductions to individuals who are currently incarcerated in Monroe County. And I'm looking forward to this robust discussion as we consider these various intersections, both in terms of the professional backgrounds of the speakers, but also how we, it's a picture of the kinds of systems that need to come together in order to meet the needs of patients who exist at these intersections. So thank you for having me. Thank you for being here. And it's just, it's been a common thing, collaboration, working with systems. So you're not doing this work in the silo. So thank you. Thank each of you. Last but not least, I will almost said it, Andre. Thank you so much for having me this evening. It is an honor and a privilege to be with all of you and on this incredibly esteemed panel. I am a psychologist by training. And so the work that I'm going to share this evening has to do with the work in the criminal legal system that we started in the women's prison in Raleigh. And we had a Foundation for Opioid Response effort funding to be able to meet birthing individuals who have opioid use disorders when they're leaving prison. And we've been incredibly fortunate to be able to work with our OB colleagues to create an integrated program inside the prison walls, where we have the OB providing prenatal care, and now our behavioral health folks, our behavioral team, peer support specialist, social worker, that is able to provide the behavioral health care. So it's a truly integrated experience for our birthing individuals that are incarcerated. We meet them when they're leaving, and we're able to provide whole-person, compassionate, equitable wraparound services. So we take them wherever they need to go. We provide naloxone. We provide medication to treat opioid use disorder, primary care, housing, whatever it is. We are there to ask what they need and how to strategize to best support them. We've also been incredibly fortunate to be able to work in the jails, as well as now the four different prisons. I have a paper we're going to put in. Where we had 132 unduplicated pregnant and postpartum individuals with opioid use disorder that we were able to work with and meet. And we had zero overdoses, zero fatal overdoses at six months. We followed everybody. People are doing well when we give them the services that they deserve to receive. We have a warm line, where we can now receive referrals from across the state of North Carolina and help get people services when they're leaving either jails or prisons. There's other things that are happening in North Carolina. We have our Dignity Act that was passed in 2021. And that's really been a wonderful addition and game changer for individuals, so that we are no longer using shackles and restraints and cuffs during pregnancy. We have pregnant individuals no longer receiving body cavity searches, not receiving solitary confinement. They're getting better nutrition and hygiene. We have a bail fund in Durham that helps pregnant individuals who are incarcerated. We have community services that's called our Children's Place of Horizon Center, which really helps with that dyadic care and advocacy for the children who have been separated from their parents during the incarcerated times. So we also have massive challenges. And I just wanted to give a shout out for the disability rights of North Carolina that did a survey of all 100 counties of our jails. And still, unfortunately, to this day, only 23 are offering medication for people who have already been on medication before incarceration. So we still have a tremendous amount of work to do. But I'm just really honored and delighted to be having this conversation tonight. Thank you. Thank you. A lot of common things about making sure people have what they need. And that goes back to that point of seeing people and seeing not just their substance use disorder, not just their involvement with the justice system, but seeing their humanity. I'm really excited to speak with you. We already have some questions coming through. But I'm going to start off, because each of you highlighted some of your successes and some of your work. But maybe if you could, we'll start with Myra. Maybe you can speak about some of the specific barriers that are introduced when people are living with a substance use disorder and involved with the justice system. So thank you for the question. And I will first start by considering the framing in terms of the use of the carceral system as a means of responding to what we now understand as a public health crisis. So individuals who have a substance use disorder are not involved in the justice system by happenstance. There are policies that have been enacted over many, many decades that increase the likelihood for individuals with a substance use disorder to be involved in the carceral system and to experience harms due to their involvement in the carceral system. And so the barriers have existed before the person develops a substance use disorder, because they're in our policies. And that's something that we really need to acknowledge. And particularly the racialized drug policy that has then led to this over-representation of both individuals from minoritized communities, but then also individuals with substance use disorders in the incarcerated populations. And so because of that intersection that's based in policy, when individuals are then in the carceral system and have a substance use disorder, what is a health condition has already been criminalized. And when you are looking to access treatment for a health condition that in and of itself has been criminalized, we speak about the stigma and the shame and all of those things that happen even when someone is outside of the carceral system. But now you have someone who is experiencing the very harms of that system, then also trying to get care for the thing that has been criminalized. These barriers are not just psychological. They're not just ideas. They're not just thoughts. They create actual systemic barriers