Good afternoon, everyone. Thank you. Welcome to our presentation. We'll be talking today about models of care for pregnant women with substance use disorders. My name is Caridad Ponce-Martinez. I'm an addiction psychiatrist from an assistant professor at UMass Chan Medical School in Worcester, Massachusetts, and I'd like to welcome my colleagues who are presenting also and allow them to introduce themselves. Hi, good afternoon. Pleasure to be here. I'm Nancy Byatt. I'm a tenured professor at UMass Chan Medical School and a perinatal psychiatrist. Hi, everyone. I'm Ariadne Frey. I'm an associate professor of psychiatry at Yale, and I am a reproductive psychiatrist and specialize in substance use in the perinatal period. Hi, everyone. I'm Courtney King. I'm an assistant professor at the Medical University of South Carolina. I work within the Women's Reproductive Behavioral Health Division, and I'm a neuroscientist by training, but I now specialize in perinatal psychiatric, sorry, perinatal substance use disorders. So these are learning objectives for this session. You can also find them on the app. We'll be talking about the effect of pregnancy on the trajectory of substance use disorders, talk about challenges and opportunities in the treatment of substance use disorders in pregnant women, and then we hope that you'll also be able to describe ways in which technology can be used to improve the care of women with substance use disorders who are pregnant or postpartum by describing several of the different models being studied. Our outline for today, I'll first provide an overview of addiction or substance use in pregnancy, then we'll present data from studies and programs that aim to increase access to substance use disorders by building treatment, to substitute sort of treatment by building the capacity of clinicians working with perinatal women to address substance use disorders. Technology is a key factor in increasing clinician knowledge and expanding access, and so the first of the studies will compare collaborative care with extension to community health care outcomes, ECHO, presented by Dr. Foray, listening to women and pregnant and postpartum people versus SPIRT by Dr. King, and then we'll complete with perinatal psychiatry access programs a description by Dr. Byatt. We'll finalize with a case presentation and then we'll open up the session for any questions from the audience. So let's talk briefly about addiction in pregnancy. I don't have any disclosures in relation to this presentation. So why is this a relevant topic? First because we know that the rate of substance use and substance use disorders, we'll abbreviate it by SUDs, among women who are pregnant are increasing. We also know that most pregnant women go untreated in terms of their SUDs and there are negative maternal and neonatal outcomes that are associated with this lack of treatment. We also know that the perinatal period is an ideal time to both screen for and treat substance use disorders. First there's increased contact with healthcare professionals that occurs during this period on the basis of repeated perinatal visits. There's access to health insurance in pretty much all states across the country that isn't the case otherwise. There's also a motivation, increased motivation, to modify behavior when women find out that they're pregnant. It's important to note that even though women may be motivated to stop use of substances during this time, some because of the severity of their disorder may be unable to stop despite their high motivation and so it's really important to think about these women when we're trying to offer treatment. Despite all these factors, women often face greater barriers to entering treatment for their SUDs while pregnant. There's substance use related stigma in the treatment of substance use disorders in the general population but this is magnified when it comes to women. There are often family responsibilities that make attendance, access into treatment more difficult, child care, etc. There is also very often a fear of legal consequences including child protection agencies, loss of custody of children, and there's also greater likelihood of co-occurring psychiatric disorders, particularly mood and anxiety disorders during this period that make access to care more difficult. So how common is substance use in pregnancy? And you'll note that I wrote substance use because one important consideration is with regards to substance use in pregnancy is that any substance use can really have a deleterious effect on both maternal and fetal outcomes. There is no safe amount of substance use in pregnancy for pretty much any of the substances. Therefore it's important to identify substance use and not only substance use disorders, although we want to make the diagnosis when it is present so that we can decide on management. So we use data from, I present data here from the National Survey on Drug Use and Health, which is a national and annual survey that is conducted by the Substance Use or Mental Health Services Administration or SAMHSA. This includes civilian non-institutionalized population age 12 or older in the U.S. So using this data, when we look at the data from 2021 and assess the past month use of women who identify as being pregnant during this time, we find that about the vast number of substances that are used, about 20% of women who identified being as pregnant at this time reported some substance use, including illicit drugs, tobacco, or alcohol. So it is not an insignificant number. Out of these, the primary substances are legal substances. So alcohol and tobacco products, each around 10%. And we also see an increase in some of the other substances as well, including opioid and cannabis, which I'll describe in detail in subsequent slides. Past month use is, which means use at least once in the previous 30 days, is often used as a proxy for current use. And binge drinking is defined as four or more drinks on one occasion, again, at least once in the past 30 days. So among women who reported substance use, the use of more than one substance is actually quite common. And this is important to keep in mind when we think about the effect of substances, because sometimes it's difficult to tell what is the effect of one substance versus co-occurring substances, or the confluence of all of those, or more than one substance, in terms of the effects. You also know, in addition to this, that because of the reasons I identified before with stigma and shame related to substance use during pregnancy, we know that drug and alcohol use during pregnancy is often under-reported. So some general principles when we think about substance use disorders in pregnancy. Universal screening for substance use disorders with an appropriate tool is advised for all pregnant patients. There isn't one instrument that, there isn't any clear data indicating the superiority of one instrument versus another. And really, so there's a number of screening tools that can be used. And typically the screening occurs during routine obstetric care. However, if we have, if we as psychiatrists have the opportunity to work with a patient who is pregnant, not only should we be assessing for any psychiatric disorders that are present at that time, but we should be also screening for any substance use that is present during during the pregnancy. Stopping use of substances at any time during the pregnancy is beneficial. There's a lot of focus on the first trimester in terms of organogenesis, but certainly stopping use at any point can provide benefits both to the mother and the infant. It's also important to think about any co-occurring psychiatric disorders that are both promoting or maybe contributing to the substance use and making it more difficult to stop. And finally, we want to identify conditions that are co-occurring, such as psychosocial conditions, trauma, other social determinants of health. We also want to consider some of the legal and systemic barriers that may make it difficult for women to seek treatment and receive care, and I mentioned those previously. And then finally, it's really important that we think about not forgetting the postpartum period. It's not only important that we focus on pregnancy in terms of the effects on the fetus, but also thinking about the period after the delivery, when actually that's the highest risk, particularly the 12 months after delivery, in terms of risk of relapse to substance use and increased risk of overdose. And there's a number of factors that are associated with that, including decreased access to care, increased stress in caring for a newborn, increased rates of postpartum depression and anxiety, there's maybe loss of insurance coverage once the baby is born, and also increased rates of interpersonal violence. The treatment for substance use disorders in pregnancy is different than what we would see from adults. Pharmacotherapy is not an option for many of the substances, as we'll describe next. And so we really focus a lot on more behavioral interventions, including motivational interviewing, with and without incentives, contingency management, community reinforcement approach. So tobacco is among the substance use that I mentioned at the beginning, the substance, the legal substance most commonly used in pregnancy. And about 40% of women who smoke and then become pregnant are able to quit. As I mentioned previously, quitting at any point is beneficial, but probably stopping before 15 weeks of gestation may have the greatest benefit. We really want to be screening for use of all forms of tobacco or nicotine, particularly now there's this perception that vaping or some of the electronic delivery methods may be less harmful, and the truth is it still provides, it still supplies some nicotine that causes a placenta readily, and so it's important that we assess for that. But cigarettes remain the most commonly used tobacco product during pregnancy. It's associated with a number of maternal and fetal complications, and there is, there are some symptoms of abstinence that occur in the neonate once exposed to tobacco, including irritability and difficulty soothing. The U.S. Preventive Services Task Force has concluded that based on the current evidence, no pharmacotherapy is recommended in terms of tobacco cessation, and so the nicotine replacement therapy, veronically invapropion, are not typically options for treatment of tobacco cessation in pregnant women. NRT has not been, is not successful, in many of the studies evaluated, it has not been consistently successful in reducing alcohol, in reducing or stopping tobacco use in pregnancy. This may be related to some of the metabolism of nicotine during pregnancy, experience of adverse events, and so it's not recommended. And veronically invapropion, even though they have, there is some evidence that they may be safe, meta-analyses have not really panned