Women’s Health, Wellness, & Recovery: An Intro to Women’s Substance Use Disorders & Health


Welcome to Women’s Health Wellness and Recovery,
an Introduction to Women’s Substance-use disorders in Health. This Webinar is the third in the
Substance Abuse and Mental Health Services Administration’s Women Matter Webinar series.
I’m Deborah — or Deb — Warner, the Project Director for Substance Abuse and Mental Health
Health (SAMHSA) Technical Assistance and Training in Women and Families Impacted by Substance
Abuse and Mental Health Problems Project and Senior Program Manager at Advocates for Human
Potential. I’m honored that SAMHSA invited me to serve
as your moderator for the Women Matter Webinar series.
We invite you to join the conversation.during and after the Webinar, join the conversation
using social media. To join the conversation about women’s behavioral health, use hashtag
Women Matter 2015 on Facebook and Twitter. And feel free to post and tweet during the
Webinar. We have some great information here. Then we have a disclaimer. This Webinar is
supported by the Substance Abuse and Mental Health Services Administration, SAMHSA, and
the US Department of Health and Human Services, DHHS. The contents of this presentation do
not necessarily reflect the views or policies of SAMHSA or DHHS and, of course, this webinar
should not be considered a substitute for individualized client care and treatment decisions.
SAMHSA created this series to build the workforce of capacity to address the specific needs
of women and provide gender-sensitive care and also to increase the national focus on
and understanding of women’s unique substance use and co-occurring disorders. And part of
that, we find, is looking across the different disciplines and really building this conversation
across mental health, substance use, health, criminal justice, child welfare, housing,
so it’s great to see people from so many diverse areas coming together.
The Webinar series also really works to create concrete resources that you can use to provide
education and tools and resources around the specific recovery needs of women. So the Women
Matter Webinar series has five different Webinars. The first two have been completed, Women In
The Mirror, Addressing Co-occurring Mental Health Issues and Trauma. And then Women Connected,
Families and Relationships in Women’s Substance Use and
Recovery, and are available at the Addiction Technology Transfer Center, HealtheKnowledge
learning portal, as well as will be on SAMHSA’s YouTube channel, and that is also true for
the webinar today. Following today’s we’ll have two additional
webinars, one addressing the specific needs of women within co-ed treatment settings and
then one that’s looking at — that’s called Women Unbarred, Recovery and Support for Women
Involved With Criminal Justice. So you’ll notice across all of these webinars we’re
really trying to provide that context, that full, kind of holistic context for what you
need to know in order to be able to work with women with substance-use disorders and bringing
all of that information together. And now let’s turn to today’s Webinar.
So I’m excited to introduce our topic for today, Women’s Health, Wellness and Recovery,
an Introduction to Women’s Substance-use disorders and Health. So many women with substance use
and co-occurring disorders, come to treatment with health problems and medical conditions.
Oftentimes, when we talk about co-occurring disorders we forget to pay attention to the
co-occurring health problems which are impacting women, including diabetes, cancer, HIV, HPC
and oftentimes women are aware of these problems but they’re also often undetected or undiagnosed.
It’s important to know that women have more severe health problems than men when they’re
entering into treatment and they often have different health problems, and that these
health problems affect treatment recovery. Health conditions can prevent access to services,
trigger discomfort, and potential setbacks. To help women recover, it’s important to understand
and address the health issues that they are facing. The actions providers take or don’t
take can make a difference in a woman’s ability to make healthy choices. Likewise primary
healthcare providers who are unaware of a woman’s substance dependence, trauma history
or life circumstances, may have a difficult time diagnosing and treating women.
This Webinar also addresses pregnancy, as addressing both physical and behavioral health
needs are of paramount importance for the pregnant women and her unborn fetus. While
health and behavior health providers understand the needs of the women they service, collaborate
and engage the woman through patient activation or shared decision-making, there’s terms for
describing it, women’s recovery outcomes are significantly improved when we work together
in these ways. So I’m delighted to introduce our session
today, and first we’re going to have Hendree Jones providing an overview of health issues,
including common health problems, promoting wellness and then an introduction to pregnancy.
Let me start by just introducing Dr. Hndree Jones. She’s a professor in the Department
of Obstetrics and Gynecology at the School of Medicine, University of North Carolina,
Chapel Hill, as well as the Executive Director of Horizons, a comprehensive drug-treatment
program for pregnant and parenting women and their drug-exposed children. She is also an
Adjunct Professor at University of North Carolina Chapel Hill and the School of Medicine at
Johns Hopkins University. Dr. Jones is an internationally recognized
expert in the development and examination of both behavioral and pharmacological treatments
for pregnant women and their children in risky life situations. She has received continuous
funding from the US National Institutes of Health since 1994 and has published over 150
publications, two books on treating substance-use disorders, one for pregnant and parenting
women and the other for a more general population, several book and textbook chapters. She’s
a consultant for the United Nations and the World Health Organization. Dr. Jones has been
involved in projects in Afghanistan, the Southern Cones, the Republic of Georgia, South Africa
and the United States, and perhaps I should mention Bangladesh, and her projects are focused
on improving the lives of children, women and families. She’s also a passionate leader
in helping women and families. Hendree, let me turn it over to you.
Thank you so much. It is such an honor and a pleasure to be with you today, and I very
much thank SAMHSA for the opportunity to share some of the research findings and clinical
importance that we’ve found throughout the years in working with women. So that’s just
the title, Women and Substance-Use Disorders, Health and Wellness, okay?
So, as I begin my talk, I like to thank, first and foremost, the patients and (inaudible)
that participate in some of the research that I’m going to share with you today that I
oversaw. Without them tirelessly coming in every day, we would not have the data that
we have today to be able to inform the health and wellness of women, both during pregnancy
and after pregnancy. And NIDA has been very generous with their funding other research
throughout the years. So just to give you an outline of what I’m
going to share today, we’re going to talk a little bit about the cooccurring health
concerns for women who have substance-use disorders, and then focus on health and wellness
in recovery and then end with a bit of overview of pregnancy and substance-use disorders with
a focus on substance usedisorders. So to start with, I think it’s really important
to recognize that both for men as well as women, ilicit substances, like tobacco and
alcohol, as well as illicit drugs, certainly are stressors to our human body. And we know
that alcohol, in particular, can lead to some very significant health consequences, for
example, liver damage, and , it doesn’t matter what gender you are, that alcohol can have
the potential to damage many organs throughout the body, including the brain.
However, I think it is important to recognize some of the different ways that women respond
to drugs and that they are often at greater vulnerability for many health-related issues.
And so when we talk about women who have substance-use disorders, we always have to talk about the
telescoping effect, and that is the amount of time between women first starting to use
and then the development of this physiological problems. And so with telescoping, it seems
that this time period between initial use and problem development is shorter for women
than it is for men. And this is true in terms of specific physical-health effects, but also
between initial use and the severity of problems that bring them into treatment. And when I
think about this, I often think about the fact that it’s much more difficult for women
to hide their substance use because women often relate or have their sort of center
of their life around relationships, they have many family responsibilities and relationship
responsibilities, and many associations with child protective services or other social
services, that it makes it harder for them to hide their substance use than it is for
men. So when we think about alcohol, because that
is the most common drug that we have, behind smoking, we know that women are more susceptible
to alcohol-related organ damage. We don’t have as much water in our bodies, so that
we feel the effects of alcohol more quickly. So, even the standard number of drinks is
lower for women than it is for men. We know that the telescoping effect with developing
alcohol abuse and dependence is also seen with women more than it is with men, and we
know that women are at greater vulnerability for becoming cognitively impaired by alcohol
than are men. So here is a laundry list of both chronic
as well as acute conditions, and the reason I wanted to include this list is that for
many of us, particularly, who are treatment providers or in terms of substance-use disorder
treatment or in general health, we often don’t think about these two together. Many of the
woman, particularly pregnant women that I have that come into our clinic to see us have
anemia. They’re chronically dehydrated, too, and so really focusing on the need to
have better hydration, to have better nutrition, many of the substances that they use are blocking
vital nutrients and minerals into their bodies. They’re often smoking cigarettes or have
grown up in environments in which asthma is a huge concern, not only for themselves, but
also for their children. Cancer is a risk. Untreated pain is a huge issue. I cannot tell
you how many of the women that have come into my Horizons program that started with beginning
prescribed opiates for their chronic pain, and then that turned into a substance-use
disorder and a dependence on opiates. Women, and particularly women who are using
alcohol, are at risk for memory problems or dementia, dental issues is a huge issue that
is often overlooked in general health settings, as well as substance-use disorder settings,
and this — the pain that is associated with dental problems can be a huge trigger for
relapse. Diabetes; women can either be often overweight
and have a long history of very poor diet and not having the skills or the tools or
the knowledge about proper nutrition. Actually just yesterday I did a group for our women
about nutrition and they had never learned how to read a nutrition label. So thinking
about how that might play into making poor food decisions, eating foods that are heavy
in starch and sugar, is something to think about and think about how we can educate our
women who are in substance-use disorder treatment. Digestive problems. A lot of time if you’re
chronically dehydrated, if you haven’t been eating, this can really do a number on your
gut and have problems with digestion later on.
