Okay, good afternoon, everybody. Welcome to today's AOAM webinar, Maternal Morbidity and Mortality Associated with Methamphetamine and Other Substance Use in the Perinatal Period, by Dr. Marcella Smith. My name is Julie Kmyk, and I'll be your moderator for this session. This is the first of our spring webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. Dr. Smith is a board-certified maternal fetal medicine and addiction medicine physician at the University of Utah. She's the director of perinatal addiction services and the medical director of the Substance Use Pregnancy Recovery Addiction Dependents, or SUPRAD, specialty perinatal clinic, a multidisciplinary clinic for pregnant and postpartum women with substance use disorder. She recently took over as chair of the Utah Maternal Mortality Committee. Her research focuses on the perinatal addiction, interventions for pregnant and postpartum women with substance use disorders, maternal mortality, and maternal mental health. So I'd like to welcome Dr. Smith. Thanks so much for the kind welcome. All right, let's get past this first hurdle of sharing. And thumbs up that we can see it. Okay, great. All right. So thanks so much, everyone, for coming. This is going to be a little bit of a whirlwind of things that have to do with maternal morbidity, mortality, and methamphetamines, and some other substances, because the phenomenon really is a polysubstance use issue and how that intersects with the pregnancy and perinatal period. Funding made possible by SAMHSA, which is great. These are my disclosures. Okay, so some learning objectives. We're going to talk a little bit about methamphetamine use prevalence and the overdose epidemic in the United States so that we can understand how pregnancy and the postpartum period intersects with that. I'll talk about some maternal, fetal, and child effects on methamphetamine use in pregnancy. And then I'll talk about some evidence-informed treatments for methamphetamine use disorder in the spectrum of the pregnancy and postpartum world. And all of this will have an emphasis on maternal morbidity and mortality. Okay, so I like to start with, like, who am I and why am I here talking to you? I am a maternal fetal medicine doc. So instead of showing you pictures of my kid, I'm going to show you pictures of my mom. So that is my mom. And then this is my co-conspirator on all things, Jasmine Charles. And we started the Super-Ed Clinic together. So that was Super-Ed's first birthday. And we're now celebrating six years. The reason I put this up is really to just show I didn't have, I mean, this is the American Osteopathic Academy of Addiction Medicine. So many of us, I think we could probably have a whole talk about how we got into addiction medicine. So I didn't start addiction medicine really until I, with a focus, or at least focus on addiction medicine until I became faculty here at the University of Utah. I really focused on obesity and bariatric surgery. And that's what I was recruited here to work on. And then I got here and I was the only person in our entire department with an X waiver. And so my clinic became the substance use or opioid use disorder clinic. And then I was at my brother's wedding and nobody could prescribe Suboxone except for me. And so we really leaned into this and Jasmine really leaned into this with me. And we started with six people on our first day. And now we have a crew of about 20. And I've really gone through the addiction medicine board's clinical pathway. And so I say that because many times there are, there are trainees or people early in their career thing about like, well, how do I get into addiction medicine? You decide that you're going to do it and you lean into it. So it's never, it's never perfect, but that's okay. And that is the beauty of this field. Okay. So now to get to the meat of the topic. So methamphetamine, it's the new old epidemic. So you can't really do a talk about methamphetamine without having a slide with Walter White on it. We used to think of methamphetamine as kind of being a West Coast problem and fentanyl as being an East Coast problem. And that is really not the case anymore. We I'd like to put this graph on here. This is Kansas. But really we thought of, we used to think of meth as being made in trailers in the middle of the wet in the Western desert here in Utah and used to be able to go on the DEA website and really find where there were sites that methamphetamine was being made. And that is really just not the case anymore. We really don't have these small really mom and pop shop methamphetamine is not how things are anymore. Really it's the super labs with really sophisticated production with chemists who are PhD level chemists who are really creating high potency methamphetamines in labs that are then coming across, usually not made in the United States, but coming across the border in various ways. And that's really translated into methamphetamine overdose rates that have been increasing and really all over the country. So that was 2011, this is 2015 and this is 2018 and the updated one is really even darker purple. And so we're really seeing this all over the country. The overdose epidemic, as many of you know, is really a story of polysubstance use and it's with methamphetamine and cocaine. It's really driven by fentanyl contamination in the supply. And so whenever we talk about methamphetamine with my patients, with people, I really drive many of the overdoses that we're associating with methamphetamine, not all, but many are associated with fentanyl. And it's especially when people that's not their primary substance of use, they have the highest risk of overdose. And this is the thing that we talk about that I talk about with my pregnant patients, especially my postpartum patients that because they don't use opioids regularly, if they have a little bit of fentanyl in the methamphetamine that they use, they're at much higher risk of having an overdose. And which is why we often talk about harm reduction strategies to be able to reduce that overdose risk for cocaine. We're going to focus primarily on methamphetamine here, but for cocaine, this the overdose epidemic