for individuals when they are trying to engage in treatment when they are in carceral systems. And this varies from state to state, which is really, really, really challenging. And that means it's so important for us to understand what's happening in our state, how these policies are affecting our patients, and what role we can play in terms of advocacy to really highlight the need to address the health conditions of individuals who are currently incarcerated. So I could say more about the specific things that happen in an individual jail or in an individual system. But I recognize that that often will vary from state to state. But these overarching ideas and this overarching understanding that our policies themselves are the barriers really encompasses a lot of the challenges that our patients face when they find themselves involved in the carceral system. Dionne, I want to go next before I forget my train of thought. I'm old and I'll ramble. OK, great. So I want to build on what you just said and say that I'm an OB-GYN who would have been a psychiatrist if I didn't do OB-GYN. So I have all these pseudo, and I get to talk to 30 to 40 women a day. So I'm like a fake psychiatrist kind of because as an OB-GYN, you talk to women all day, right? But so one of the, we talk about your subconscious, right? So the subconscious imagination or the global consciousness, how we see people who are involved in our carceral system and people who have substance use disorder are both negative. And so because you have that framing already in your head, so that's why you can be in different systems. You can be in a state system. You can be in a city system. And you still see the same thing where they don't, where only 23 of the 100 counties are giving the medication that the patient should have. And we all know that many of the people who are in these systems need this medicine, like way more than 23 counties. Even the idea that we are criminalizing substance use, somehow we have to get that out of our subconscious. Like that should not be what our common understanding of how one manages a substance use disorder is with jailing them, right? Like that, we should all be offended by that. Like I had a, so there's an organization in New Orleans called, you talk about barriers. So a specific barrier, so that understanding is just this big, huge barrier. So LIFT is a small, amazing nonprofit in Louisiana, and they work on reproductive justice work. And we had passed a law that you don't just shackle women in childbirth. So the young woman who was the attorney who was running the organization called and said, Dr. Joya, there's a person in jail who's pregnant. And I said, uh-huh. She wasn't in birthing. She wasn't going to a visit. She just was already in jail and she was pregnant. And for this advocate, no human being who is pregnant should be in jail unless they've done something hugely wrong, right? Like unless you're a murderer, but most people who are incarcerated, who are pregnant, have either been sex workers or they have robbed something. So couldn't their sentencing wait till after the baby was born? Because we know that the prenatal care that's given inside of jails is highly inadequate, that babies are being born into an environment where they're born in a trauma. They're being born inside of with the mom being there. So her understanding, her subconscious, her understanding of the world was that why would any human being even want to put a pregnant person into jail in the first place? And I was just so excited to hear her even think that way because I live in a framing where we're still shackling people while they're pushing the baby out, right? So those two different versions of the world is really where we live. And how do we get the version of the world where we see people as being valuable, that they should be able to have a baby without being shackled, which should be just natural. Like you wouldn't just do that. That's really what we have to get to. Thank you. And Anastasia, you work in policy. So you see the big picture. Maybe you could comment on how some of the challenges that you know of and maybe some of the ways that people in other states can find out what the challenges are and some ways to find solutions for their patients. Absolutely. So I think as many people alluded to, stigma is a really huge problem. And I really think that's the biggest problem that we face in the field of addiction period. Stigma, it's everywhere, including healthcare systems, certainly in criminal justice systems. It's internal within people who have addiction. And so, because we've all grown up in this community, in this society, hearing messages that have been incorrect around a moral failing, not recognizing that addiction is a medical disease, not recognizing that the approach needs to be a public health approach or a medical approach instead of a criminal justice approach. And so really taking on stigma is a really important thing. And so I think webinars like this, talking to the public, thinking about the language we use, telling other stories, right? Because we hear all the negative stories in the media and really working with the media. And I think that we in the healthcare system actually don't do a very good job of this and need to step out of our world of healthcare to the public and talk to people, right? In a way that they can understand and really let them know that what a substance use disorder is, right? And what the appropriate treatment is because a lot of people still don't even know. So that stigma is a really big barrier. And so when we look across 58 counties, 58 jails in New York, every jail is run by the county. And some people may not know the sort of criminal justice landscape. Let me just say that, right? So our prison systems tend to be run by the state. So we have 44 prisons and all 44 prisons run under one system in the state of New York, but the jails are run at the county level. And so when you've seen one jail, you've seen one jail and