Certainly gynecological problems are of concern, because many women who have substance-use
disorders are forced to sell sex in order to provide for their family or to buy the
drugs that they need, and so thinking about infectious diseases as well as other types
of communicable diseases is important. high blood pressure can also be a co-occurring
issue for women who have used alcohol as well as other types of substance-use disorders
and especially thinking about this in terms of our stimulant users.
Nerve damage can happen because of injection drug use as well as because of other forms
of taking drugs. Thyroid issues, seizures, skin issues from repetitively pulling at skin,
picking at skin, and just generally not having the nutrients that the skin needs to service
as a healthy barrier. And then there are acute conditions like bronchitis,
again going back to the issue of a depressed immune system and secondhand or initial smoke
exposure. Colds, ear infections, headaches, again, that pain can be a real trigger for
relapse for some women. Throat infections, sinus infections, and certainly urinary tract
infections are all things to consider with our women who are either actively using drugs
or in treatment for substance-use disorders. So we know that in terms of alcohol dependence
and drug dependence, there is not a huge gender difference in terms of prevalence, except
when you’re looking at younger children, that gender gap has been closing among, I
believe it’s our 12- to 17-year-olds, and so now our young girls are acting more like
young men. But we also know that although the prevalence
overall might not be that much different, we know that women tend to show more severe
psychiatric medical and employment and problems. And, actually, we have done a study, when
I was at Johns Hopkins, looking at both men and women who were using cocaine or opiates
as their primary dependence when they came into treatment. And what we found is when
we looked at those women who were using cocaine versus opiates, we found across multiple domains
that our women who were using cocaine had more problems, they had more alcohol problems,
more family social problems, and more psychiatric comorbidity.
And then for comparing relapsing across cocaine and opiates, women differed from men by having
more medical and more employment problems, as well as having more major lifetime depression.
The good news is that women tended to have lower rates of personality disorders than
the men did. So we also know that many women do not get treatment, even though they might
need treatment for their substance-use disorders. And we know that women tend to come into treatment
more often with cocaine as their primary drug of addiction. Women tend to come into — or
be identified for treatment either through Child Protective Services or through criminal
justice of social service agencies and sometimes through self-referral. And women often identify
stress rather than drug use as their primary reason to enter treatments.
Women are more at risk, as I said earlier, for having co-occurring mental health issues.
They’re more likely than men to have multiple comorbidity, that means having three or more
psychiatric diagnoses. And I think a lot of the psychiatric diagnoses, we need to be looking
at trauma, particularly childhood sexual and physical abuse, and the relationship between
that and a later developmental — later psychiatric diagnoses that are identified later in life.
Many women that I have talked to, as well as reported in the literature, talk about
using drugs or alcohol or them together to self-medicate, doing anything they can to
numb out the pain. They talk about having this big, dark gaping hole that the wind blows
through and they want to do something to make themselves feel better, and oftentimes using
drugs is the only coping mechanism that they know.
Women are more likely to have anxiety disorders. We have data from our pregnancy studies looking
at more than half of our women coming in for substance-use disorder treatment when they
are pregnant have a diagnosis or major depression. And then certainly eating disorders. Women
who have substanceuse disorders are at great risk for having either anorexia, binge-eating
disorder or bulimia, and then obviously with the trauma that they have likely been exposed
to, there’s a high risk of them developing a posttraumatic stress disorder.
So we know, in terms of opioid use disorders with just adults, that’s collapsed across
men and women, somewhere between 15 to 30% of them will have depression. And we have
more recent data to also show that this can be higher, up to 40% with prescription opioid
use disorders. And we also know that there’s a higher rate
of injection use with adults who have a co-occurring depression and opioid use disorder. And really,
when you have those co-occurring disorders, it — we need to be treating them in concert
together, not in parallel, but really looking at good, effective treatments at the same
time that we are doing treatment for opioid use disorder, because if we’re treating
them independently or only treating one and not the other, the chances for successful
outcome become more minimal. We know that over 40% of individuals who enter
treatment for a use disorder can have a history of having previous diagnosis or some type
of mental health disorder, and in about 80% of these that have that history, their behavioral
disorder predates their use by at least five years.
For pregnant women who have an opioid use disorder we know, as I said just a few minutes
ago, that depression and anxiety are very prevalent.
And we cannot ignore the effect of relationships. So we know that many woman who are using substances
and have a substance-use disorder also have partners that are using substances, and so
we need to be thinking about the current and ongoing emotional, physical and sexual abuse
that they might be exposed to. So thinking about those other social factors
that might be important contributors to substance-use disorders among women, we know that, compared
to men, women are more likely to start drug use and alcohol use initiation in the context
of some type of intimate relationship. I have women that they’ve told me that they’ve
started using substances at seven or eight, because their abuser gave them substances
so they could have access to them to sexually abuse them. And then those patterns are set
really early on and every relationship subsequent to that relationship is intertwined with interpersonal
violence. So this is a highly prevalent concern. In looking at the data from Horizons, I can
tell you that over 80% of our women have a history of physical, sexual and/or emotional
abuse. So there’s a lot of pressure for young women during adolescence, and so they are
very likely to be introduced by that intimate partner to such substances, whereas men or
young men are more likely to be introduced to substances from a peer.
So when we think about the effects of interpersonal violence, this impacts every aspect of a woman’s
life. You can see on the slide that there’s psychological effects, there’s social effects
and there’s physical effects. We know that 22 to 35% of all emergency room visits by
women are related to battering. We know that somewhere between 25 and 45% of all battered
women are abusing drugs during pregnancy. I think that that’s a startling statistic,
and we know that battered women are four times more likely to have a low-birth-weight baby
and her chances of miscarriage actually double. We also know that 26% of all women who commit
suicide are victims of domestic violence, and I can tell you from the work that I’ve
done with other pregnant women who have substance-use disorders, 33% of them have a history of attempting
suicide, so it is a huge issue that we need to be quite vigilant about looking at.
And how do we best screen and recognize violence? And I really like this tool, this women abuse
screening tool. It’s a short form and there are basically only two questions to it. In
general, how would you describe your relationship? A lot of tension, some tension, or no tension?
For those that bingo on a lot of tension, that’s a red flag. And then the other question
that we ask is do you or your partner work out arguments with great difficulty, some
difficulty or no difficulty? And if women respond positively with a lot
of tension and with great difficulty, this short tool correctly classified 92% of the
victims. When those questions are identified both as positive, we want — that’s a key
for us to be able to ask other questions, but also make sure that we are validating
her. We want to listen to her; we want to believe her stories, acknowledge her feelings,
let her know that she is absolutely not alone, that this is not right, no one deserves to
be abused. And then make sure that you have those resources
on hand where she can seek the help that she might need.