out that they have great effectiveness, and so again, not recommended. So the mainstay of treatment really becomes SPIRT, so screening, brief interventions, and referral to additional treatment. Ideally treatment for pregnant women, but we know that that's not readily available everywhere. In terms of cannabis, cannabis is the illicit substance. Cannabis remains a federally illicit substance, and it is the most commonly used illicit substance during pregnancy. And the legalization of medical and recreational cannabis at the state level is increasing, which has led to an increase in a number of areas. And so there's increasing rates of use among pregnant women, the use of cannabis products with higher THC content is increasing, and there's also this very important perception that there's, that it's less harmful. And so as a, compared to some of the other substances, about 50% of women that use cannabis prior to pregnancy continue using cannabis during their pregnancy. And this has an important effect, particularly in terms of the neurodevelopmental impact, which can affect anywhere from infants all the way to adolescents. There was also an interesting study that was, that came out recently, looking at a retrospective study of about 500,000 pregnant Canadian women who reported cannabis use during their pregnancy and associated with 50% increase in autism spectrum disorders in their offspring compared to unexposed children. Cannabis is often promoted or thought of being as helpful in terms of nausea and vomiting during pregnancy, but certainly, and this can be a risk factor for prenatal cannabis use, but chronic cannabis use can also cause a hyperemesis syndrome, and so that's something important to evaluate. We don't have, as with many of these substances, a lot of data in terms, in terms of effective treatment. There is no evidence of anything that is helpful in terms of pharmacotherapy options. And in non-pregnant women, reduction in cannabis use has been studied using motivational interviewing, contingency management, community reinforcement approaches. Alcohol is a teratogen that impacts fetal growth and development at all stages of pregnancy. There's no no safe amount for consumption during pregnancy, and the associate, the exposure of alcohol use prenatally can have a number of physical, cognitive, and behavioral effects, ranging from fetal alcohol syndrome, with its particular physical changes, to what is now on the DSM-5 neurobehavioral disorder associated with prenatal alcohol exposure, which combines a number of neurobehavioral effects related to exposure during pregnancy. So alcohol use during pregnancy is highest during the first trimester, you'll see on the figure on the on the right side, is highest during the first trimester of pregnancy, often related to women not knowing that they are pregnant initially, and then declined significantly in the second and third trimesters. And so, so this does suggest that there, women tend to stop, and a large number of women tend to stop alcohol use once they find out they are pregnant, about 60% of them. Mainstay of treatment remains psychotherapeutic interventions. In terms of pharmacotherapy, disulfiram is thinking about our pharmacotherapy that we use for alcohol use disorder in non-pregnant adults. Disulfiram is contraindicated during pregnancy, and acamprosate and naltrexone have not been well studied. Certainly, they could be used in the setting of adequate evaluation of patients and discussion of a risk-benefit analysis of continued use, for example, in women that may have achieved abstinence before then, with these medications. Stimulants are associated with a number of pregnancy complications, and there are some neonatal effects when they are exposed to stimulants in utero. Cocaine is, tends to be more highly concentrated in the amniotic fluid, both related to lower pH in the amniotic fluid, as well as liver metabolism not adequately processing the cocaine. And so, one important consideration, as with tobacco, is that exposure to stimulants and tobacco may actually worsen withdrawal syndrome, particularly for opioids in infants that are exposed to both after pregnancy. There are neurological, developmental, and behavioral problems of an infant all the way to children when they have intrauterine exposure. And most, a lot of the study that, the information that we have relates to cocaine, but amphetamines is certainly an area of increasing concern. There's estimates of up to 1% of all deliveries in the rural West having exposure to amphetamines. The treatment primarily studied for cocaine use, or for stimulant use disorder in pregnant, or a stimulant exposure during pregnancy, is contingency management. As in non-pregnant individuals, we don't have any pharmacotherapy available for the treatment. And I'll end with opioids. So the, the diagnosis of opioid use disorder may occur in pregnancy, but it almost never, use of opioids almost never begins in pregnancy. It's far less common, opioid use is far less common than the use of some of the other substances that I described before, but it, but it certainly is increasing as the rates of opioid use disorder across our, across the country are increasing. The, the primary things to think about is, is that the complications, particularly neonatal complications and maternal complications relate not only to exposure to opioids, but also to opioid withdrawal as well as use of other substances and, and associated complications. The primary risk to the fetus occurs with opioid withdrawal, and so there is an increased risk of intrauterine death due to opioid withdrawal, which can present as spontaneous abortion, premature labor, stillbirth, and that's really what we're trying to avoid. There is a well established neonatal opioid withdrawal syndrome, or NAWS, and that term has been used to replace what we previously used quite frequently, so neonatal abstinence syndrome, NAWS, because it is more specific to opioid use. And for women with treated opioid use disorder, what we find is actually that the birth outcomes are quite similar to the general population, so there is a lot of, there, there is, it's very important that we address treatment adequately. Harm reduction should be considered with this patient population, particularly when there is continued use, including provision of naloxone as an overdose rescue medication, even with the understanding that it can precipitate intrauterine death, but obviously it's a lifesaving medication to use in an emergency if the mother suffers an overdose. And medical, medically assisted withdrawal or detoxification is not recommended, as it would also cause opioid withdrawal in, in the fetus. So the pharmacotherapy, as I mentioned, is, is the, is the gold standard. It's recommended by multiple societies and agencies, and the medications that we use are methadone and buprenorphine. In, in an evaluation of over 6,000 pregnant women in Massachusetts with a diagnosis of opioid use disorder, MOUD, or medications for opioid use disorder, was associated with lower rates of overdose during pregnancy and one-year postpartum. So these are, they're, they're very powerful medications that should be continued. Both buprenorphine and methadone have proven efficacy in treating pregnant women with opioid use disorder. Neither is clearly superior. We have much more experience with methadone because it's been around for longer. We also have the article that I mentioned that I, that I'm referencing here, which came out many years ago, looking at a comparison between buprenorphine and methadone, showing that there, there was no, there was no significant difference in the percentage of neonates that developed. In, in this, in the article it was referenced as NAS or NAS, but there was, with buprenorphine, less morphine needed to treat NAS in, in infants that, that received, in infants whose mothers were treated with buprenorphine versus methadone, and also that the amount of time in the hospital decreased. Naltrexone is, is not recommended, and lactation is encouraged also to continue once the baby is born, potentially even as a way to help reduce NAS. And one last comment that I'll mention is that even though we're, we're talking about pharmacotherapy, and I'm mentioning it as, as, as, as the gold standard, it's really important to, to understand that successful pharmacotherapy of opioid use disorder depends on, on really a comprehensive, multidisciplinary, coordinated approach to care. So we're addressing all of those factors that I mentioned before that impact the care of pregnant women. Okay. So we now will go to Dr. Fori. Thank you very much. And so we're going to be switching gears a little bit. And, sorry, let me go back one slide. And we're going to be shifting to talking about different models, potential models of care for pregnant patients with substance use disorders. In particular, I'm going to be focusing on the treatment of opiate use disorder within prenatal settings. So this presentation is based on a current study that's underway called Support Models, oh, and I forgot the S there, for Addiction-Related Treatment, Project SMART. And this was funded by the Patient-Centered Outcomes Research Institute. So, I mean, this is a little bit of an overview. I mean, I know Garida just had talked about this, but sort of put in more perspective specifically around opiate use disorder in pregnancy, about 7% of patients report using prescription opioids during pregnancy. That doesn't count the patients or individuals that are using other illicit opioids. But when you look at those individuals that are using opioids in pregnancy, about 32% report not being able to get appropriate counseling around their opiate use during their pregnancy. A fifth of them report misusing their prescriptions. And 27% wanting to cut down or completely stop their use. And again, this is just sort of some of a review of kind of what was just presented. But again, some of the important things to think about and consider when we're talking about particularly illicit opiate use in pregnancy is that it can lead to stillbirth, preterm birth, maternal mortality, as mentioned already, increase in neonatal withdrawal syndrome, and also low birth weight. So, and this is more the case when illicit opioids are being used. So as we, I was mentioning before, right, the rates of maternal opiate use during pregnancy have increased significantly and actually quadrupled between 1999 and 2014. And they've continued, unfortunately, to increase. And despite this, the issue has been as obstetric providers are less likely to treat women with medication for their opiate use disorder than non-obstetric providers, which might not be as much of a surprise, but what's actually more detrimental and disappointing is that actually within substance use treatment programs, pregnant patients are less likely to get care and get medication for their