they're run by the sheriffs. And so sheriffs are elected in New York. And so every sheriff may have a different opinion about substance use disorders and the treatment for substance use disorders, right? And so we have to work across these systems. And so we are having discussions with sheriffs about what is substance use disorder? Like really the basics. What is the treatment for the substance use disorder? Really the basics, right? And then, so we really start there. We start with stigma, we start with education. I think when we look across, for example, all of the medications, naltrexone and buprenorphine are much easier to implement than methadone because of all the regulatory challenges at the federal level. And so that, and we know that with fentanyl in the drug supply, because it's just a potent opioid, that in fact methadone treatment is more important now than ever before. And with some of the regulatory changes now at the federal level that happened with COVID and have been made permanent, we have an unprecedented opportunity to really change the way we deliver care. And so it's new and a lot of programs and providers have been using methadone in the same way for about 50 years. And so changing that can be challenging, right? Any change. And so it's a paradigm shift. It's a much more harm reduction approach. It's a much more peace and centered approach. And so this is what we work with our jails and our opioid treatment programs across the state to really help foster those relationships. So for us, we bring the parts of our system, the opioid treatment programs together with the jails and the sheriffs and the jail administrators to figure out how we can all work together, right? And so it looks a little different from county to county, but it includes transporting methadone to jails. It includes mobile medication units. Again, this is a new opportunity at the federal level. So we are funding 11 mobile medication units. So bringing a mobile unit that provides methadone treatment to the jails, to the courts, to the prisons, to the homeless shelters, to the parks, right? I'm very excited about this. This is really new opportunity. So there are these great opportunities, but a lot of them are new and we sort of haven't figured out how to necessarily address all the challenges and barriers. And we have to work with our federal partners. We have to work with the DEA. We have to work with the SAMHSA, the Substance Abuse and Mental Health Services Administration because they have to approve all of these mobile units and ways that we're delivering care. So as you can hear, as I'm talking, it's very, very complicated. So we work with our two federal partners. We work with state partners across the jails and prisons. We work with our programs who are on the ground delivering care all to get to the people, right, on the ground. And so that's a very complicated web and we in the state really helped to bring that all together. So it sounds like you're focusing not just on innovation and making sure there's a medical model, but the basics of educating our partners. So like in the case, if you're working with justice-involved individuals, administrators who have the keys to, who can, you know, have to be open to those changes, educating them about not just the basic of what it means to live with a substance use disorder, some of the challenges that got that patient into the system, but ways that the sheriff can help. And maybe sometimes that's just talking about their bottom line and how they can save dollars, whatever their language, whatever their motivator is to help them to enact some of these innovations. So thank you. Andrea, I don't want to leave you out. Did you have any comments about the question? Yes, thank you so much. I just want to mention a few things that haven't already been mentioned. And one is just the overarching fear that pregnant and postpartum individuals have with seeking either substance use disorder treatment care or prenatal OBGYN care. We've criminalized pregnancy in this country in so many different ways. And it's compounded by having a substance use disorder. And when we think about people who are incarcerated, at least in the state of North Carolina and other states, we have something, a law called safekeeping, which I don't know how many of you all are familiar with safekeeping, but literally you can be a pregnant person in jail and then moved without any warning or ability to contact your care providers or your loved ones. You get moved to prison so that you can receive healthcare. And so in some places they haven't, you know, been charged and convicted. And so that is a unique barrier that pregnant individuals face. And I think the other really important thing is that we need to be talking to people who are in incarcerated settings or who have been in incarcerated settings because they have the wisdom and the keys to help us improve the entire system. But so often we don't talk to them to find out what's going on. Thank you. Thank you. And we have some comments in the Q&A really talking about how we're criminalizing pregnancy. So that could be a webinar all on its own. But I think one of the questions that we wanna start with from the chat is how are people who are living with substance use disorders getting treatment while they are incarcerated? New York was mentioned specifically, but we also have representation from North Carolina. I know Joya, you've worked in several different states and I know when Louisiana comes into the news related to healthcare, the news isn't always good. So maybe you can really talk about some of the ways that people who are in custody can get treatment and when they release, how they can continue to have access to treatment. Thank you. And I think, I'm sorry. No, it's fine Joya, you can jump right in. Okay. I was just gonna say, I think Andre really highlighted what I was, so probably the jails were getting in trouble for not providing prenatal care. So instead of saying, you just get to stay