So just to summarize that part of the talk, we know that there are a myriad of health
concerns for women who use substances, and these include not only physical health, but
also mental health issues. And that all physical health and mental health
affects, we definitely deserve consideration and evaluations for treatment as part of a
complete treatment for substance-use disorders and the whole woman.
So now let’s focus on health and wellness as a part of recovery. And there is definitely
a big distinction between being drug abstinent and being in recovery. So drug abstinence
really is the act of being away, not having substances like alcohol or other drugs in
your system, staying away from them, remaining free of them. However, you can be in — you
can have the absence of drugs in your system, but not be in recovery. Recovery I really
see as a whole life. It’s a whole way of living. And so what are the components that recovery
includes? First and foremost, it means maintaining control of your life after you’ve taken
control of it. So thinking about healthcare, what is good healthcare? What is important
to you to have not just the absence of illness, but to have a healthy life. What is a living
circumstances? What is — in terms of where you’re living, are you living with healthy
people? Are you having those relationships that are down in the bottom in your living
circumstances? Even if you’re not living in the greatest
living circumstance, what can you do to make your environment a more positive, clean and
calm and unstressful place to live? Thinking about stress, everybody has stress
in their life, but what can we do to effectively manage the different levels of stress that
come up and having those skills in place to be able to recognize signs of stress in ourselves,
the physical, emotional and behavioral signs of stress, and then also being able to know
where to go to seek the internal or external resources to be able to reduce and manage
stress. Having healthy recreational activities. So
one of the things we do at Horizons is we have women exposed to all sorts of different
types of activities from chess to knitting to laser tag to walks in the park to playing
with their children in different healthy ways. So anything that we can do to increase the
positive alternative reinforcements to taking drugs. To have a purpose for living more than
where is my next drug coming from? To have a higher purpose, to feel good about how we’re
spending our time and how we’re employed or fulfilling educational or other types of
higher power aspects in our life that give meaning to our life.
Thinking about diet, that whole idea of adequate nutrition and proper nutrition and hydration.
Think about exercise and the importance of healthy weight control as well as exercise
to help resources and minimize stress levels. Sleep. I cannot tell you how many women have
sleep problems that I work with. So thinking about what role caffeine might be playing
or energy drinks or all those things and how can we have positive healthy sleephygiene
routines that keep sleep in check. Positive social supports. Obviously NA and
AA, Celebrate Recovery, all of those types or organizations can be important for positive
social support, can be out in the community and volunteering.
And then, of course, relationships with family, friends and other romantic or intimate partners.
So recovery is absolutely a life-long process and it is inextricably intertwined with human
development, with continual intellectual growth and learning, with the human experience, experiencing
many different things, both positive and negative aspects in our life and realizing how to frame
them to make a healthy human experience. And also healing. To learn to forgive ourselves
as well as forgiving other people. So we want to see recovery in the context
of the whole person and not just in the absence of a substance.
So SAMHSA has outlined eight dimensions of wellness for everyone, and these certainly
apply to women. I think these are fantastic. So thinking about emotional,, like how are
we effectively coping with life and creating those satisfying and safe relationships. In
terms of environment, thinking about environment from an internal standpoint of good health,
as well as outside. What do we need to frame our environment and form our environment in
a way to help give us power and control over ourselves and our destiny.
And one client told me one time that her closet represented her recovery, so if it’s nice
and neat and tidy, then her recovery is in really good shape. If her closet starts being
in shambles, then she starts stuffing things in and hiding things, then she knows that’s
a red flag for her. So environment can also be a red flag or a green flag for how we’re
doing in recovery. Financial. Many women have tremendous anxieties
and fear and have just never had the tools to be able to manage money or know how to
write checks, how to open a bank account, how to navigate the financial future for themselves
and their current status. Intellectual. Recognizing that we have creative
abilities and finding ways to expand our knowledge and skills. To have an occupation that is
both fulfilling and enriching, for physical activities, for healthy foods and sleep, and
the social, obviously having a sense of deep connection and belonging.
And then the spiritual, again, it goes back to that purpose and meaning of life.
So I think that the lens through which we view the world shapes our reality. And so
our job as treatment providers, either in more general health or in substance-use disorder
treatment, wherever you are interacting with women, it is our job to help women change
the lens through which they view the world. If they have a more positive outlook about
the world, then their brain will actually react and become more positive. We are what
our brain focuses on, so if we choose to only focus on negativity and all the things that
we aren’t and all the obstacles that we have, that’s where we will be.
If we choose to focus on the success and the — and see obstacles as opportunities, that’s
where we will be. There’s been studies that have been done that actually look at the external
world only predicts 10% of our happiness. That means that rich people or poor people,
it doesn’t matter. That external world is such a small, minute contribution to our happiness.
It’s our internal world that predicts the other 90%, and so it’s our job to help women
change their formula for success. So thinking about just the mere absence of
disease doesn’t equal health. You can be in remission from cancer, but that does not mean
that you are in full health. So we need to be thinking about what makes
us healthy, not just drug abstinence. And thinking about what is happiness? If happiness
is getting a job? If happiness is being the best parent I can be, then as soon as you
get that job, then you’re going to raise the bar. And then happiness needs to be, I
have to get a promotion. If happiness means being the best parent I can be, as soon as
I do something right as a parent, then the bar keeps going up and up and up. And so then
happiness becomes something that is completely unattainable.
So we need to reframe happiness and think of happiness as what we have right now, being
happy with what we have rather than looking for happiness in what we don’t have.
And there’s actually great research to show that when we reframe our brain to be more
positive, it increases performance, it increases performance in job, it increases performance
in relationships, and we get to better performance overall.
And we can rewire the brain for happiness with just a few simple things. And these are
the things. And Mr. Steven Aker, has a great head talk on this, and this is for 21 days
he suggests that you do these next five things. Every day, write down three new things that
you’re grateful for. Not the same thing, but three new things. Journal gratitude. Take
one positive experience that you’ve had in the last 24 hours and write about it, because
that brings you back to the experience and you can feel it.
Get physical exercise. Spend at least 30 minutes doing vigorous exercise five days a week.
Practice meditation every single day. And do something nice for others. Pay it forward.
Notice what people are doing well, rather than what they’re doing wrong.
If you practice this every day for 21 days, you can rewire your brain to be more happy
and to be a greater performer in whatever aspect of life you are looking to enhance.
So I think we need to be person centered and collaboratively caring for our women, because
that will improve outcomes, not just for substance-use disorders, but for other chronic conditions
too. And that’s so key to help woman, give them the power. It is their body. They need
to have control over their lives. And the more that they have that personal power and
control and have them be active participants in their treatment, in whatever treatment
that may be, they’re going to buy into it more, and the chances that they’ll improve
their quality of life and reduce the risk of relapse for substance-use disorder becomes
greater. So thinking about health and wellness in recovery,
I think it’s important to mention positive psychology.
And thinking about those six components of positive psychology, that it is possible to
be above normal. We can actually raise the whole average up if we all retrain our brains
with a positive sense of well-being, to have maturity, to have — how do we develop that
capacity for love and hope? How do we have realistic expectations for our own destiny
and have appropriate expectations and goals for ourselves?
In terms of positive psychology, thinking about those positive emotions, not just about
ourselves, but about others, to express love and hope and joy and forgiveness and compassion.
To have awe over small things in life. To have socio emotional intelligence and to have
really successful relationships. To have a more general and better sense of subjective
well-being. It’s great to think about giving joy to others, but we also need to believe
that we have subjective well-being. And then, finally, resilience, which is really
our capacity for successful adaptation and change. How do we become more like the willow
tree and bend with the wind and not break? So now let me turn, so the last part of the
talk is about substance use during pregnancy. So I think it’s really important to note that
it is very unusual to meet a woman who starts using drugs during pregnancy. It’s much more
the norm that women are using drugs and then they become pregnant.
And I think it’s also important to not look at just the legality of the substance as related
to potential harms. If anything, we know, alcohol and tobacco, we have much more data
on them to suggest more harm than we do any other substance. But even for that, there
are many other risk factors that go into the determinants of the negative impact on the
fetus and the child, such as genetics, maternal age and nutrition.