opiate use disorder. And we know, as has already been presented, the importance of medication for opiate use disorder in pregnancy and the benefits of that, right? And we, you know, understand that sort of either buprenorphine or methadone are really important as well as potentially integrating it with a behavioral therapy. And so one of the reasons, potentially, that women have trouble accessing care other than some, you know, some providers might not be providing this care or having access, some of there's some patient barriers, right? So it's availability of these services, depending on where, again, as I mentioned, where these patients live and whether they're providers willing to prescribe a pregnant patient accessibility. And I apologize that these slides got shifted when they got uploaded here. Affordability and, you know, even within patients with an opiate use disorder really accepting the idea of treatment. I think a lot of patients are reluctant because they're concerned about the potential impact of the treatment, right, methadone or buprenorphine on their infant and they're also worried about if they're on these medications, that might also lead to involvement of child protective services later on, if particularly the infants develop nows. There are significant barriers for providers as well, right? There's a lack of experience or expertise for some providers. This is particularly true of obstetric providers. There's concerns about stigma and there's also a lack of sort of institutional support for providers to actually deliver this treatment and also a lack of resources. So as we've seen, we clearly have a need for provision of treatment for opiate use disorder in reproductive healthcare settings, right? Like that's one place where pregnant patients are going routinely, right? Initially maybe, you know, just a couple times a semester and then as the pregnancy continues, they're getting treatment routinely and it might be the only place that they're really accessing care. And so it'd be really important and beneficial to be able to offer treatment in these settings. And despite this though, at this point, we don't have any established optimal models for delivery of this treatment in reproductive healthcare settings. And for this reason, the PCORI or the Patient-Centered Outcomes Research Institute put out a funding announcement wanting to evaluate what are the potential models that might help pregnant women with substance use disorders using either opioids or heroin. And so we responded to this funding opportunity and proposed Project SMART. And so the aims of our project is a cluster randomized clinical trial that compares the effectiveness of two models of support for reproductive health clinicians. One is a collaborative care model that some of you might be familiar with and the other one is a Project ECHO which I'll talk a little bit more about but it's a remote kind of tele-education model. And one of the things that we're measuring several things but the main sort of outcomes is measuring differences in engagement and retention of patients at these prenatal clinics and also patient reported outcomes in terms of their connection with their providers, engagement, I mentioned engagement treatment but sort of, and pregnancy outcomes as well. And one of the things sort of to note is that we're doing this across 12 different clinical sites in Connecticut and Massachusetts. And it varies in the setting. Some of them might be hospital based sort of city urban clinics and some of them might be more suburban or rural private clinics. So for the collaborative care model, as many of you might be aware of, one of the fundamental pieces is that it includes screening for substance use and it's usually done by a care manager. And there's also sort of enrolling the patients in a registry so patients can be tracked across their treatment. And there's also the care managers assist sort of in the assessment, maybe initiation of treatment and those follow ups and the management of the registry as I mentioned. And they also can provide education, behavioral treatment and care coordination. And so for our model, for the Project SMART, you know, we followed the Massachusetts OBOP model. So it was the outpatient buprenorphine treatment model and unlike traditional collaborative care model, they also include sort of a psychiatrist as a consultant. This model didn't actually have a psychiatrist. So we really sort of, by PCORI's request, we're following that version of a collaborative care. And then the other, the other method we're studying was the Project Extension for Community Healthcare Outcomes or Project ECHO. I don't know if many of you are familiar with that. This actually was designed in New Mexico when there was really recognized the need to have expertise, you know, within rural communities. So many times it might be sort of a primary care clinician but not many other experts that can provide care. And so they designed this model where you have, it's a hub and spoke model where it's a learning community that essentially has a core expert faculty that, you know, at sort of at a distance that has month, and so you have a structure where the communities where they don't have the expertise meet on a usually monthly basis with the expert team. And this is all done through telehealth and are able to then get training and background in the area. In this case, it would be management of opiate use disorder and pregnancy. And they also get a chance to discuss cases that they're actually treating. So it both provides education and supportive ongoing management at the local site. So it's sort of this telehealth hub and spoke model that has been proven very effective in non-pregnant patients for opiate use disorder. And so that's the model that we were following here. And so in terms of the study, this is more for the overview of the study, you know, we asked all clinical sites to screen all their pregnant patients for opiate use disorder. Any of those that endorse a history of opiate use disorder are asked to participate in the study. And if they consent to participate, then we want to make sure that they're eligible, which is essentially that they have used and meet criteria for an opiate use disorder in the last year and are planning to continue their care at that prenatal clinic. And then they're either randomized to, as I mentioned, the collaborative care model or the Project ECHO model. And if they did decline to participate, we still sort of just track sort of kind of the reasons they didn't want to participate and they received their stranded prenatal care. And so just to give you a little bit more of a sense of kind of what we found so far, so the study is ongoing, so I can't sort of provide the results of kind of which model was better, but I can tell you a little bit more about how it was perceived by providers. And just to give you a little bit more of a sense about the ECHO sessions, because I broadly kind of described the model of having like a core faculty that provides didactic education and review of cases. So for our model, we had these sessions carried out between June 2020, and at first, the first four to six months, we actually did two sessions per month, and then we spaced out the sessions to be every month. And we met at the same time, and it was the same group that were members of the clinic that were randomized to this model. And we usually have a setup of having initially a didactic presentation around a specific topic. And it was anything from just basic background and overview about opioid use disorder to then how to initiate buprenorphine in pregnant patients, how to manage subsequent care of a patient on buprenorphine, what to do if there was some precipitated withdrawal. We also talked about comorbidities, such as psychiatric comorbidities, comorbid substance use, child protective services involvement, stigma, trauma-informed care. All of these topics were covered in these ECHO sessions. So the sessions, like I mentioned, concluded in December 2020. And we have done some qualitative interviews that were conducted earlier this year from six of the providers that participated in the ECHO sessions. And we wanted to make sure that we had providers that kind of routinely were engaged. And what was really nice to see about this model is that while initially the obstetrician providers, right, these are from, because it's half of the cohort, so it was six clinical sites across Connecticut and Massachusetts. They didn't really know each other. They really became a very collaborative group. And actually, as we discussed cases, began to really support each other, which was really great to see. And then we also did a few questionnaires to sort of just assess sort of more quantitatively their response to the program. So when we asked them about their satisfaction with the curriculum and the topics that I already mentioned, you can see that 33% of them were satisfied and the majority were very satisfied with the content. They were also very satisfied with the interactions, the ability to ask questions, to feel that that was a sort of safe learning environment. And I think the interesting thing about this model too, we launched this, right, as the pandemic was underway. And even though Project ECHO has always been this telehealth model, right, where you have the faculty kind of remotely meeting with all the different clinical sites, I think it, in a way, made it easier because we were all getting used to using Zoom and being on these calls. So I think it was sort of, the timing of it actually, I think, worked really well from that perspective. So I think folks felt pretty comfortable using that technology. As you can see here, it was 50-50 in terms of being satisfied and very satisfied. And then overall, the majority of them were very satisfied with the ECHO sessions. In terms of professional satisfaction and organizational environment, they felt that ECHO reduced my professional isolation and we had 83% of them said they agreed and about 17% said they strongly agreed. Again, I think one of the issues is that we were doing this in the middle of the pandemic and a lot of time, these providers might have been the sole providers that were actually taking on the care of opioid use disorder in their pregnant patients in their area or in their clinic. Participation in the ECHO enhanced my professional satisfaction. Again, you can see that the majority of them agreed or strongly agreed. In terms of feeling that the leadership in the clinic or the place they practice supported their involvement in ECHO, it was about split evenly between agree and strongly agree. Similarly for the clinical environment I work in, it makes it easy for me to apply the knowledge I gained from the ECHO sessions. Like I mentioned, we did some qualitative interviews to take a look at what some of the themes that might have emerged