Melanie Cole, MS (Host): Welcome to AHN MedTalks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field.

I'm Melanie Cole. And joining me today is Jean Fitzgibbons. She's a certified registered nurse practitioner who specializes in maternal addiction at AHN, and she's here to highlight pregnancy and postpartum substance use disorders for us today.

Jean, thank you so much for being with us, and I'd like you to speak about addiction in the context of pregnancy. How common is this? The scope of the issue that we're discussing here today, tell us about this.

Jean Fitzgibbons, CRNP: Thanks so much for having me, Melanie. Yeah, I'm honored to be here talking about this really important topic. As we all know from just looking at the local media or national media, substance use disorders are a huge epidemic in our country right now. And substance use disorders don't stop when a person becomes pregnant. We are seeing more and more cases of folks struggling with substance use disorder facing pregnancies, and oftentimes this is their entryway into healthcare. And so, we have a unique opportunity with the Perinatal Hope Program that I work with to connect with folks at this important and vulnerable time.

Melanie Cole, MS: Well, as you say, it's a vulnerable time and some of the barriers to care that pregnant women, especially in diverse communities, face. These substance use disorders are more common than we think, just as you said. Speak about some of those barriers, whether they're afraid to come in, whether there isn't access to healthcare, whether they're afraid of judgment and judgment by the healthcare community. Tell us about some of the barriers you've seen.

Jean Fitzgibbons, CRNP: Yeah, absolutely, Melanie. So as you mentioned, there are a lot of fears about judgment, particularly, you know, I think any individual who has had a pregnancy or had a loved one who's had a pregnancy knows that the mom guilt starts pretty quickly and the fear that you're not doing everything perfectly. So, there's a lot of shame and guilt that folks innately have once they find out they're pregnant and are with an active substance use disorder. And then, there starts to be concern about judgment when they enter the healthcare system. What would their provider say if they disclosed that they were with active substance use? What would their family members say? What would their community say? So, you know, there is a lot of shame and guilt, not only that the patient puts upon themselves, but real judgment that they know that they could potentially face and may have faced with other healthcare interactions.

Another concern that's particularly unique with our patient population is concern about child protective services and their involvement in their care, and what that might look like. a lot of the folks that come to work with us, their goal is to parent their child and they have real concern that if they disclose this information, the child will be taken into custody of the state, will be placed in foster care and they will not have an opportunity to parent, you know, as they hope to. So, it's a really multifactorial problem these patients face once they enter the healthcare field or find out that they are pregnant and start to interface with medical providers.

Melanie Cole, MS: Well, those are legitimate fears, and also, nobody is judging them more than they're probably judging themselves at that point. So, it's the stigma, it's the fear of Child Protective Services, as you say, and there's a lot. As you say, it's a very complex issue. Now, I'd like you to give us an overview of AHN's Perinatal Hope Program.

Jean Fitzgibbons, CRNP: Yeah. So, this program was started in 2017, and it was started by a really innovative maternal-fetal medicine physician in our healthcare system, Dr. Mark Caine, who has recently retired. And what he particularly identified is we had a lot of folks who were struggling to make their appointments with substance use providers. So for example, trouble getting to their buprenorphine appointment, buprenorphine clinic appointments, meeting with drug and alcohol counselors, which was often required of the clinic and then finding time to get to OB visits. OB visits were kind of falling off of the list of priority for folks, which is understandable, because maintaining on maintenance medication and maintaining adherence with medications that are providing stability from a substance use standpoint was paramount, and is paramount.

So, the goal of the program originally was to try to consolidate that care as much as possible. So, our program is a wraparound program where we have the appointment, folks can get their buprenorphine. They have the opportunity to get connected with drug and alcohol counseling. And then, they're getting their OB care all in one-stop shop, one appointment that they can come to, their children are welcome to come to these appointments, support people, partners, anybody. We then will follow these folks up to five years after they have delivered.

In addition, so there's myself, we have an OB-GYN who is our medical lead. We have an addiction medicine physician who also serves as a medical lead for us. There are a couple of nurse practitioners. There's social workers. There is a peer recovery specialist, so that's an individual who's in recovery herself, who can work with folks and kind of meet them where they're at and help them connect with meetings or whatever might be helpful for them. We have a doula who accompanies folks to deliveries, which is fantastic to have that consistent person that they can meet with throughout their pregnancy care. And then, we'll know that somebody will be available for them to support them in labor. And we have a nurse.

So at this point, it's a pretty robust program. It grew from just two staff members to, I think, we're at about 12 at this point. Pretty robust program that connects with folks. And we are a low barrier, nonjudgmental, harm reduction program. So if folks are struggling with active substance use while they are pregnant or while they are working with us, they're never discharged from our program. We will continue to work with folks, and support them in whatever their goals may be throughout the pregnancy.

Melanie Cole, MS: What a comprehensive program that you've built. Now, speak about drug screens and when they're appropriate in care. What's the protocol, Jean, if someone self-discloses and they're not interested in treatment or what to do if they are?

Jean Fitzgibbons, CRNP: Yeah, absolutely. That's a really great question, and it's a really complex question. So like with any medical test that we do in healthcare, we want to make sure that if we are doing a drug screen, we have some medical reason to do it. So, we don't order any other tests just as a gotcha or trying to catch a patient. So if a patient discloses substance use and they are not interested in engaging in treatment, there's really no utility in providing and doing a drug screen. If I come into a visit and I say I'm actively using cocaine, if you do a drug screen on me, it will probably show that there's cocaine in my system, which is consistent with what I've already self-reported.