And we also need to be thinking about those other social determinants of health that can
also be overriding influences on child outcome, such as poverty, abuse, neglect and psychiatric
comorbidities. So when we think about the different substances
that are out there, like I said, we know a lot about tobacco. For example, smoking during
pregnancy increases our risks of stroke, of preterm delivery, of low birth weight. We
know that there are a myriad of child effects for kids that have been prenatally exposed
and then postnatally exposed to tobacco. For alcohol, we know that alcohol use during
pregnancy increases problems with fertility as well as fetal abnormalities and certainly
we have a lot of research on fetal-alcohol spectrum disorders to know that there’s a
whole range of effects from behavioral to actual physical, morphological changes.
With our amphetamines, methamphetamines, and I’ll skip down to cocaine, we know that
there are affects, but they tend to be more subtle effects than what was originally believed,
particularly when the research first came out on cocaine. So that is not to say that
there aren’t effects, they’re just much more subtle than what we originally expected.
In terms of benzodiazepines and opioids, we also know that there are affects with those;
however, with both of those you can have a neonatal withdrawal syndrome that can occur
and we’ll talk a little bit more about that. And then just in terms of cannabis, we have
really nice data from Nancy Day and separately from Peter Fried showing the long-term effects
of prenatal exposure to cannabis can cause problems up to 21 years of age, particularly
with executive functioning. So this is a very busy slide, but I wanted
to just remind you that there are treatment approaches for women who have substance-use
disorders during pregnancy. Most of them are behavioral treatments. We do have nicotine
replacement and medications that have been used for smoking cessation; for alcohol, we
really don’t have medications that have been approved for use in pregnant women. Naltrexone
(phonetic) might be a candidate. Cannabis, we don’t have any medications; cocaine,
no medication; amphetamines, methamphetamine, no medications.
We have behavioral treatments, though. Cognitive behavioral therapy, motivational interviewing
and contingency management have all been shown to be effective. And in terms of benzodiazepines
and alcohol, we need to be really — as well as opiates, we need to be really careful with
using medications to help women withdraw if that’s what we’re going to do and certainly
with opiates, we know that agonist pharmacotherapy really is the first line of choice versus
detoxification. So when we’re talking about opiates, that
was just what I said before, is that maintenance pharmacotherapy like a methadone or buprenorphine
is appropriate for use during pregnancy. We know that if medication assists withdrawal,
it is possible to do with women, but the concerning thing is that we know that over 80% of them
will relapse if they don’t have an incredibly structured routine after the detox is over,
and so it’s — the World Health guidelines and others have recommended that maintenance
pharmacotherapy really is the first choice for treating pregnant women who have -use
disorders. So why would we use opioid medications? And
this is true for pregnant women as well as non-pregnant women, and it’s to help with
control, so it gives back life control to the patient. It helps the person focus on
rebuilding her life. It helps with reducing the compulsivity to use opiates and also helps
control craving. It prevents erratic withdrawal and lessens fetal exposure and we know that
in the context of comprehensive care that we have really reduced fetal complications.-
And the biggest issue that we have is neonatal withdrawal, traditionally known as neonatal
abstinence syndrome. It’s been defined as neurological excitability, gastrointestinal
dysfunction and autonomic signs. And these are data from Steven Patrick which
nicely show national data, which just show in the bottom right-hand side here that the
rates of neonatal abstinent syndrome have gone up in the past decade.
And these are the primary outcomes from the mother study, which is a double-blind randomized
comparison of methadone and buprenorphine, to treat opioid use disorders during pregnancy
and what we found was out of five of our primary outcome measures, two were significantly different,
so if you were a baby that was exposed to buprenorphine during pregnancy, you required
less morphine to treat your neonatal abstinence syndrome and you stayed in the hospital for
a shorter period of time. However, it’s really important to note that both medications in
the context of comprehensive care produced similar maternal outcomes in other treatment
delivery outcomes. And so what I think is really nice about this study is that it gives
us randomized control trial data to show that there are two medications to treat opioid
use disorders during pregnancy. This is the last data slide that I have and
it’s just to put a plug in for the need to aggressively treat smoking during pregnancy.
So what we did is we actually collapsed across methadone and buprenorphine and found that
it didn’t matter. What mattered most was the amount of smoking that women were doing during
— we looked at the amount of smoking when they came in. That showed that for — the
more women smoked, the more amount of morphine was needed to treat the NAF; the number of
days of medications for NAF increased in a dose way with more smoking; the neonatal weight
at birth was significantly lower in the above-average smokers and then the length of hospital stay
also increased the more women were smoking. And so just to wrap up, we know that substance-use
disorders are treatable illnesses for women. It’s important to look at physical health,
as well as mental health. And that we also know the more medications we have, the better
off women’s health will be in terms of options and giving them power and control, and we
know that neonatal opioid withdrawal is a treatable condition, but we definitely need
more studies to understand the best medications and the best treatment protocols.
And with that, thank you very much for your time and attention.
Great, thank you very much, Hendree, for such a rich, nice sort of travel through a lot
of different territory presentation. . Thank you.
We do have some questions that have come in and we have a little bit of time for questions.
Some of these questions, I think, also may be addressed by Nancy, so we may hold those
related to pregnancy for the very end. But can you talk more about the relationship
between interpersonal violence and birth outcomes? Yeah, so we definitely know that women who
have interpersonal violence are at much greater risk for having poorer birth outcomes. So
we know, like, in terms of low birth weight and terms of prematurity, so I think the message
to that is that OBs, midwives, whatever, healthcare providers, or family docs, we need to be asking
about violence. We need to be not afraid to ask about it. And we need to know what the
resources are in our communities so that our women can get the intervention and the help
that they need so that we can have a better chance of improving those birth outcomes,
like what the actual mechanisms are with the depression — or with the interpersonal violence
leading to this poor birth outcomes, I think are potentially a myriad of things. Women
might be smoking more. They could be eating less. They could be depressed, which is going
to affect appetite and weight gain. There could be controlling issues in terms of being
at risk for anorexia and weight. So I think that there’s a — it’s not just the interpersonal
violence by itself, I think it’s all of those things that go with it.
Great, thank you, yes. And that interpersonal violence also has a tendency to increase during
pregnancy in violent relationships. Absolutely, it is definitely — it used to
be thought that pregnancy was somehow a magical, protective factor, and that is absolutely
not the case. Great, thank you. The next person asks, What
about women who are homeless? How does that affect health?
Absolutely, I mean, homelessness is such — one of the social determinants of health. It’s
incredibly difficult for homeless women to get the healthcare services that they need.
Homelessness, we know, is really hard on the body, just physically and then, of course,
the ways that women have to survive often on the street we know is selling sex for — exchanging
sex for a place to live, exchanging sex for food. So certainly homeless women are at huge
risk for a whole myriad of health affects. We put that chronic and acute slide back up
there,that would certainly work for homeless women too.
Uh-huh. And then going back to that chronic and acute care piece, this person was asking
about the resistance to medical care, that many women who she sees have a resistance
to accessing medical care and how do you support women when they don’t want to go to a doctor,
but you think that they probably do need some — have some health issues?