from what these providers thought about the ECHO sessions. The themes really indicated that ECHO was feasible for most OB-GYNs. Once we set that routine time, they always can even, usually it was at lunchtime, so it worked for a lot of people to sort of meet the second Tuesday of every month at noon, for example, and that it was effective and useful for them to actually implement medication treatment for pregnant patients. And then the participants were satisfied to very satisfied and strongly agreed with all the satisfaction statements of ECHO overall, and I think we had already discussed more specific details about that. So in terms of some of the quotes that we have from the providers, they said that I got some great ideas for training and it filled a lot of knowledge gaps. I didn't really, didn't have any training on this in medical school, or very little, and has some significant knowledge gaps. So it really felt like it really fit the purpose of the model, right, is having the expert fill in those knowledge gaps. Somebody said, again, it was really just fear of the unknown at first. Sometimes those patients could be very challenging. They want to come in, they want to start the initiation, meaning buprenorphine initiation, but they get scared and they put up barriers. Just navigating through the induction process and just kind of the patient's own hesitancies and needs at the same time are just a little, sometimes frightening to people, and they felt sort of that in general, being able to have the ECHO and the support of the faculty and other providers was really helpful around this. So impacted positively in being able to confidently speak to a patient about buprenorphine and methadone induction and being able to provide another layer of support to them during their pregnancy and being able to be those providers. So to actually be able to take on and support the substance use, opioid use treatment in pregnancy. In terms of the collaborative care model, so a little bit more about how we did this model for these clinic sessions. So again, six clinics that were randomized to collaborative care. We had trainings at the beginning when they enrolled and they were randomized into that model where we had our experts kind of come. This was all, again, because it was in the midst of COVID, was done sort of remotely. And we had, you know, some faculty provide sort of some of the backgrounds, describe the model. You know, we trained the collaborative care manager. You know, we had to identify someone. It was either usually either a clinic nurse or a social worker in the clinic that was the collaborative care manager. We taught them how to use the registry. And then we also trained the collaborative care manager in kind of how to provide sort of a brief intervention for substance use and also connected them to peer counselors. So when we looked at sort of the different aspects that are essential to collaborative care, like I said, in terms of having screening and a screening tool for all patients coming to the clinic, the average adherence was not great. It was only about 43%. The thing to note is that some practices were really good about it and some were not. So it was a really wide range. The median was about like 50%, but they did really well in these other, you know, areas of the collaborative care model, including using of the registry. So pretty much all the clinics were successfully able to use the registry. They were able to have discussions between the patients that were registered and the OB and have the care manager facilitate those conversations and those connections. The calls to participants to follow up were happening routinely, and they were actively, based on the follow-up, changing and updating the management of the patient as indicated. In terms of some of the qualitative interviews, what some of the participants said is I think definitely having coordinators who are engaging and really connecting with providers. I'm going to see this patient today. This is how she's doing. I think this really is helpful. So they really kind of found having that person, that care manager, is a key component to their delivery of the opiate use treatment in their clinic. I think more, like, I feel more comfortable asking questions about substance use and sort of being able to offer them resources. So when we ask, we always get concerned, well, if the answer is yes, what's going to happen? And that's kind of how a lot of providers felt before this study and participating in this study. Now we know that they have resources, particularly because of the care manager and the training the care manager received, and that makes it easier to ask, and I think this makes my patients more comfortable. So that is it for me, but this work obviously wouldn't be possible without this really amazing team of collaborators, including my co-PI, Dr. Kim Yonkers, and the rest of our amazing research team and collaborators. Thank you. Hello, everyone. I know we introduced ourselves in the beginning, but for those of you that came in a little bit later, my name is Dr. Courtney King. I am an assistant professor at the Medical University of South Carolina working in the Women's Reproductive Behavioral Health Division that's led by Dr. Connie Gill. And today I'm going to be talking about using technology to improve maternal mental health and substance use disorder screening and treatment. And so we know from, with data from our Maternal Mortality Review Committees in 36 states, that the most frequent underlying cause of pregnancy-related death is maternal mental health conditions. And that includes homicide, which is largely driven by intimate partner violence, which is often comorbid with substance use disorders, by suicide, and by drug overdoses that are often driven by opioid use disorder, often in the postpartum period. And although that number is kind of bleak, we do know that with additional data from our Maternal Mortality Review Committees that 100% of these maternal deaths due to the mental health conditions that I just described are preventable. And they're preventable with things like better screening, better identification, and better access to treatment. And for that reason, 100% of our professional organizations recommend this really effective screening, brief intervention, and referral to treatment or SBIRT tool system. But unfortunately, even though we know this is effective, we know it helps women get into care, and we know that it prevents some of the maternal mortality that I just discussed, only one in eight women will be screened. And an even smaller number will actually receive treatment. So about 75% of the women that are screened will actually make it to treatment, leaving a majority of the mental health problems unrecognized and untreated. And unfortunately, there are large racial disparities in the identification of maternal mental health issues, as well as women accessing care and getting to treatment with black women significantly less likely to receive treatment compared to white women. And so what our group has spent a lot of time doing, both in clinical practice as well as in clinical research, is understanding barriers to successful screening and treatment at the patient, the provider, and the healthcare system level. And so mimicking what we've kind of already heard from some of these presentations as well as was often seen in the literature, is patients tell us that they are unlikely to disclose issues with substance use disorders, with mental health issues due to stigma, to fear of legal and social consequences. Our providers tell us that there's often insufficient time in our already busy appointments, but they could also be unfamiliar with the SBIRT tools or systems. And they often lack, or there's a lack of available providers in the area. So if somebody were to identify a mental health or substance use disorder issue, where would we refer and send the patient? Similarly, healthcare systems often talk about the cost of implementing SBIRT training and retraining due to frequent staff turnover. There's a lack of care coordination across providers and health systems. And again, there's a lack of referral if we do find issues, endorsed issues. Is that showing up? Yeah. So through a lot of qualitative work, talking to our patients, our providers, and our health care systems, we developed a program called the Listening to Women in Pregnant and Postpartum People program. I'm going to call it Listening to Women just for ease. And it was actually developed from a completely different system. It started as a shared decision-making tool. And through iterations and iterations and iterations of qualitative work, it slowly became a text message based screening system based on what we heard from our interviews. And so this text message based screening system works by enrolling women in their prenatal appointment, or it could be in a pediatric office in the postpartum year. We just need their phone number, and they are enrolled into the program. They then receive screening questions asking about intimate partner violence, about substance use disorders, about mental health, as well as social determinants of health that they can just fill out on their phone. And one thing I'd like to mention about that is that the questions were shown to patients before we put it into the system to make sure that the wording was something that they felt comfortable with that was approachable. So everything that they're getting on their phone has been vetted by patients themselves. So they can fill that out while they're in the waiting room, or they can wait until they're at home and fill it out wherever they feel safe and comfortable. And then that information that is collected on their phone is then fed back to a system. We use RedCap, which is a secure system where it's reviewed by a remote care coordinator, which is somebody with a master's in clinical social work and a history of behavioral health clinical work. And they look over the responses. If a patient endorses any of the questions, mental health, substance use disorders, intimate partner violence, or needing support with social determinants of health, they'll give that woman a call and do a brief intervention, talking to her about what she is needing in the moment, and figure out the appropriate level of care. She'll then get referred to treatment. And our care coordinator will work on making sure that she also gets to treatment by following up with her. And then she will communicate that information back to the obstetrics or the PEDS teams, including what the screening questions let them know, what referrals were made, and their treatment attendance and progress within that treatment. So there's coordination between mental health and the OB and PEDS teams. And so the screening system happens throughout pregnancy as well as the year postpartum. So ideally, we would