It can be helpful for some patients if they are saying, "Somebody told me the pills that I'm getting on the street are Xanax, but I'm not really sure what it is." I will talk to patients about we can do a drug screen and that will tell us what's in your system and that will give you some education information to better empower you with the substances that you're using. So, you know what you're being exposed to. Drug screens are always done only with the consent of the patient, so a conversation happens with a patient prior to us sending out a drug screen. And we really want to think critically about whether or not this is going to influence our management at all. And if it's not going to influence management, then there's really no utility in doing it.

Melanie Cole, MS: Wow, that's so interesting. It makes a lot of sense as well and probably saves on healthcare costs too. So, as providers, how can we navigate that stigma that can come when there's substance use disorder in a pregnant woman? Speak to other providers right now about how you would like them in their practices to work with these women, because it is a difficult situation. As you've said, there is the stigma and fear that goes into it, but they're seeing them, and what would you like them to know about creating programs and helping these women out themselves?

Jean Fitzgibbons, CRNP: Absolutely. So, I think the big thing to keep in mind is if a patient comes to you and tells you that they are struggling with substance use in pregnancy, you should really have a moment of pride, because you are a trusted person for this patient to disclose a really, really a very vulnerable and potentially alienating piece of information. It's one of the hardest things that somebody has to say, is to sit in front of our provider and say, "I am struggling with heroin use," right? "I'm struggling with alcohol use." It is a really hard thing to do. So, you've already done a tremendous job if you are that safe person for that patient.

And then, I would say honor that space. So when a patient has made that disclosure, let the patient lead that conversation, and know your limits. If you're not familiar with what treatment options are, that's okay. With any other thing that we encounter, if we don't know what to do, it's okay to say, "I don't have the answers right now. But I'm going to get some information and I'm going to get back to you." The most important thing, I think, is to thank the patient for telling you what is going on, so that you can help them navigate the resources that are available. Making sure that folks have support is critically important.

The one thing that healthcare providers can do that really can save lives is, if there's a disclosure of any sort of opiate or even benzodiazepines or any substance, we are finding fentanyl and cocaine at this point, making sure that folks have a naloxone. Naloxone is available over-the-counter; however, it's often cost-prohibitive for patients who are on medical assistance or income-limited. So, providing a prescription will often allow for patients to get that through their insurance free of charge. And so, if anybody discloses, if patients are running out of the door, and they just happen to disclose, "Where can I send a Narcan prescription for you?"

Most of the time, folks who are having some sort of interaction with substances are familiar with Narcan, so don't stress too much about having to provide education. They can also get education from the pharmacist. The most important thing is that they get that Narcan in their hands. So, that is one critical piece of information that I think is really important in that initial interaction, and then just support and building rapport and getting folks connected to resources that are available in your community. And obviously, at Allegheny Health Network, we have the Perinatal Hope Program. There's a bigger program for folks who are not pregnant or postpartum called the Center for Recovery Medicine. And really, most large healthcare systems at this point do have an addiction medicine arm. So, you should have resources available.

And I think the other thing to keep in mind is we who work in this field really are passionate about it and we are always available and happy to curbside. So if you have a patient that's sitting in front of you and you don't know what to do, just try to look up who one of the addiction medicine providers is in your area. And I think that they would be happy to talk to you and help you navigate some of the resources.

Melanie Cole, MS: Jean, this is such an important and interesting episode. How does the program get referrals? As we wrap up, I'd like you to offer your best summary of the program, the Perinatal Hope Program at AHN, and when you feel it's important for other providers to refer.

Jean Fitzgibbons, CRNP: Absolutely. So, referrals come from a lot of different places within our health system. So, folks are able to go inpatient for conversion to buprenorphine or methadone in pregnancy and be admitted and have that as an inpatient, conversion. And we get referrals often from that avenue. We get referrals from private general OB-GYNs who have somebody who discloses like we discussed earlier. Those referrals come in that way. We get referrals from substance use providers in the community with patients who have positive pregnancy tests and they don't really know how to enter, obstetric care at all. that's another source of, referrals. And then, we get word of mouth referrals, so patients who have friends who are pregnant or needing some additional support. They also get referred to us.

So, a lot of different avenues and, you know, we're always happy to answer the phone. And even if somebody's not an appropriate candidate for our program, we will get them into a program that makes more sense or help bridge them until they can get into appropriate care.

As an overview of the Perinatal Hope program, we're a comprehensive wraparound program for folks with substance use disorders who are pregnant or postpartum. We follow women throughout their pregnancy and up to five years postpartum. We also will do preconception counseling with folks with substance use disorders as well. So, it starts even before the pregnancy starts. We have a robust team of social workers, doulas, healthcare providers, nurses who really help support folks throughout their pregnancy and parenting journey and help support them in their recovery and continued success in parenthood.

Melanie Cole, MS: What a wonderful program. Thank you so much, Jean, for joining us today. And to learn more or to refer a patient, please call 844-MD-REFER or visit ahn.org. Thank you so much for listening to this edition of AHN MedTalks with the Allegheny Health Network. Please always remember to subscribe, rate, and review this podcast and all the other AHN MedTalks podcasts. I'm Melanie Cole.