Yeah, that is such a great thing. So we certainly — I encounter that probably every day. And
so I think talking with the women about what they’re scared of. Oftentimes they’ve
had an incredibly negative experience from the front desk person treating them terribly
to the physician or other care provider, nursing provider, not believing them, treating them
poorly and with huge stigma and judgment. And then there’s also the fear of if I go
to the doctor and I have a positive, they’re going to test my urine and it’s positive for
drugs, what’s going to happen to me? Am I putting my children at risk? Am I putting
myself at risk in some way? So what we’ve done is help the women through
that, find providers that are trustworthy, that are trauma informed, as well as informed
about substance-use disorders, often having a warm handoff, so it’s not just telling them,
Go call this number and make an appointment, but it’s sitting with the woman and calling
with them. Maybe even taking a tour of the medical facility. They can meet the front
desk person. They can be told what to expect in the appointment, and the other thing that
I’ve found that physicians do is just because we’re busy, is we don’t think to talk
through what’s going to happen. Like, just with a gynecological exam, that’s
— that can be incredibly trauma triggering, so if you put the cold, you know, the cold
apparatus into the vaginal cavity and you’re not explaining what’s happening, so really
talking — taking that time to explain to women before the visit and during the visit
about what’s going to happen to help give them more control. Those are things that have
been successful for us. Great, thank you. And then I think one other
question, this person talks about women she sees often are disconnecting from their bodies
and so it — she finds it hard to get them to desire to start really looking at health,
as they’re not in touch with their bodies. Uh-huh. Oh, absolutely, that is such a common
phenomenon. We work with a lot of grounding techniques to help them go slow. I think it’s
an unrealistic expectation for ourselves or our women to expect they’re going to be
ready to, boom, start addressing all of these issues. It’s really scary to look inside,
and they’ve ignored issues for a long time. So just starting with something that’s really
simple. What is your most pressing health condition? Thinking about grounding and, like,
(inaudible) grounding techniques of, like, feeling the floor, thinking about your different
senses, there’s dialectical behavioral therapy techniques are helpful for that mindfulness
and the grounding. Thinking about simple things that they can do — yeah, are some of the
things that we have done. Great, thank you. And I think we’ll hold
the questions. We do have some time for panel questions at the end, so we’ll hold the
questions related to pregnancy until after we hear from Nancy.
So we’re giving a virtual round of applause to Hendree right now. I won’t actually applaud
because it sounds so loud in people’s ears. I’m using sign language for clapping.
Thank you so much. And now I’m going to go ahead and introduce
Nancy Goler. Nancy Goler is a board-certificated obstetrician and gynecologist. She has been
the regional medical director for Kaiser Permanente’s Early Start Program since 2003. She also is
currently the Assistant Regional Clinical Director of the Appointment and Advice Call
Center, specifically focusing on strategic programs as well as overseeing the Wellness
Coaching Program, the Regional International Travel Services Program, and Kaiser Permanente’s
Patient Outreach Support Team. In 2008 she was selected by health leaders
as one of the top 20 people making a different in healthcare, based on her work as the lead
investigator of a research study about Kaiser Permanente’s Early Start Program in the Journal
of Perinatology. She also takes great pride in her team’s January
2011 published article which appeared in the American College of Obstetrics and Gynecology’s
Green Journal demonstrating a substantial cost benefit analysis of the Early Start Program,
with significant implications for our current model of healthcare delivery, stressing the
importance of investing resources early to provide better outcomes and cost savings later.
So with that, Nancy, I’ll turn it over to you.
Thank you very much, Deb. I want to thank you all for attending and
Dr. Jones for an excellent presentation and, let alone, setting me up right into pregnancy,
which is very helpful. And I also want to thank all the SAMHSA support
for your — all the SAMHSA staff for your support and expertise through this whole process
or coordinating our two talks. Let’s see; here we go. What I’m going to
do today is, for those folks who aren’t familiar with Kaiser Permanente Northern California,
just give you very briefly an idea of our size and magnitude of we’re covering so
that you have a sense of how that can relate to your own service areas. And then an overview
of just understanding, what is SBIRT? What does that stand for? What does it mean?
Looking at our program, which is really SBIRT on steroids, and then recognizing that, even
though, as Dr. Jones said, there’s a lot of any type of medical treatments for a lot of
substance-use disorders that actually using an SBIRT model of care, particularly motivational
interviewing, brief negotiation and having a support, both in your community, as well
as in your medical health profession, to support women through this, you actually can make
market benefits on the outcomes of the pregnancies for women, their babies and the families.
So Northern California Kaiser Permanente is a large service area, we cover 50,000 drivable
square miles. We are spread out amongst 15 hospitals, there’s 42 outpatient clinics.
We serve — actually now we’re closer to about 3.9 million members. There’s been some
growth with covered California and the ACA. Our birth rate has been about 38,000 last
year. I think this year we’re probably going to get closer to 40,000, and you can see we
have a very coordinated care program. We have a lot of preterm prevention programs in Early
Start, so our preterm rate is a little lower than national average, and our C-section rate
is as well. Part of that is also because we have 24/7 physicians in-house.
The Early Start program itself started 25 years ago and the mission statement which
was started back then still stands today. And really our mission is about creating a
non-punitive healthcare environment so she can access services and support for a healthy
baby and be free of drugs, alcohol and cigarettes. And one of the things that Dr. Jones alluded
to was around whether or not — how everything is it that women are using? And there’s a
lot of social constructs that, indeed, would make it that you would think women would not
necessarily hide their substance abuse as much as men and perhaps it would be more obvious,
but pregnancy is a really interesting state. There’s a huge amount of fear when you’re
pregnant and stigma in pregnancy. Even in substance abuse clinics, there’s stigma of
pregnant women. So even within the community of substance use and abuse, there is stigma
on women who are pregnant and using. There’s huge societal stigma. Pregnancy is one of
the very few medical conditions that’s rather public. I would imagine if anybody had a big
mass on their shoulder, you wouldn’t find people coming up saying, Can I touch it? And
yet there’s still women in the supermarket that have complete strangers asking if they
can touch their belly? And, you know, really, it’s — life is so
extraordinary that — that you’re drawn to it when you see a pregnant women and you’re
drawn to it when you see babies and it’s so compelling. But if you are using, it’s very
scary. Also with 50% of pregnancies in the United
States beginning unplanned, many of which associated with drugs or alcohol and cigarettes,
there’s great fear. So there’s great fear about have you done harm? You want a healthy
baby. What if you’re found out that you’re using? This is not necessarily the time that
you want your whole family to know that you’ve been using. Many of the women we see in Northern
California are addicted to opioids, often started from prescriptions, things like that,
so our entire program is around creating an environment that allows women to have a non-punitive
place for care and to get them free of alcohol, drugs and cigarettes.
SBIRTitself is a model to deliver intervention and was largely — has largely been used around
alcohol and identifying alcohol use and not only leading to recovery of alcoholics or
identifying of alcoholics but actually decreased use for folks and it makes folks aware of
it, as alcohol, even if you don’t have an addiction to alcohol, could still be causing
problems both for you and for our society. And it’s a very simple acronym, SBIRT. The
first is screening. The screening can be very simple. It’s generally a self-administered
questionnaire, often five questions or less. Sometimes if a question’s positive, there
may be another question that gets asked. But it should be something that’s very straightforward.
Many folks are familiar with Cage Tweak, but some of them are even a little different than
that in the asking other questions. And then there’s the brief intervention. And
this can be variable. It can be anywhere from simple statements up to one hour interventions
with a longer session with somebody, whether it’s a physicians, a mental health provider,
someone trained in motivational interviewing. And the goal of the brief intervention is
to get the person who’s done this screening and has screened positive for risk of alcohol
use or other things that you may be screening for, to rethink about their use and make changes.
And when you look at, the technique that’s most used is something called motivational
interviewing, which is really a type of approach that is nonjudgmental. It’s objective. It’s
compassionate. Transparent, honest, reflective, and the goal of all of that is about increasing
the patient’s awareness, trying to get the patient to see what is their relationship
with alcohol? How — I only use alcohol as an example, because of the — the historical
basis of SBIRT, but how is it affecting their lives?
What are the things that trigger them to drink? What are the barriers that make it hard for
them to stop using? Very often in our program, and Dr. Jones alluded to this as well, the
partner plays a significant role in her use, whether it’s that she’s self-medicating with
something because of the difficulties in their relationship, or that that’s part of what
they do together. And now there’s this conflict about his — or if her partner’s a woman,
her use and hers, the pregnant woman. So brief intervention is really about not
me telling you don’t do that and me imposing something, it’s about reflecting back and
trying to get into the underlying issues that are causing that use, and it’s really about
meeting the member where they’re at and getting them to start this process of self-reflection.