enroll women during their first prenatal care appointment. But it can happen any time after. So it can be any time during pregnancy. And like I said, they could show up in their pediatric office and get enrolled during the postpartum year. And once a woman is enrolled, they are texted each trimester of pregnancy, as well as 30 days after delivery. And then they are continued to be screened every three months during that entire year postpartum. So we're really monitoring them almost two full years during the perinatal period. And so what we did with this system is piloted it in our MUSC-OB clinics. And so we, as a clinic, as the Women's Reproductive Behavioral Health, are already well integrated into the obstetrics clinic. And so we looked at data from about 3,000 women and then halted all of the in-person standard of care screening. We flipped everybody over to this listening to women system. Obviously, they were asked if they wanted to participate. And we examined the results from listening to women versus the standard of care or in-person SBIRT screening. And some of the outcomes that we looked at were the percent of women screened, the percent of women screened positive, the number of women referred to treatment, and the percent that received treatment. And so this is just our demographic data. And so what I'm showing you here are our outcomes. The standard of care is in that lighter blue. And the listening to women text message-based screening system is in the darker blue. The percentage is on the y-axis. And then our outcomes are on the x. And so that first two bars is the percentage screened. And you can see that women in the listening to women system are much more likely, significantly more likely, to be screened. They're 1 and 1⁄2 times more likely to screen positive, so endorsing that substance use disorders, intimate partner violence, or maternal mental health issues. They are two times more likely to be referred to treatment and five times more likely to actually receive treatment. And so I just want to remind everyone that this was in an OB clinic that already has integrated mental health care. We have worked with their staff to help them through screening. Their SBIRT system is pretty well up and running. And we're already seeing this type of increase and better access to treatment with the technology-based system. And so what was really interesting about this data is some of the racial disparities that we typically see in in-person screening were eliminated using the listening to women text message-based screening system. So if you look over on the left-hand side of the screen, I'm showing you a percentage of black women that were screened with the light blue bar and the percentage of white women that were screened in the dark blue bar. So if you're looking at the listening to women, you can see that that disparity in the number of women who actually receive treatment that get to treatment using the text message-based screening system is the same between white and black women. And based on this data, we thought it would be interesting to then go and do some qualitative work with some of the black women that were in this study. So we interviewed about 70 women, and we just asked them about their experience with the system. And they let us know that they felt that there was less judgment without that face-to-face screening questions. And they felt a lot of trust with that care coordinator. So having somebody call them and talk to them for a little bit before they just jumped into what's going on with their mental health really helped them feel comfortable getting to the next step. And having that follow-up, if they were to miss their appointment, having the care coordinator call back and make sure things were OK, did they need help with barriers, really got them across the finish line. So the next steps are we did a large randomized controlled trial looking at the listening to women in pregnant and postpartum people program versus usual care or the standard in-person screening. We recently completed enrollment for the large study. It was a little over 400 people. And we also did some surveys afterwards that we're just looking at. We did some baseline mental health measures and then followed up three months later just to see how if women are engaged in treatment and retained in treatment. And that three-month follow-up date is expected to be completed this July. So we'll have a pretty good cohort to take a look at to see if this pilot data is replicated. So with that, I just want to thank our entire team. And again, shout out Dr. Connie Gill, who is our division leader and really pioneered engineering the system. So thank you. Do you want to go that way? Yeah. I can probably do it my way. Oops. There you go. Why don't you just click it there? OK, thank you. All right. Hi. So thank you, everyone, to our previous presenters. I'm going to present a different model that I think really builds on what we've heard from already. And I'm going to present the Perinatal Psychiatry Access Program model as another approach to improving access to treatment for substance use disorders during this time period. These are my disclosures. So as we heard, so I won't belabor this because we've heard it, but these illnesses are common. They're undertreated. And they are leading cause of maternal mortality in the United States. And I just want to say a little bit more about, so we heard earlier that mental health conditions in general are the cause of 23% of deaths. And that includes mental health and substance use disorders. And you can see they're 10% higher cause of death than any of the other medical causes. This is very recent data. I mean, all these cardiovascular causes, they're almost 10% higher than any of these. And this is new data from the past year from the Maternal Mortality Review Committees across the United States. Also, in a prior study using older data, they found that of, it was still a leading cause of death, but in the prior data, it wasn't the leading cause. They haven't done that analysis yet, or at least haven't published it for the more recent data. But in this old data, I'm actually on this paper, what we found was that of the deaths that were due to mental health causes, 100% of them were determined to be preventable by the Maternal Mortality Review Committee. So all of these deaths could be prevented. So it's really important that we're thinking about models to increase access to care, because we have to be able to do that in order to prevent these deaths. And the United States has an increasing mortality rate, particularly compared to other high-income countries. And we've heard this, that these are reckoned, and because of this, these illnesses are common, they're undertreated, and they're leading cause of death. This is being recognized by many professional societies and policymakers. And all of them recommend screening in medical settings, particularly obese settings. And they all recommend doing that in the context of a system to help people get care. We've been hearing from Ariadna and from our group around all these different approaches in this setting. So I'm going to build a little bit on what we've already heard about from other speakers around this. So we've heard about the problem is there's so many barriers. People may be wondering, well, why is it these are so hard to address? So at the patient level, patients don't want to talk about this, particularly for SUD, because there's so much stigma. And they're really worried about talking about this and about losing parental rights, which is a very real concern. Even if they do feel comfortable talking about it, clinicians may not feel comfortable answering their questions. And even if they do, they may not know who to refer to or how to treat them themselves. And then from the systems level, the systems are silent, as you've heard about from our prior speakers. And then there's also community level barriers where adverse social determinants of health and other barriers. And so what we have is a situation where patients aren't disclosing symptoms or seeking care. We have unprepared clinicians with limited resources, low treatment uptake, and negative outcomes. And I also want to note that our current approaches to mental health care in general, but including substance use disorders, lead people on a road to frustration. If we think about the individuals at risk, and then we think about if we actually screen everybody, and then we think about the positive screens and who we refer, and the treatment becomes less. There just isn't enough treatment, particularly treatment by a psychiatric specialist or addiction specialist, to see them. So you have the available treatment is much less than the people who need it, and you have the circle where people are going through a cycle trying to get into treatment. And the only really way that we can solve this, there'll never be enough psychiatrists to see the people that need one, is to build capacity of medical settings and also community settings to provide this treatment themselves. And so we think about the parallel time period, every time someone's seen as an opportunity to engage, talk about this, engage people in treatment, and perinatal care professionals have an absolute pivotal role in this process. And in general, most mental health conditions are treated by primary care professionals. Not everybody needs to see a psychiatrist. So as you've heard from our other speakers, and I'm going to build on this with another model, we've all been working on these models at the patient level. We've heard about the screening model, building screening trust, training and toolkits, resource and referrals. And then what I'm going to talk about is also in a higher systems level, statewide programs that provide stuff that can actually work in tandem and in synergy with the models that we just heard about from our other speakers. And hopefully then we get to a place where patients are disclosing symptoms and seeking care. We have prepared clinicians with resources, treatment uptake, and improved outcomes. So the model I'm going to talk about is the Perinatal Psychiatry Access Program model. This is a, I developed the first program like this in Massachusetts. And I'll talk about how it's become a model in the rest of the country. And what it is, it's a population-based approach to building obstetric provider capacity to providing both mental health and substance use disorder care. And it really does this through three ways, training and toolkits. So we go, we do ground routes in birthing hospitals, we can do practice level trainings, and we also have toolkits. We have a SUD specific toolkit for obstetric providers. We also have one for substance use disorder providers. We also provide consultation. So if anyone actually, OB or any other provider is seeing a pregnant or postpartum patient and they have