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Dr Huh (Host): Hello, this is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama at Birmingham. And I'd like to welcome to you yet again to this monthly episode of Women's Health with Dr Huh. Today, we're going to talk about addiction in pregnancy. And I think pretty much all of our listeners are quite familiar with the ongoing opioid addiction crisis and the lives that either have been deeply effected or lost as a consequence of this. And pregnant women are not exempt from this. And so this is an ongoing issue and we need to provide care for women who have issues related to addiction and how to optimize both their pregnancy outcomes, both from a maternal as well as fetal perspective.

And so with me today is Dr. Carolyn Webster, who's an Assistant Professor in the Division of Maternal-Fetal Medicine here at UAB, as well as Suzanne Muir who's the Associate Director within the Department of Psychiatry and Neurobiology. So welcome, Dr. Webster and Suzanne Muir.

Dr Suzanne Muir: Thanks for having us.

Dr Carolyn Webster: Thank you.

Dr Huh (Host): Okay. So, I guess I mentioned earlier, I think most of our listeners are quite aware of the ongoing epidemic with substance use addiction, particularly with opioid addiction in the United States and the tragic consequences, including loss of life. I thought maybe one of you could just talk a little bit about addiction in pregnancy and the impact of addiction on maternal and fetal and infant health.

Dr Carolyn Webster: Sure. So in the same way that pregnant women remain susceptible to the illnesses of non-pregnant individuals, such as diabetes, high blood pressure, asthma, substance use disorder does not discriminate. Opioid abuse, as you know, has become an epidemic in the general population and pregnant women are not immune. Opiod use disorder in pregnancy has increased over fourfold between 2000 and 2015. Substance use, including opioid use in pregnancy, is associated with many adverse pregnancy outcomes. Some substances such as alcohol have a well-known association with birth and cognitive defects. However, the range of adverse outcomes includes increased risk of preterm labor, preterm birth, placental abruption, and stillbirth, as well as neonatal withdrawal syndrome, particularly with opioids.

Additionally, there's always a risk of overdose and death. In the most recent report published by the Alabama Maternal Mortality Committee, found that substance abuse contributed to over half of all maternal deaths in our state.

Dr Huh (Host): So are there specific challenges that pregnant women specifically battle when facing addiction?

Dr Carolyn Webster: Absolutely. We do see that pregnancy itself can be a motivating factor toward entering recovery for many. However, it's also an added stressor, often an unintentional and surprising added stressor, for an individual who is often already in crisis. In addition to typical obstacles to recovery, such as limited resources, limited support system and the disease process of addiction itself, the stigma of addiction in pregnancy often leads to delays in obtaining pregnancy care or a lack of willingness to disclose substance use or misuse during prenatal care for a fear of retribution.

Dr Suzanne Muir: Yeah, those that struggle with addiction talk about their shame. Moms here, if you really loved your child, you would just stop. But we know it's not that easy. In Alabama, there are limited residential treatment beds for pregnant women. This group is given priority, but they are waiting list. Most times we cannot place someone who asks for help when they ask for help and we do our best not to lose them and hope they can maintain their motivation. Pregnant women can also be charged with chemical endangerment for using illegal substances and non-prescribed substances during their pregnancy as a felony offense, carrying up to 10 years for exposure and more for harm. Lots of barriers and reasons for a woman to not seek care.

Dr Huh (Host): So let's talk a little bit about the Comprehensive Addiction in Pregnancy Program, also, what we know as CAPP. Can you comment on what the goals of this clinic are and what services are offered or provided, Suzanne?

Dr Suzanne Muir: A group of us convened in the spring of 2017, over a common concern for the stigma that we just discussed and a strong desire to intervene early to improve the outcomes for mom and baby. Our early champion, Dr. Lorie Harper, was the first to receive funding through the Health Services Foundation. And soon after, we received our regional partnership grant through the Children's Bureau. And we accepted our first patient in April of 2018. The mission of CAPP is to partner with expectant mothers to provide holistic family-centered care and promotion of recovery and intact families. We do this through an integrated prenatal care and substance use treatment model. We offer prenatal care medication for opioid use disorder, social work, case management and peer recovery support in one safe and nonjudgmental place. UAB Beacon facilitates an outpatient treatment group for our moms and local residential treatment providers transport their patients over for our Tuesday clinics. And we also meet women where they are at jails, court hearings and hospitals. And we offer case management and peer support to our postpartum moms for as long as they need services.

Dr Carolyn Webster: Our CAPP clinic visit looks similar, but also very different to a typical clinic visit. Our clinical space is dedicated to CAPP and therefore only patients within our program are present during these visits. This provides a safe space for our patients to open up, share their experiences and seek help. We generally see our patients at least every two weeks throughout pregnancy. And during their visits, they see an OB provider for typical prenatal care. But these providers are also experienced in the care of pregnant patients with addiction. And therefore, medical issues related to addiction can be addressed including medication management for opioid use disorder.