home because you're pregnant and we're not providing prenatal care, they just make people go to prison without even having a charge or without having a conviction. So that shows you how we are structurally creating harm by our knee-jerk scarcity mentality. We with the power have to interrupt that harm and say, no, we're not gonna let y'all pass a law that says people just go to prison because we're not providing with care. They can go home. It's okay. They're not mass murderers. It's really okay. So anyway, so how in Louisiana specifically, we have a lot of jails and not just Louisiana, as was mentioned, many people who are pregnant are usually in jail. They're not necessarily in a prison, because the jails are before you're charged, so people who are doing smaller crimes. And so they get a lot of their care from residents, OB-GYN residents. They usually have agreements with a lot of counties to provide prenatal care with the residency program. So at Tulane and LSU, I'll use Louisiana as an example, the people who are generally attending the births of people who are justice involved are OB-GYN residents, who are the least powered. I know they think they're powerful at the time, but they are still just students. They're still just learners. And so when you pass a law that says you no longer have to shackle patients when they're birthing, a person who's only 26 years old, who is in the room just getting their first delivery, they're the least likely to even know that there's such a law, and they're the least likely to then debate with the guard about taking the shackle off, because they're just trying to get through the day and finish their residency program. So truthfully, because the people who are justice involved and also have substance use disorder are two identities that are already marginalized, the care that they receive across the country is also marginalized. And how if I were a psychiatrist working those systems, really knowing that walking in, that you're caring for a population that is being doubly harmed, and advocating for all the things that you know are best practices, because you know that they deserve those things. They deserve to have access to the methadone. They deserve to have access to treatment. I mean, I know that a lot of people actually are still addicted to crack cocaine, and we have not even addressed that as far as how that's showing up in our birthing and the higher rates of, and with the laws around DOBS and the overturning of Roe v. Wade, we're having higher rates of abruptions and c-sections. So it is a perfect storm for harm. And so how that shows up in the carceral system is people are just not getting care that they're supposed to be having. But Joya, one of the things that you mentioned that I think gives me hope is that there are people from different levels in their medical training who are learning about some of the disparities, learning some of the challenges, so that even if they don't choose to work in a facility, we know that there are many more people who are involved with the justice system who are under supervision, some type of like court jurisdiction, and they now know how to treat them in their office. So even that exposure is helpful. So they're giving direct care, but also when they leave their training, they have skills that can help them. Great. I think we're at a crossroads and we're all learning new skills. And I think that's really important. Anyone else want to talk about some of the challenges, like making sure that people get treatment in custody, but also upon release? Well, again, it does go back to these partnerships that you're developing at your local level. That, for example, if we're inducting someone on methadone while they are incarcerated, they then become our patient. They are part of our opioid treatment program. But we've already done an intake. They've already been assigned a counselor. When they're released, they're going to have a case manager. We have peers that they can access. But that means we get involved before someone is released, so that we decrease the likelihood that they're going to be lost to follow up. So are you doing warm handoffs? Beyond warm handoffs, actually, we're doing collaborative treatment. We are working with the patient even while they are incarcerated. We have dedicated counselors who collaborate with the carceral system, who are going into jails, who can also do virtual sessions with patients. And so we are working with them throughout the time that they are incarcerated so that they don't feel disconnected from us. Okay. Now, we have a very practical question when people are talking about wraparound services, about, like you said, collaborative care. Are those services reimbursed? Great question, and a very important question. So I think the last time I was on one of these webinars, I mentioned the CCBHC, the Certified Community Behavioral Health Center, which is a federal designation that is sort of analogous to a federally qualified health center on the primary care side, so an FQHC. But the CCBHC is on the behavioral health side, and it's supposed to be like an analogous structure. But the CCBHC, what it really does is allow us to essentially, we can say what it will cost to deliver these wraparound services, and we can essentially, to a certain degree, set our reimbursement rate based on the fact that we know we need a peer, like it requires peer services, it requires case management, and so all of that is built into our annual report in terms of how much funding we would need to continue to run a CCBHC. So there are creative mechanisms that exist to help with being able to support billing and reimbursement for these services. As an example, the CCBHC, we have a flat rate per day, so a patient comes in once per day, but they receive a flat rate for that day, regardless of the service that they receive. So that flat rate is higher than what we would receive for any other individual service under regular traditional billing, but it does mean