a question, they can call us and we can answer their questions and really help hold their hand while they're managing the patient because they may not feel comfortable with this as we've heard. And then we also provide resource and referrals. So we have an SUD specialist who can reach out to patients and help link them with resources in the community to help them navigate what is a very complicated mental health system as we all know. So Massachusetts Child Psychiatry Access Program for Moms is the first of these access programs. I founded and developed it. And it provides these three components that I just spoke about. And I'm gonna give you an example of how this works. So telephone consultation is really the engine of these programs. So if, I'm gonna give you an example. So I take calls for this program, I provide consultation through them and I got a call earlier in the week when I was covering the phones and an OB provider called asking about that she had a patient who was on methadone. And she was calling actually saying the patient just found out she's pregnant, she's on methadone and she wasn't sure what she should do. Should she recommend the patient stay on methadone? This is a very simple answer as you heard about earlier from Karadad. There's a very clear evidence that methadone outweighs, using methadone outweighs the risk of relapse and of ongoing substance use during pregnancy. So we talked about that and she said, thank you, that's so helpful. It was a five to 10 minute conversation and she went and counseled the patient and that was the end. Another example is a call I got from somebody who had a patient who had a significant, was using alcohol and it was very interesting because this particular provider actually called asking, well I have a patient, the patient was about six months postpartum and the patient that she was calling about was drinking during breastfeeding and the provider called saying, well I'm really worried about the alcohol and breastfeeding, I'm not sure how to counsel her. I'm like, well let's take a big, let's take a step back, what about the alcohol use disorder? It's really interesting because substance use disorders I find that they often don't necessarily know what question to ask and so a lot of what we're doing is counseling people on okay, let's take a step back and look at the substance use in the context of what's really happening. Like in this particular case, the provider was particularly concerned about what about the alcohol going through the breast milk which is of course important but also let's talk about the alcohol use disorder overall and how can we support this patient in addressing that. And then another example is somebody called and the patient was already on methadone, it was already being prescribed, they felt comfortable and she needed some additional resources so we can, one of our resource and referral specialists can call the patient and refer her to resources in the community. So just to give you a sense of how this is a scalable model, this is a statewide program. So we cover all of the births in the state and that any of the providers who are serving pregnant and postpartum individuals, they can call us. We have one full-time equivalent of a psychiatrist so one psychiatrist split between five or six of us, it fluctuates. We have three resource and referral specialists so we cover the whole state with only one psychiatrist and we have about, we've enrolled 84% of the practices in Massachusetts and of the practices who enrolled, more than half are currently calling us. And since we started, which is just about 10 years ago now, we've served over 6,000, almost 14,000 individuals and of those, less than half, we actually do that telephone consultation. Many times they're calling for resource and referrals and for help navigating the referral pathway to therapy. When we do do a phone consultation, only about 15% of the time or so, actually less, 12%, they, do we do a face-to-face evaluation? So for example, I got another call recently and the provider said, I have this patient, she's been on a lot of different medications before, she was also using substances. We could have talked for an hour, not that the OB would have tolerated that but even if we did, I wouldn't have felt comfortable with her treating her because the diagnosis wasn't clear. So in that case, I said, we're happy to see her for one-time consult. We saw the patient and we see them, we do a diagnostic assessment and we provide recommendations back to the OB-GYN. And when we do that, we can typically get people in within a week or two. It is unheard of in anywhere I know to get to see a perinatal psychiatrist in a week or two. So what this program does is it leverages perinatal psychiatrists as a limited resource by building the capacity of the OB providers to do this themselves. And most of the time, we do it over the phone and only in, when it's more complicated, do we actually do that one-time consult. And we serve three to 400 individuals a month. Since the inception of our program. And again, with one psychiatrist, I could never see three or 400 new patients a month. So it really does that leveraging us as a limited resource. And I wanna note that we serve all providers caring for perinatal individuals. Most of our calls come from obstetric providers or midwives, but we often receive calls from family medicine. As we've expanded and done more with SUD, we also get a lot of calls from SUD providers. We specifically get calls from people often providing care for people like primary care providers who are seeing people in grouped homes who are there in recovery with their infant. And also psychiatrists, about 15% of our calls come from psychiatrists. And then pediatricians who are screening at well child visits. And so it's interesting, because when we originally developed MCPAP for Moms, it was actually developed primarily for depression. In 2014, or 13 when we first developed it, it launched in 2014. There is no way we could have gone to OB practices and said, we wanna help you address depression, anxiety, bipolar disorder, substance use. They would have like kicked us out. They would not have tolerated that. At the time, it was really a paradigm shift to even be addressing anything in obstetric settings. People really believed that they won't ever do this. It's not a great idea. But what we found with time, and also ACOG did not have any recommendations, few, I should say, recommendations around this. But in the past 10 years, now we're in 2023, ACOG has recommendations around mood and anxiety disorders, also around substance use disorders. And so we have, over time, expanded what we're doing to include, to be, we always took calls about everything, but we weren't necessarily getting those calls or being really explicit about that, because we're always sort of balancing building their capacity versus scaring them because they think we wanna make them into a psychiatrist. It's always a balance. We wanna help them and help them do things that are not to build their comfort and their skills without taking it to the point where they feel like it's too much. And so in 2018, we actually had increase in our funding. We're funded by the state legislature. It's a statewide, we're funded by officially by the Massachusetts Department of Mental Health. And we had an increase in our funding to address substance use disorders specifically. That is led by my colleague, Lena Mattal, who is the director of SUD services through MCPAP for Moms, and also of all of our DEI initiatives. And we had very specific outreach to both OB practices to help them provide SUD, and also to SUD providers themselves who aren't necessarily comfortable treating pregnant individuals. I wanna point out something about our cost. It's not compared to a lot of other things. It's a very scalable program in that the program costs just under $14 per individual covered in the state per year. We have 72,000 births in Massachusetts, and just over a dollar per woman per month. So our total budget is one million per year. And also in 2015, before we had this legislative surcharge, the commercial insurers were benefiting from this program and that their members could call our program, they could get free consultation, we could see them, and they weren't covering any of the cost. So after a lot of advocacy in 2015, our state passed legislation that legislated a surcharge such that the commercial insurers have to pay a surcharge that's proportional to the amount of their patients that are insured. So about 50% of our patients that we serve are publicly insured. The health plans together pay for half of that surcharge. So it makes the program even more sustainable. And we started this program, as I mentioned, in 2014 is when it launched. It quickly became a national model for perinatal mental health care. It informed federal legislation for other programs like it. And there are now 21 access programs across the country. And there's actually funding right now from HRSA, one of our federal agencies in the US, for more programs. So we expect there to be 28 by the end of this year. So many of your states may have one of these programs, and you, as I'm sure many people here were at the APA or psychiatrists, if you have questions as you're treating a pregnant or postpartum individual, all of these green states have an access programs you can call as well if you have questions. The psychiatrists typically will call back within about a half an hour. The blue states are ones that have aspiring programs, there's also a national line, so if you don't have one in your state, postpartum support international has a national line, and the VA also has a line. And, you know, so the current funded programs have the potential to cover 1.9 million of the 3.6 million births in the US, or that's just over 50%. So when we think about access program implementation, one of the things that's really important to think about is that, you know, in my experience, so we actually developed a network of access programs, so we bring all the 21 states together and we do peer learning and resource sharing, and what we find is it's one size fits none. It's different through different jurisdictions, through different states, what different states have different values, they have different populations that they're serving, and certainly the state legislature often has different needs and values as well. And so, you know, these are implemented very differently, and here's an example. You know, in Massachusetts, we really focus on the consultation, as you heard in those case examples, and we also provide those face-to-face consults, which we feel is really important when people are particularly complicated. Yeah, should all these people have a psychiatrist? Absolutely. But in our state, it takes at least six months to see a psychiatrist if you have, not at least, but