Patients participate in group sessions, facilitated by a nurse and a peer recovery support specialist to discuss prenatal care topics, parenting, and treatment and recovery. We also have a dedicated social worker who works diligently with our patients to meet their needs. And this includes ensuring that patients are plugged in to dedicated addiction treatment programs.

Dr Suzanne Muir: We are in our final year of our five-year research project. And midpoint, we had 73 deliveries. For these moms and babies, one in 20 or 5% tested positive for a non-prescribed or illegal substance. Fifty percent of our babies born to mothers with opioid use disorder did not require methadone at delivery. And 83% of moms were either active or had completed substance use treatment at study exit. Further, our moms had an average of 11 prenatal visits compared to five for similar patients seen before CAPP.

Dr Huh (Host): You know, I think you both mentioned this, but I want to make sure that we give credit where credit's due. And I think you mentioned Dr. Lorie Harper's name, who is really credited for getting this clinic off the ground. She's no longer here. She's actually in Texas practicing maternal-fetal medicine, but it's really her vision that really started this clinic. And just hearing the two of you talk, I think one of the amazing aspects of this department in UAB Medicine is that we provide this level of care. I consider this to be a true mission-driven service to our patients particularly with addiction. And I think that this topic is important, because I want our listeners to understand how big of an issue this is. But you talked about the stigma and just the comprehensive nature of that care. It's just really impressive what you all have accomplished. Congratulations to both of you. So, how does one access the program and clinic? You mentioned that referring providers or other obstetricians in the city and the state will send patients, but could you go into more detail? Can like any patient access the program or how does that work?

Dr Suzanne Muir: Yeah, we accept moms who were 32 weeks or less in their pregnancy and have admitted to current or recent substance. And a referral is very easy. Moms themselves or family members can actually just call one of our teams. So we have a peer recovery support specialist that can be reached at (205) 264-8157 or you can call our social worker directly at (205) 934-5795.

Dr Huh (Host): I think you both would agree that addiction is not just a pregnancy-specific issue, but obviously a lifelong issue that many women battle. Can you guys comment on the paradigm of care or what happens after the pregnant patient has their baby? What happens in the postpartum setting? I was just kind of curious.

Dr Carolyn Webster: I'm so glad that you asked that question. It's one thing that's really important to us both in this program. And I think also speaks to some issues just in pregnancy care in general is just making sure that our patients are taken care of through the transition outside of pregnancy care with an obstetric provider. But we work very hard to make sure that our patients have we call it a warm handoff, meaning we are really taking that patient and making sure that they are plugged in to addiction treatment moving forward before they "graduate: from our program.

Dr Suzanne Muir: And we introduced them to staff from other programs before they deliver. We have another program at UAB called UAB Family Wellness. They work with moms and dads that are child welfare-involved or at risk for being child welfare-involved. And so often they're transitioned to that program that they need extended care. But like Dr. Webster said, we work very hard to introduce them to all those folks before delivery. So we have a very smooth transition.

Dr Huh (Host): So, do you all have any additional information or advice that you'd like to give to someone who is struggling with addiction or someone with a loved one in this situation?

Dr Suzanne Muir: I always recommend that they call our state's 24/7 helpline at (844) 307-1760. That hotline connects you to someone with lived experience, and those are the really good folks to connect you with resources and support.

Dr Carolyn Webster: If you're struggling with substance use disorder and you are pregnant, please know that help is available. We're here to help. We want to help. You don't have to have the full plan. You just need to make the first step.

Dr Huh (Host): So I think one thing for our listeners to take in consideration is that this is an enormous, important service to our community, probably more so than ever. And much of the success of this clinic is driven by contributions that are made from the community to support women who are facing addiction battles. Suzanne, I don't know if you have a thought about that or if you can suggest a number that individuals and listeners can call, if they do want to make a contribution to this clinic.

Dr Suzanne Muir: Sure. We welcome contributions. Often people will make a contribution in memory of a loved one, or to honor somebody, but anybody that would like to contribute to our mission and our purpose can call 205-264-8157, and somebody will get back with you.

Dr Huh (Host): Great. I appreciate it. And again, I want to thank both Dr. Webster and Suzanne Muir for coming today and sharing their thoughts about this CAPP clinic. Again, i want to congratulate both of you, because the enormity importance of this clinic can't be overstated. And as we continue to struggle with the addiction crisis particular with opioids, I think that this clinic is more important than ever. And I think for our listeners, it's also important to recognize there are not many clinics of this nature, particularly in the obstetrical space nationally. And so you all definitely need to be commended for the work that you do. So thank you.

So again, I'd like to thank both Dr. Webster and Ms. Muir for updating us on addiction and pregnancy and the importance of the CAPP program. As always, I learned a huge amount from our faculty and the services that they provide. And again, today was no exception. So as always, please rate this podcast and we welcome any comments, particularly on topics that you're interested in. And for more information on our obstetrical services, expertise, as well as this particular clinic, you can also call the number that Suzanne provided or also check out uabmedicine.org. And until next time, thank you. Have a great day and be good. Peace out. Take care. Bye-bye.