And then referral to treatment can be highly varied, depending on your resources, whether
it’s an internal resource, whether it’s just a continued follow-up, or if you are identifying
somebody who actually meets chemical dependency of addiction diagnoses, making that referral
to a treatment program, whatever that may be in your area.
So why are we using SBIRT’s model of care? It’s evidence based. There’s tons of literature
that shows that this very simple model of care which can be done in a primary care office,
can be done in an urgent clinic, it can be done in a hospital setting, an PC setting,
it works. It identifies levels of risk associated with alcohol or substance use.
And by having it be from a self-assessment right from the start and using techniques
like motivational interviewing, it really draws the patient into their own use and into
their own issues and helps uncover those things so that you can change that behavior.
And what you see is you see both decrease in use overall, as well as decrease of risky
behaviors. So you decrease accidents associated with alcohol; decrease of diseases associated
with alcohol and substance use or other health risks.
And in the larger context around what Dr. Jones was talking about, you would expect
to see decreases of those chronic illnesses, decreases of some of the acute illnesses,
decrease of relationships that are putting a woman at risk for intimate-partner violence,
all of those things, the larger societal issues that are part of that as well.
When you educate people about — the SBIRT goals are to educate people about the risks
of alcohol and other drugs, make them aware and do this larger societal reduction of use.
And then, of course, the key is to find the people who really have dependence as well
and get them rapid access to care. So SBIRT and pregnancy is it different? And
what is the goal really when you’re talking about a pregnant state? And it would contend,
in pregnancy, it’s not — you could look at it maybe as a larger societal, because you’re
going to have healthier moms and babies, but you’re really much more specifically looking
at a model of care that’s going to prevent the maternal and neonatal morbidity and mortality
associated with drug and alcohol use, such as those that I have listed here.
And all of these both cost — you know, the emotional toll is extraordinary, but there
are lives and there are very substantial financial costs, particularly to babies who are born
that go through neonatal abstinence withdrawal who are preterm, who need ventilators and
who spend long times in our NICUs. So the other thing about pregnancy is pregnancy
is one of the few states of being where we are — actually our goal is complete abstinence,
because we don’t know all the genetic factors that make one woman’s more prone to fetal
alcohol spectrum disorder versus another. We don’t understand all of that. We don’t
— the brain develops from the time, essentially of conception through teenage years, and huge
rapid development in utero. So we don’t have the luxury of time to try to get to abstinence.
We have this very short period of time. Women come in, they’re often, depending on their
program, in their first trimester or early in the second trimester, and you’re trying
to get them abstinent. And we’ve really showed in Northern California
that if we can get women abstinent by 32 to 36 weeks, we markedly will change the fetal
outcomes. So it’s a very different type of program because of the lack of the luxury
of time. And that’s why I say it’s on steroids. I was going to say it’s on speed, but I was
a little — or amphetamines, but I — I thought the play might be a little too much, so I
call it SBIRT on steroids when I talk about it and I think most folks get what I mean
when I say that. The other thing that is interesting about
having a coordinated SBIRT program like Early Start is that within 12 months of implementation,
you will get improved outcomes. And that improvement in outcomes will provide you a net cost benefit.
And I can say that with great confidence because pregnancy, no matter what, is nine months
long, and even if you decrease the number of babies in a neonatal intensive-care unit
by one or two per year for almost any delivery group that’s delivering, let’s say, 10,000
babies or less a year, you’re going to save substantial costs and mental health professionals
such as licensed clinical social workers, MFTs, which is what we use in Northern California
to deliver the program, are not very expensive employees. As a matter of fact, I don’t think
they’re paid nearly what they’re worth as a general rule, but in terms of the cost
benefit, you’re able to recover those costs very quickly, which is why in our papers we
speak to the fact that paying for the costs in the hospital does not make sense. We, of
course, would always pay for those. It makes much more sense to move those dollars up front
and be paying for the services in the ambulatory setting, so that these women can get the care
that they need. The way Early Start works, it’s a very straightforward
intervention. And, actually, I would love to take credit for the program. I have been
the medical director for about 13 years now, but it was actually started by a nurse practitioner
who worked in the pediatric ICU who partners with one of our physicians back in 1990, very
upset about seeing babies born on drugs. And we put in four principles back then. And
that was right around the same time that SBIRT was really getting going. But if you talk
with Annie Bodim (phonetic) who started these principles, she wasn’t thinking of SBIRT,
but I’m going to take you through our core innovations and you’ll realize it really
is like an SBIRT model. First of all, we universally screen all pregnant
women. So we do not — you know, you come in to Northern California to get care, you
get a universal screening questionnaire. Our questionnaire is a fairly sizable questionnaire.
We ask both questions about use before pregnancy, use during pregnancy. We ask about partner
use, tolerance questions, some family questions and we really put out a wide net.
And the reason why we do that is that most women want to get help when they’re using,
but they’re very afraid that they — even in a program in Northern California where
it’s been for 25 years, they’re very afraid of not getting the same care by their doctor
because they think we might be biased or discriminate against them. Fear of the judicial system,
even though in California there’s no mandated reporting to — to any type of police force,
just by toxicology, there’s not even mandated reporting to CPS on drug screen alone. It’s
only after psycho-social assessment, but there’s great fear.
The flip side is there’s a great desire to have a very healthy baby, so in their ambivalence,
what they’ll do, quite commonly, is downgrade their use but still screen in positive, so
we have a very wide net. We also universally do toxicology screening
on all women. We have a declination, if they say, but we do consider this to be part of
our standard of care out here, so we don’t require consent for the toxicology urine screening.
We put the licensed mental health provider right inside the Department of OB-GYN, and
we link all of her appointments with the appointments with the — the obstetrician, nurse practitioner,
midwife, whoever is delivering her care or family practice doctor, with the Early Start
specialist. So she doesn’t have to see me as an obstetrician and then go down the hall
to find a mental health provider to review this with her. She sees me and down the hall
from me is my Early Start specialist and I can take her right there.
This isn’t the time for the woman to have to go back out to her mother-in-law who’s
watching her kids and say, I have another appointment over in the chemical dependency
department. She doesn’t want her mother-in-law to know she’s using to begin with, so what
we want to do out here is remove every barrier we possibly can to get her the care.
Why? Because we don’t have the luxury of time, and we have a baby in there and we’ve
got to do our best to make sure that we have the healthiest mom and baby by the time delivery
occurs and we want delivery to be at term. And, lastly, we do a lot of education of all
women and all our providers around this program. Just you know, with universally screening
all pregnant women, I get asked this a lot, especially I work across the states with other
states who are trying to put in these programs and the urine toxicology is often a real tricky
part for them, particularly because of mandated reporting rules.
In Northern California, only 2% of our positive toxicology screens have a negative screening
questionnaire. And, again, that’s because most women will put something in there that’s
positive for the screening questionnaire, so the key is your screening questionnaire,
without a doubt. And that’s SBIRT as well. SBIRT doesn’t say you should be doing urines,
it’s the screening questionnaire that sends out that net. And also by doing it universally,
you remove all the judgment that can come before.
Our brief intervention is really a little bit multi-stepped. It’s not as classic as
the one that you’ll read about if you go online with SBIRT and alcohol. And that’s
because of the nuances that happen in the program.
You know, someone comes in, there’s a different person that reviews that screening questionnaire,
who notes whether it’s positive or not. They’re putting a note in the chart for the obstetrician.
In some places it’s actually a midwife or nurse practitioner who might be doing the
screening questionnaire, remember they need to feel comfortable going right into that
first step of the brief intervention and that first step is just a very frank, honest, transparent,
compassionate discussion around what you see in the screening questionnaire, where your
concern is, asking a few questions, telling the woman about your concern, and then moving
her down to the Early Start specialist. And the Early Start specialist is really the
person that we’ve trained very well in motivational interviewing, brief negotiation, who ready
does a 45 — 45-minute, one-hour psycho social assessment. Included in that are things like
ACES or adverse childhood experiences, IPV, et cetera, and she provides a lot of education,
and then determines what type of referral we may need.