often it takes six months if you have MassHealth or public health insurance. So we feel that that's really important because we can see the patient and they'll be prescribed until we can get them in longer term. Wisconsin, for example, doesn't have that. They really focus on the telephone consultation. They do not provide the face-to-face. In Florida, they really focus on the training. That's really core for them and also resource and referral. So, you know, depending on the leadership of the program, what the Department of Public Health or mental health values, these are often implemented very differently. And just another note about it is that the White House recently released a blueprint this past summer, last summer, for maternal health, and it actually also called for access program extension, specifically increasing real-time psychiatric care, psychiatric consultation, healthcare coordination, and training for frontline healthcare providers, as you heard is the model. So I want to note a couple of things as we think about these models. So we've heard about, from all of our speakers, around these wonderful, you know, we heard about the ECHO model, we heard about collaborative care, we heard about the text messaging system, which clearly are getting over a lot of barriers, and you've heard about the access program model. All of these are steeped in the medical system, right? And that's important because, honestly, when I started this work, I thought we can address it all through the healthcare system. I realize, in retrospect, that was very naive. And, you know, but I think, you know, when we think about the healthcare system, it's really important, because it's at the, does this clicker work? Let me see. I don't know. Yeah, there we go. You know, obviously the patient's at the center, clearly the patient, the pregnant individual, and their infant are at the center, and their partner and family. And then the care team, and the system in the setting, and all this collaboration we're hearing about is also there. But then there's this other piece, right? The healthcare system, the policy, and the financing, and the parental psychiatrics programs do interact with this, because they're state-level programs. So they're sort of unique, or they sit in between this, in a way. But then there's all these other things happening, all these social determinants of health. If they aren't addressed, our ability to change that within this inner circle is going to be limited. And then there's all these structural inequities and biases that drive these differences in outcomes. So I want to note that while these are really important, we have to also be pairing these with these, you know, policy changes and interventions to be also addressing these other adverse social determinants of health, and inequities and biases. Hold on, it's not going, it's not clicking. I think I did something when I... What's that? Is that why? Maybe that's why. Okay. And I also want to note that, you know, our motivation when we think about perinatal mental health, you know, not everybody cares about pregnant or postpartum individuals. When I know, when I write a grant, I always start with like, you know, the baby, because everybody cares about babies. But really what's important is the relationship. And there's, and when we think about why this matters, and we think about this relationship, and we just think about in general, psychiatry in general, family relationships are really pivotal in the role of physiology, biology, and physical and mental well-being overall. And we think about child mental health, it's a component and a result of positive caregiving relationships. And there's this, and when we think about relational health, it's critical when we're thinking about perinatal mental health. And then the child mental health is going to be most malleable to safety, stability, and nurturing by that caregiver. And when we're thinking about substance use disorders, and also any other mental health disorder, that has to be addressed for the child to be brought up in a safe, stable, and nurturing environment. And also when we're thinking about trauma-responsive care. And I want to add a note that with all of these things we're hearing about, we've all worked in all of our different interventions to embed these into existing infrastructures. Because I think there's a, you know, we all have, you know, when we think about creating these interventions, there's just never going to be enough people to see the people that need to see a psychiatrist, for SUD and for also other mental health disorders. So, you know, as you've heard, all of the work we've talked about today really focuses on creating a nontraditional workforce. And I want to also add that we don't have to only focus on healthcare settings. We need to do this in community settings too. We have a lot of wonderful psychosocial interventions that people don't necessarily have access to, and we don't necessarily refer them to. I know when I sort of did residency, I learned like therapy and meds. There's so many other things, peer support, other psychosocial interventions I think we often don't utilize, or people don't have access to as much as we could. And also, when we think about all the different people that pregnant and postpartum individuals are interacting with, there's the pediatrician, there's early intervention, there's community health workers, there's so many different people. And there's an opportunity for all of these people to be interacting with people with a relational health, trauma responsive way that can, and together that can be therapeutic. And we don't, you don't have to be a therapist to be therapeutic. That's what one of my, our colleagues in our center always says. And there's so many, and so I think when we're thinking about doing this in a really scalable way, we need to embed it into existing infrastructures, and also be thinking along these lines, that everyone knows someone interacts, just really needs to be trained of how to make these interactions helpful so the patient leaves it feeling like they have more self-efficacy, they have more trust in themselves and the healthcare system, and they feel safer in the world, and that'll allow them to be, give that child the safe and nurturing environment that they need. So in summary, we really need to think about developing, and you've heard about all of our interventions today, but there's still way more to be done, scalable and practical approaches to integrating mental health and SUD care into perinatal infant and child healthcare. And we also need to create, when we think about these models of care and tools, it has to be regardless of what professional setting they refer to. Of course, including healthcare settings, but there's many others as well. And while we've made a lot of progress, and you've heard about these interventions today, there's still so much that we need to do. So I love the implementation science model of impact being, I'm an implementation scientist, that's the kind of research that I do, and in the implementation science model of RE-AIM, it talks about impact being reach times effectiveness. We have effective interventions that work. We have tons of them, but they're not reaching people, and that's the challenge, and that's where we really need to be continuing to focus on. As you've heard from the presenters today, there's some great progress. So a thank you to all of the funders for our work, and the many people who we've collaborated with, particularly all the patients who participated in our studies, and that we've learned with over the years, and all of our funders, and trainees, and students, and so forth. And I think we have some time for the case and questions. Thank you. Thank you to all of our presenters. I will bring up a case that highlights some of the issues that we talked about today. So we have a 32-year-old female patient that presents the clinic with complaints of insomnia. She is 17 weeks pregnant. She has a history of opioid use disorder and sustained remission with buprenorphine, 16 milligrams daily. She reports no use of illicit opioids, has no cravings for opioids. She has continued using cannabis near daily, which she states helps her with morning sickness, and her tobacco use is unchanged from prior to pregnancy, typically around five cigarettes per day. In addition to addressing the insomnia, she is concerned about now, so neonatal opioid withdrawal syndrome, involvement of child protective services, and inquires about tapering her dose of buprenorphine. So some questions for all of you today in thinking about this case. How do you assess the impact of her reported substance use? What advice would you provide regarding cannabis and tobacco use? Would you recommend tapering buprenorphine until discontinuation? And are there any other ways in which the patient can reduce the risk of withdrawal syndrome in the neonates or nows? And if you come up to the microphone, if you can just speak into the microphone since the session is being audio recorded. And certainly open to our panel as well in case they have any comments about this case. In regards to recommending, can I start there? Absolutely, anyone. In regards to recommending buprenorphine, my thoughts would just, is that better? Yes. My thoughts would just be, you wouldn't want to taper it, right? Because then you would potentially have the presentation of withdrawal symptoms in mom, and my thought is that any withdrawal symptoms in mom would lead to increased risk for baby. So I would want to keep her on that same dose of buprenorphine. I kind of have an also like a question in related to that, that I was thinking about when the presentation was going on. What if you had a patient that came in with opioid use disorder, not on any medication for opioid use disorder? Would your go-to be a full agonist like methadone to avoid withdrawal symptoms? Because it's my understanding you have to wait for some withdrawal to present before starting buprenorphine, unless you were to do like a micro-induction, right? So what would your recommendation be in that situation? Okay, so I think that's a great question. And really, when I think about care for patients with substance use disorder and pregnancy, particularly opioid use disorder, it's really being patient-centered approach, right? So you want to talk to the patient, like what treatment have you been on methadone before? Have you been on buprenorphine? So which one, and if it was both, which one worked better? So part of it is going to be really sort of patient choice, right? Because you really want buy-in for this, because if you don't have the buy-in, then they're not going to continue the treatment. So that's part of it. The other is access, right? Some patients don't have access to transportation to get to a methadone clinic every day, and that might be a barrier. Conversely, some