that the patient can come in and see three different providers on that one day, but we'd only get billed once. So it incentivizes engagement, it incentivizes us enrolling and connecting the patient to multiple different types of services, and it makes sure that we don't lose financially in our bottom line while we're doing that. Thank you. So going back to- Can I add? I just want to add one thing around the financial question. I know this was about wraparound services, but I want to make sure that everybody understands this, which is that when people are incarcerated, they no longer have access to Medicaid or insurance, and so those services, while incarcerated, are not reimbursable, and this is a really big issue. So think about the medications and what the cost is, especially some of the injectable forms. Think about what the jails have to then deal with with their budget, right, from the local counties, and so there is movement with Medicaid and Medicare. It's called an 1115 waiver with Medicaid to be able to provide services and get reimbursement for up to 90 days before people are released from carceral settings. So right now, there's only a handful of states where that's happening. A lot of us in states are waiting for the federal government to weigh in on this because we want this so that we can get the reimbursement for the jails, right, so that we can pay for the services, but that is another huge barrier, and again, these are big policies. Of course, people don't get medical care in jails and prisons because no one's paying for it, and so, right, we want to be able to tap into Medicaid or, you know, so that we can use the same kind of, you know, reimbursement that we have when people are out in the community. Thank you, and I think we'll make sure that there's information about the 1150 waiver. Also, I think January 1st, there's some new mandates as far as services that juveniles who are in correctional facilities must have when they're in custody and also when they re-enter community, so we'll make sure that that information is available to our learners. Andrea, I'm going to ask for your help. I'm going to try to get through a few more of these questions, so I'm going to start with you because you had mentioned, like, some of your counties are not fully engaged with giving all the services, but you're doing some advocacy work, and there's a couple questions that are asking about advocating for this work, maybe through your legislator, maybe locally with an administrator. Can you talk about your experience with advocating for legislation to protect justice-involved patients or policy changes locally, whichever one you feel comfortable with, Andrea? Yeah, sure, and I also just wanted to kind of build on what Myra had said earlier in terms of the importance of having a stable, consistent person inside the walls of incarceration working with those that are there so that you're building trust and rapport. What we are doing through the UNC Horizons program, working inside prison or jail and then outside, that continuity of care with the same team is so important. It's not rocket science, but it is critically important because if the people that we're working with don't trust us, they will disappear, right? So making sure that they trust us, that we know the resources in the community, and so much of our advocacy, it is slow, grinding work of getting to know people, of having cups of coffee, of having tea, of going to the meetings, of having the conversations repeatedly, right? So we can meet somebody in our local legislative policy-making bodies, and they don't necessarily trust us, but if they see us repeatedly over time and we're showing up and we're at their meetings, we're at the job fairs, we're showing up on legislation policy day to advocate, and we're positive and we're a responsible person, then we're positive and we're respectful and we figure out what the right language is that we need to talk with them so that they can hear and truly listen to what we have to say. That can make an incredible difference, and there's nothing fancy about it. It's just putting in the commitment and the time, and I think getting to know, we've been really successful with getting county money. We've been really successful with getting opioid settlement money in North Carolina. We are very fortunate to have that body of dollars to be able to reverse some of the harm, to start to heal some of our communities, and so just being there is so incredible. More grassroots. Grassroots advocacy with getting to know your legislators so you can have conversations, and again, going back to that, making sure you educate them about some of the challenges so that they can be a partner with you. One of the questions that came up was that we have some health care providers who may be willing to have casual employment at a jail or prison. Is there an opportunity for somebody to have casual or maybe, as needed, a few shifts here and there in these settings, and how can they volunteer or be employed in the settings? So I would say that it's very variable how these settings work across the state, and so there are some programs, as Myra mentioned, that have these relationships, and so that would be working with the program that exists to see if they're interested in having per diem, for example, providers. Some of the jails contract directly with other kinds of providers. Some use people in the local community, and so it's very variable. Here's what I do know. There's a tremendous shortage of providers who are willing to do this work, who want to do this work, who are qualified to do this work. So it's fantastic to get this question, and I would say go to see in your community who the providers are and see if they're working with the local carceral settings, and then also see who your sheriff is or your jail administrators are, and contact them, because I can tell you this is a big problem across New York State, I'm sure everywhere else as well, and people would love or