And when we talk about referral, we’re talking about a couple of different levels of referral.
So it may just be continuing to follow with your Early Start specialist, that there’s
not a true — we’re not a chemical dependency program, so there’s not a true chemical dependency
diagnosis. It’s not someone who warrants treatment; it’s not someone that we need to get on methadone
or buprenorphine for an opiate addiction or anything like that, but this woman’s going
to need continued support thru the pregnancy and she can continue to have that relationship.
Or it may be someone who does need to go to our chemical dependency program. We also use
quit lines for cigarette. We have addiction services, obviously, at Kaiser Permanente,
although we do partner with our methadone clinics for methadone, but we also use our
community services for support. And so that’s how that SBIRT model looks.
I would say the key things that we’ve done is co-locating the Early Start specialist
in the room. We also have worked with our health plan to have this program be a no-cost
share. And I know that sounds tricky for everybody else on the phone line, I get that. But I
do think that’s — it’s very key to try to remove the cost barrier. We use telephone
and video, everybody is involved in the process and very committed to the program.
So the question is, Does it work? And I will tell you it does. We have two papers that
I’ll show the titles of. And we both improve maternal and infant outcomes. We reduce utilization
of our resources. And we’ve also shown enhanced provider satisfaction.
Whoops, sorry about that, let me go back up. Here are the two papers. And just so folks
know, I’m not going to go through all the research for the interest of time, but we
are looking at close to 50,000 women. That’s the cohort that we were working with. And
we looked at women who screened positive and were able to access Early Start and had their
follow-up visits versus the controls who had nothing, no substance use on screening questionnaire
or toxicology versus those women that screened in positive but were unable to access Early
Start for a multitude of reasons. They might have sort of disappeared through the cracks
or we — they might have been somewhere where maybe the Early Start specialist was out on
leave. And what you can see here is pretty marked
results. Decreasing preterm birth rate by more than 50%. Of course, that ties right
to the neonatal ventilator, also more than 50%. We also decreased placental abruption
when the placenta separates from the uterus early by seven-fold. That means decreases
in maternal transfusions as well as in baby transfusions.
And we decreased the rates of stillborn by 14-fold, so pretty dramatic decrease in rates
of stillborns from 7.1% to .5%, which is the — of users versus the program, .5% was the
rate, both for the Early Start group, as well as our group of women that screened negative
for everything. And the net cost benefit for our organization
is close to $6 million annually, looking at this program. Sorry, my slide just went. Let’s
see if it will work. There we go. Whoops. When I go out to communities, there’s known
barriers. Hospitals are actually not motivated to save money. I know that sounds horrible,
but I’ve actually had people tell me they’ve tried to go to their hospital boards and directors
of hospitals say, Well, why would I put a program in that, you know, we actually get
money reimbursement for babies in the NICU. It sounds like a terrible thing. I don’t
think that’s all hospital administrators, but hospitals are a business and as long as
it’s a business and it’s for-profit, it’s a little trick to take that way.
There has to be a willingness to take a risk, to risk a new budget for a larger savings
for healthcare. I have to hope at some point we’ll make some progress with legislation
around moving those monies around and giving incentives to hospitals that put these types
of programs in so that women can access these programs.
There’s denial at all levels; everybody involved in substance use. And it is a difficult population.
It’s — it can be hard work. It’s a lot of pain and confrontation of pain and issues
and people have to look at their own issues and it can be tough. It also is, I believe,
probably one of the most rewarding parts of my entire job. And I’ve been an OB-GYN for
20 years, and I oversee a lot of programs and this is, by far, the most rewarding work
that I do. And on that note, I’ll stop for questions.
Great, thank you so very much, Nancy, and, yes, just kind of going back to that last
slide that you had around the barriers and I really do think, just looking over the last
several years at the significant progress that we’ve made, in terms of integrating
behavioral health and healthcare, that we have such an opportunity right now, like just
the group of people even coming together for this particular Webinar, to have that population
focus and really start to look at the comprehensive needs and how do we address both behavioral
health and health, particularly with the population focus of women and pregnant women, and address
and intervene early so that those cost savings are beginning more and more recognized and
shared, rather than being in different silos than where the costs are occurring.
So I was really glad to see that you put that into your presentation as well.
Most of the slides — the questions that we have are more detailed questions. We did have
one person who asked a clarifying question about can you talk about what you mean by
abstinence? What about tobacco, methadone, as a preferred method of treatment? So could
you clarify just a little bit about that? Yeah, absolutely. So I’m going to hold on
the opiates for just a moment. So when we say abstinence, our goal is actually to try
and have patients not using any alcohol, cigarettes or other drugs. And, again, I’m just holding
onto opiates for a moment. Or at least reduced to the smallest amount they possibly can.
So that’s kind of our goal and that’s what we mean by that.
And it’s almost — it’s almost in line with somebody being identified as someone with
a true addiction and having them not use completely. A lot of people use alcohol and even recreational
drugs and don’t have a substance abuse problem. And we’re not looking for people just to
be cutting back. We actually — our goal is to stop use. So that’s the focus of our program.
In terms of opiates, it’s a little bit trickier, because of addiction to opiates and the difficulty
people have stopping and we do actually — we will work with women to wean off, despite
relapse rates, certain women who are — have the right social structures around them, who
are highly motivated, in the second trimester, we will work with them to take — to try and
get them off opiates. Right now we’re using a lot more buprenorphine.
The mother study was helpful. It’s not FDA approved and we share that with patients.
It’s a partial new agonist, so some could — you know, can be withdrawal, but there’s
a safety factor there. If you take away someone’s opiates and you don’t treat them with even
methadone or buprenorphine, the risk of them going on the streets and either getting drugs
that are being marketed as a pill that they took before like Norco or moving to heroin
is such high risk behavior that we would rather have them on a treatment, even though methadone
is also an opiate, where we are controlling the amount and we are doing some harm reduction
as well. And then we do deal with the neonatal withdrawal
in the hospital and watching these babies a little longer.
Great. And then a related question, and then I’ll invite Hendree to also comment, has
to do with detox during pregnancy, and how do you handle detox during pregnancy?
So as I was just mentioning a little bit, we do have detox programs in pregnancy. We’ve
done both inpatient and outpatient slow weans, depending on the amount. And we have a couple
of peri- neonatalogists, which are high-risk OB specialists
that are very comfortable with helping to oversee this. I actually sit on the Chief
of Addiction medicine group and we’ve been working with our addictionologists and we
will withdraw people in-house. There’s other programs around the country
that do a lot of detox, actually, in pregnancy in-house. Up in Washington State there’s quite
a bit right now. They have very good success. I have not seen it published, but I have spoken
with the people there, so it is doable. We generally recommend second trimester. You
can do first trimester. We put people on buprenorphine first trimester. The risk of opiates is the
number one for people, from a drug point of view to be miscarrying, once you have a fetal
heart tone, the risk of miscarriage goes down quite a bit and we don’t see any increases
by switching people over from their narcotic to buprenorphine in the first trimester. I
hope that answered that. And, Hendree, would you like to also chime
in on this? Yeah, absolutely, so I completely am really
glad to hear, Nancy, your clinical experience with transferring women from their drug of
addiction on to buprenorphine without having clinical issues with that and so I think that
that’s great and you can do it. It’s been our experience that you can do that in the
first trimester, second trimester or third trimester.
One thing that you said that I just want to make sure is very clear that I think is — might
have gotten, been a bit confusing, is this whole issue around FDA approval. We actually
have a paper on which we had a consultant from the FDA that — it should not be considered,
buprenorphine shouldn’t be considered off label because we’re never going to get an
indication for pregnancy for buprenorphine or for methadone because they’re not medications
to treat conditions or pregnancy, if that makes sense. So we need to be –
– I think that there’s been a reluctance to use buprenorphine because it’s, you know,
somehow misconstrued as off-label when it actually is not. We’re never going to have
statin indication for it, just to clear that up.