patients might not have access to buprenorphine providers. Obviously, that's going away now with some of the regulations that have been relaxed around who can prescribe buprenorphine. So essentially, you would really just want to start with talking to the patient, getting the history, getting a sense of what preference they have, and then taking it from there. You can always start either medication. Obviously, you, unless you work in a methadone clinic, wouldn't be able to start the methadone unless they're coming in. So one of the things that's really important to note is that if a patient is 24 weeks or greater gestation, you do not want to be doing the initiation, because that's what obstetricians call initiation instead of induction, because for them induction means something very different. So they want to do initiation of medication for opioid use disorder in the hospital setting where they can be fetal monitoring, just to make sure that it's going to be okay. So you want to, so having said that, if that is the case, then you could potentially start the methadone in the hospital if that's what you're choosing. In terms of more specifically about your question of which medication to choose and how you do it, we talked about sort of patient preference, but if you can do buprenorphine, they do have to be in mild to moderate withdrawal. So again, for that reason, if they are beyond 24 weeks gestation, you want it to be in patients so that there can be fetal monitoring. But usually you can initiate someone on buprenorphine. You just have to just be more mindful about monitoring for withdrawal symptoms. And if there's any precipitated withdrawal, then you would refer them to the hospital. There are some low dose protocols out there that some people feel more comfortable using, but I know speaking to a lot of my colleagues, obstetricians that are also addiction medicine trained, they say it really depends on the patient. So you can do it with a traditional buprenorphine protocol. I know that was a really long-winded answer to your question. You can clearly tell that I'm really passionate about this stuff. Thank you. Yeah. I'll also add in regards to this case in terms of the tapering of buprenorphine. So yes, the recommendation would be to continue treatment. So continue the MOUD throughout the pregnancy with either medication that the patient is already in. But there will be some patients that are very adamant about discontinuing the medication. And so you want to be able to really meet the patient where they're at and be able to support them during this process if that's their choice. One consideration is that for many of our states, including Massachusetts, a woman who screens positive, including for treatments that are prescribed to them. So buprenorphine or methadone at the time of pregnancy, it automatically triggers a referral to some of the state agencies, which is incredibly unfortunate. And it's often a deterrent for treatment, but it means a report to these state-managed agencies that then come in. We have to provide a lot of additional documentation about how the patient is doing, but it's a lot of extra scrutiny for the patients at a time when that's already stressful for them. So I think that's an important limitation of our system that we have to take into consideration. And so there are ways to do that. There are ways, same as you would with other non-pregnant individuals, to be able to very gradually decrease the medication as a way to minimize the impact of withdrawal. But yes, it is not preferred. »» There are times I continue bupropion and who are taking it for depression. If I followed you right, I think you said not recommended, though, to help with smoking. »» Yes. So there are no specific — so certainly if a patient is already taking bupropion for depression, I wouldn't discontinue the medication. There are no specific recommendations about use of bupropion for smoking cessation in pregnant women. Some of the studies that have looked at it have shown that the safety profile is actually okay, but there isn't a robust evidence, I think as many medications for use in pregnant women that would make it a first-line treatment. »» Just to jump in, so yes, absolutely, if they're already taking it for depression, that is actually the one time that I do actually use bupropion when I'm treating a patient that also is smoking is when they have — »» Bupropion. »» Sorry, bupropion. So bupropion is a patient that has depression and smoking, right. Like in general, like if a patient's just depressed, you know, we tried like maybe SSRIs, SNRIs. But a patient that is smoking and has depression, absolutely bupropion would be appropriate. What we don't have is just the data to support that it's efficacious in helping with the smoking cessation. That's all. »» And I would say, I'll just add something quickly. In general, with the exception of like Depakote and a couple of other anticonvulsants, like if a patient's on a medication and it's working, we typically continue it in pregnancy, just to be super clear about that. When we talk about antipsychotics and antidepressants and so forth. »» Maternal stability is paramount, whether it's for substance use or underlying mental health disorder. Because if the patient's not doing well, then, you know, they're not going to maybe engage in more substance use, maybe not, you know, see prenatal care, etc. »» Any other questions or comments, either related to the case or about the presentation? »» Thank you so much for your talk. I'm Vanessa Padilla at the University of Miami and do some reproductive psychiatry. My question will be about micro-dosing of buprenorphine for those patients who are using. If you had any experience with very tiny doses of buprenorphine while they're trying to come off, either in a new patient setting primarily or with collaboration with other physicians? »» So micro-dosing refers, is often the term used to referring to using very small doses of buprenorphine in order to do induction into the full dose. It has gained popularity, particularly with the wide availability of fentanyl as part of the illicit opioid supply and the thought that there can be precipitated withdrawal if starting a partial agonist when fentanyl and other illicit opioids are present. And so the evidence, even for the non-pregnant population is certainly emerging for this. There is some evidence that the risk of precipitated withdrawal is less with using low doses. And that would be something that we definitely want to avoid in pregnant women. And so I don't think, I haven't seen very much that has been, in terms of it being studied, I think it can be done in clinical practice. And I think depending on the practice setting, it may be something that is beneficial in terms of depending on the gestational age to do inpatient. »» Thank you. »» Hi. PGY2, Renato Velie at University of Miami. I had a question about the, well, first naltrexone use in pregnant women. I'm not really sure why it's not really recommended. I had thoughts that it was potentially due to studies. That's my first question. My second question was regarding sort of contingency management implementation for pregnant women. Like in Florida at least, we don't, I mean, at Jackson we don't really have anything to start with. And I'm trying to look into that. And I don't know if you have any tips. I know this is probably like a big question to answer. But any tips to start, particularly with funding or like something? Thanks. »» I can answer the second question. Were you asking about funding for, just say that second question. Oh, contingency management. »» Contingency management. »» Oh, I see. I just want to, Arianna is going to answer the question. But I want to say that, I want to, Florida has an access program. So if ever you have questions, and these are great ones, they have an access program. And their psychiatrist is actually also board certified. She's triple board in psychiatry, OB, and addiction. They're psychiatrists. You can always call her and ask her questions. And she would be happy to answer. So like you have her, she'll answer the phone if you call her Monday through Friday 9 to 5. So I just wanted to add that. »» Okay. »» Yeah. And I don't really have a really good answer to your contingency management question. It is the one model that has been found, particularly for smoking, to be the most efficacious. And I think for other substances as well. But it is a challenge depending on the state of whether there is state funding available for that and how do you implement that. But it is like fantastic. I wish we could just have that available everywhere. And then remind me of your first question again. Because I was going to answer it. »» Naltrexone. »» Naltrexone. Yes. You are absolutely right. So it's not that we don't think it works. It's that we don't necessarily know because it has been tested. I think in general we feel that it's generally safe in pregnancy. And there are studies underway right now studying it for the treatment of opiate use disorder in pregnant patients. And I think there was a pilot study that came out of BMC that showed that it was promising. Again, no adverse effects. And I am hopeful that then we will begin to have that as part of an array of treatments for pregnant patients with opiate use disorder in the near future. And I also hope that as a result of that, that we can also start thinking about potentially studying it as a treatment for alcohol use disorder in pregnant patients. So I think it's just more that we don't have the studies show its efficacy in this population yet, yet. »» Thank you. »» And I will add that there are some promising smartphone applications and some promising settings in which contingency management is being used in an electronic format using vouchers, et cetera. I think Massachusetts has a couple that I'm aware of that where some of the commercial insurance companies actually pay for it. So this might be an area. I mean, we certainly I think don't have, I recognize as I was preparing for this presentation that I'm talking a lot about contingency management and promoting it as effective treatment, which it is. But I think in reality it's hard for us to implement it into practice. And so that would absolutely be a place where it can be useful. »» We actually had Reset and ResetO. I don't know if you guys, yeah. But I think it recently went bankrupt. »» Yes. »» And so that's also... »» Yes. Promising intervention that did not get the right funding. So that was my go-to. Thank you everyone for your attention. And thank you for being here.

Caridad Ponce-Martinez

pregnant women

substance use disorders

perinatal psychiatry

reproductive behavioral health

SUD trajectories

technology in healthcare

Project ECHO

collaborative care

opioid use disorders

Listening to Women

Perinatal Psychiatry Access Program

healthcare integration