constantly, they're short-staffed constantly, constantly, constantly, and so would love to look for people who are qualified to do this work. So it's lovely to hear this kind of question. And even then, so I imagine that we're thinking about healthcare professionals from all disciplines, whether it's nursing, physician, psychologist, I don't know anywhere where they're like, oh, we're completely flush, we don't need that profession. But I think one of the questions, what professions are needed, all the professions, it sounds like. Okay. As we, let's see, this question, what is the status of supervised consumption sites, which are harm reduction, and are they legal in your jurisdictions? Anybody want to start? So there are two open overdose prevention centers, they're both in New York City, and they've been there now for two and a half years. So they are, they do, they are privately funded, they do not receive money from public government. And they are not regulated by the state of New York, because they are illegal in the state of New York, and based on federal laws as well. So I think, you know, there are other states, for example, Rhode Island and Minnesota that have passed laws to have overdose prevention centers. But as of today, there are no sanctioned overdose prevention centers that exist outside of the two in New York City. So it's a really, it's a legal issue, and sort of both at the state but federal level, particularly. Okay. Anyone else want to add? I just want to say, can I just say one other thing? I mean, overdose prevention centers are, you know, when you think about harm reduction, it's a full continuum of services and overdose prevention centers are really at the end of that continuum. There's so much harm reduction that we can be doing that's that is legal, and that we really should be doing because we know the evidence from decades shows that it saves lives. And so meeting people where they are, I mean, part of this is going to the jails and providing treatment to where people are, right? It's the way in which we provide treatment, not expecting that everybody's going to be abstinent, that that's their goal. It's providing harm reduction supplies, naloxone. When people leave the jail and prison, we know that's the highest period of time where they're at risk for overdose and death, right? So giving naloxone as people are being released and entering the community, giving fentanyl test strips and xylosine test strips as well. So there's so much harm reduction work to do. And so embracing that, you know, I would highly recommend, and that is certainly one of our guiding principles in New York. Thank you. So making sure people have access to life-saving treatment. So Joya, can you give, we're going to give a chance for you to give your final thoughts, and then we're going to say good night. Great. Well, this has been amazing. You know, one of the other things when it comes to harm reduction is that birthing people, parents don't have time off after they have a baby. And if you also have substance use disorder, this is really deeply complicated. And so I saw some questions about family separation. And so that's also really important to acknowledge that the harm and the trauma of having your child taken away from you also cause you to have higher risk of heart attack, higher risk, you're more likely to have sepsis and bleeding because your body's fighting for social survival. It can't really also fight for its own physical survival. So just think about how our decisions and choices around family separation are also causing harm, but we are the psychiatrists. This group can change the world because you now have all this information. You have a desire to treat people well. You wouldn't be on this call this evening if you didn't want to do something different. And so we are the future. We are the people we're looking for. Nobody else is coming, baby. It's just us. So we're going to change these policies. Okay. Myra, did you have a closing comment? I will just add, actually, I think that is the closing comment, what Joya just said, that nobody else is coming. We are the people. We are the ones that have this entrance, this passion, and that are qualified and skilled in order to really serve this patient population. So let's get to work. Okay. Andre? Yeah. I am super hopeful. I have the chance to talk with residents and fellows and they are advocates and they are asking questions and they're challenging and they're disruptors. So I am so excited that we have us. And I think there are some other people coming that are the future generation that get this, right? So there's a lot of us. So thanks. Thank you. Thank you so much. I learned so much from listening to each of you. Thank you for your willingness to share your experiences and your pearls of wisdom with our learners. I'm going to turn it back over to Dr. James. Well, thank you so much. I mean, I know that, I mean, it was just really just invigorating, and I've just learned so much listening. This discussion was phenomenal. I mean, our speakers have discussed, you know, treatment, access, policy, billing, reimbursement, and the like. I just want to thank all of you for joining us this evening and a very, very special thank you to our esteemed moderator and panelists who brought you perspectives from psychiatry, OBGYN, psychology, and research. Thanks again, Drs. Dionne Hart, Chinazo Cunningham, Joya Crear-Perry, Myra Mathis, and Andre Jones, you all did a phenomenal job. And to everyone on Zoom, please join us for our next Looking Beyond webinar on August 6th, where we will focus on integrating cultural humility into mental health care for American Indian and Alaska Native birthing persons. Again, good night and have a wonderful evening. Thank you all. This was awesome.

American Psychiatric Association

justice involvement

substance use disorders

maternal mental health inequities

pregnant individuals

marginalized communities

stigma

policy changes

wraparound services

carceral settings