And then I think the issue of detoxification during pregnancy, I really think it’s such
an individualized patient and provider and discussion that you have to really weigh the
risks and benefits of very carefully. So for the population that I work with, it’s much
more the exception than the rule that we would ever look at having women withdraw over time
with a medication you really have to, just underscoring what Nancy already said in terms
of having incredibly strong social supports and just a really detailed plan and looking
at good job support. You have to — thinking about ACM criteria,
that they need to have, like, the lowest ACM scores possible for us to really think about
that because the risk of relapse is so high. And, you know, you can get them through pregnancy
but then what happens afterwards, like what is the long-term outcomes with those women
that have been weaned and detoxed to nothing. I think it’s certainly an area for search
that we don’t know that much about. Uh-huh, yeah, and to emphasize, when Nancy
was speaking, she’s also speaking from a medical clinic point of view as well, and I know many
of the providers who are out there are providing more bio-psychosocial service.
Let’s get to a next topic. Another person has asked about do you use peer support? If
we could hear from Nancy first and then from Hendree around the use of peer support as
part of your interventions for women. Yeah, so I would, on and off. We’ve had
some groups — we — what we find is that our pregnant patients are very reluctant to
partake in our usual chemical dependency groups out here because of the stigma that I told
you about earlier. So women are often stigmatized in substance abuse programs — use programs,
excuse me, and particularly pregnant. We’ve had some special (inaudible) groups
and off. Then we’ve had some success and some not success. It’s — it can be tricky
because, actually, as Hendree alluded to, there’s all these other issues that are going
on for women, too, and sometimes, especially with pregnancy, and the timing of the issues
that are happening within your pregnancy, it doesn’t always work as well and sometimes
the group doesn’t mesh as well. So we are not doing much peer support at this point
and we’ve had intermittent success with it over the last 20 years.
So I have a kind of a different take on that. So we have a number of peer support — certified
peer support specialists that work in the Horizons program, and they’re absolutely
essential to the work that we do, because they can talk to our women in a very different
way than a traditional sort of clinician might be able to, so we use our peer support when
women are first coming into the program and then particularly after they’ve graduated
from the program, because that just allows a sort of really nice connectivity back to
the program. So they — our peer supports go out, they do a lot of outreach. They work
with our women. They help them get connected to other support resources. They take them
to NA meetings or AA meetings or Celebrate Recovery meetings.
And we actually have a practice of hiring our graduates who have been in sustained abstinence
and drug recovery and I think that, out of a staff of about 70 people, we have eight
of our women that have graduated, have been in that sustained recovery and come back to
work as real models in our community and leaders in our community. And that’s been fantastic
for our new women coming in and our women in treatment to look at the women that have
been there and done that and done such a beautiful job and have this great purpose and light
in their soul. So it’s worked really well for us.
Great, great. And different settings also. So sometimes you’ll find that as providers
are working together, what works in one place doesn’t work in another place as well.
Right. And the role of peer support often happens
in very, very different settings. Thank you. We have two other questions that I want to
try to squeeze in to the remaining two minutes, so I’m going to ask you them both, but I
recognize that they’re very, very different. The first one has to do with special considerations
for women with both mental health problems during pregnancy as well as substance-use
problems and what those special considerations are. And the second one has to do with how
to you address the shame and the stigma? So if each of you can take a moment and, again,
why don’t we hear from Nancy and then Hendree around those pieces and integrate any closing
comments with those and then we’ll conclude the session.
Sure. So the issue of dual diagnosis, with having both a psychiatric diagnosis and a
substance use diagnosis, is one we’re confronted with all the time. With our program, and we’re
fortunate, we’re a large system that’s multidisciplinary and we are integrated. So we are able to work
very closely with our psychiatrists and the folks that provide our mental health services,
along with our chemical dependency programs and our Early Start specialists. And we — we
integrate that care, so we will have multidisciplinary meetings for complicated patients that have
issues with dual diagnosis, with the obstetrician involved, maybe even the peri-natologist,
the addictionologist, the psychiatrist. We get release from patients to be able to discuss
their care so that we can coordinate that care as best as possible, but those are very
complicated patients and they’re very high-risk patients, and so we obviously — they aren’t
being followed in just the routine manner. They’re seen more frequently and there’s
much more coordination of their care. Hendree, do you want to chime in on dual diagnoses
first before I go on to shame stigma? Yeah, no, other than just kind of like ditto.
That’s what we do. It’s very interdisciplinary. We work with the psychiatry team and the OB
team, so, yeah, we do the same thing. I think shame and stigma is one of the most
difficult. And that is really where our Early Start specialists who are licensed clinical
mental health — licensed clinical social workers and MFTs are very well-trained to
work through those concerns no differently than any mental health provider can do. I’ve
alluded to stigma a number of times and really, for us, it’s been about removing as much judgment
and providing an extraordinary amount of education across all of our 42 clinics.
I’m very fortunate I have physician assistant at every single facility that provides OB-GYN
care that I work with, that I help them to work with the OB-GYN providers of obstetric
care, because I think that’s where actually the stigma is more difficult to break down
than with the Early Start specialists who are much better trained than any OB-GYN around
drugs and alcohol in pregnancy and shame stigma and all the other issues.
The docs and the midwives — well, the midwives are probably better than the docs are. The
docs are good at knowing the complications and how to treat them. They’re not nearly
as well-trained and our residency programs don’t do a very good job teaching physicians
about this in providing obstetric care. So we really work through our champions and we
provide a lot of education around the amount of shame that happens and the effects of those
shames across many, many health conditions and accessing care because of shame or the
lack of access. And just to add to that, so in terms of shame
and stigma, I think the best way that we’re ever going to eradicate it or at least drastically
reduce it is if we have more training for every single medical professional and every
single law professional. In fact, anybody that contacts a woman of child-bearing age
who might have a substance-use disorder, we need to have more education about substance-use
disorders, their treatment and recovery. So I’m a huge advocate for more education
in particularly medical schools, nursing schools and dentists. And so that’s kind of our mission
here at Horizons is we go around and we constantly are talking and humanizing the issue and bringing
women with us, because I think that’s actually one of the best things that we can do is for
those care providers to actually hear from the women, kind of on the other side when
they’re not on the exam table, about what their experience is like in healthcare and
mental healthcare and physical healthcare, because that can just humanize it and help
also the providers understand the trauma that these women have gone through before they
get to them and it helps put their behaviors, some of their behaviors in context.
In terms of the women themselves and dealing with their own shame and stigma, we very much,
obviously, work through with our therapists, but in addition we also work on language of
recovery and have used a lot of the material for faces and voices of recovery, where we’re
actually training our women to be advocates for themselves and for other people who have
substance-use disorders that are in treatment and in recovery.
And we found that that is actually helping them talk about that, helping them talk about
their story and what recovery means to them and personalizing that can be a really powerful
experience for them and help them think about their illness in a more positive way.
Great. Thank you both so very much for both your time here today and for all the work
that you’re doing, educating the medical community, the legal community, and all of
the work that you do for pregnant women and children and their families.
This was a great session and such an educational piece. I also want to really thank Sharon
Amatetti, Linda White Young and Kana Enamoto from SAMHSA for all of their leadership on
these topics. You are seeing some slides come by that are
related to resources that you’ll be able to access when you look through the resources
as well. And, Emily, if you can get it to the announcements slide, we do have a brief
satisfaction survey and that e-mail address is beginning put into the chat bar. You will
receive an e-mail from GoToWebinar in the next hour or so that also contains that link.
It does take about an hour, so you don’t have to e-mail us if you don’t get it right
away. And that survey is going to be available until the close of business on Wednesday,
May 13th. Please remember if you are seeking CEU credits, you must complete it by close
of business on that day. All qualified attendees for today’s training will receive an email
with instructions for obtaining your certificate of attendance by May 27th.
And, again, thank you for everything that you’ve done. I hope that you’ll join us
on the Gender Responsive Co-Ed Treatment Recovery for Women on June 9th.
Have a wonderful day and thanks again to everyone. Bye, thank you.

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