is it's the methamphetamine is a combination of both just increasing use and overdoses related to methamphetamine in general. But cocaine, the overdose epidemic is really being driven by this cocaine, by cocaine being contaminated with fentanyl. And this has gotten worse within the pandemic. So as the pandemic lockdown happened in March of 2020, we really saw the rates of methamphetamine and cocaine related deaths skyrocket. And this has not come back down now that we're in the post pandemic era. So that's just a really important thing to keep in mind. So who is being affected by methamphetamines? The largest increase that we saw was really here in the up in the inner mountain West with Native American population. So we largest increase was among Native American men and women. And then we also saw triple among heterosexual women, and it's tenfold times higher among black individuals. So this is really affecting many men, all and many different types of communities. So just very briefly about the difference between methamphetamine and cocaine. What I like to the point that I like to drive home here is that if 50% of the substance is eliminated from the body after 12 hours for methamphetamine and 50% of the half-life is in an hour for cocaine. So really the pharmacologic properties are very, very different. Methamphetamine both increases the dopamine release, but also blocks dopamine reuptake, whereas cocaine really only blocks the dopamine reuptake. So you're really getting a very different pharmacological profile of these two substances. Another important thing I point out on this slide is that the difference in the stimulant related deaths are there's an intersection with race and ethnicity, and we're really seeing the stimulant related deaths being primarily driven by methamphetamine with Native Americans and then primarily driven by cocaine in African Americans. Although the previous slide I just said it is increasing tenfold among African American individuals. So we are seeing it across all populations, but these populations are really being affected disproportionately. So I am an irreverent human and I am an OBGYN, so we talk about holes a lot. In all the holes that you have, you can consume and ingest methamphetamine or most substances with all the holes that we have, and we certainly see that happening. So the sky's the limit, the possibilities are endless. And really asking people how they use their substance is important, especially in a harm reduction framework where we talk about smoking may actually decrease your risk of overdoses as compared to, for example, IV drug use. So this slide is just one to reference how methamphetamine really affects the brain. We're not going to belabor this, but I want to say, and I think in a society of addiction medicine and the Academy of Addiction Medicine, we know this, but really framing this as a brain issue. I don't think I have to belabor that in this group, but I do have that slide up there just to remind folks that when we frame it as not a choice or a moral failing or you have chosen substances over your family, that is the symptom of the condition. That is why this is a medical condition. And then importantly, in a talk about sex and sex and gender differences, it's important to frame in terms of pregnancy and postpartum, especially with methamphetamines, there are some sex related factors that are important to consider. So telescoping is a phenomenon or quicker initiation from use disorders, and women are much more likely to go from first initiation to use disorder than men. And there may be biological underpinnings from that. So estrogen and progesterone levels may influence dopamine signaling. We have some data, both in animal models and in human experiments where even the cycles of a woman's individual cycles can affect her addictive, her perception of cravings and the threshold that people act on those cravings. And pregnancy, because of the changes of progesterone and particularly progesterone, but also the ratio between progesterone and estrogen, we see progesterone really driving its progestation, it's progesterone in pregnancies that we see pregnancy really have these really high levels of progesterone. And that may in fact be the reason why in pregnancy we see a substantial decrease in use. And then in the postpartum period, we see this precipitous drop in the postpartum period of hormone levels and an increase in return to use. And that the biological underpinnings and sex factors may be because of these, at least in part because of these, the hormonal changes. And then there's important gender roles. So caregiving really affects the way that women specifically experience the drive to use methamphetamines, particularly when it's caregiving, they may be sandwiched, they're taking care of older relatives, they're taking care of children of their relatives, they're taking care of their own children. So really having that, the energy, it's often a thing that I hear from my patients. And then in the postpartum period, weight loss, I mean, I cannot stress how important that that's a thing that I don't think like my patients will bring that up on their own, but often when we, when I enlisted, when I ask, what is the driver? Tell me about what's driving methamphetamine use and in a substantial proportion of my patients and the literature would support this, it's weight loss and really body image that if you're using methamphetamine, you're not eating as much and you lose and you lose weight, particularly after a pregnancy. And then stimulant over, so this is all about morbidity and mortality. So we, we have to frame this in, in what is stimulant overdose. So in a lot of them, especially recently it's, it's fentanyl contamination. So 67% of methamphetamine that was related to a overdose tested positive for fentanyl in a DEA study. So we're seeing those overdoses though are increasing independently. So it's not just fentanyl overdoses. That is a partial portion of it, but it's also that there's this increased toxicity and lethality with the amount of, with the purity that is being released and these super labs that are making methamphetamine, we're getting higher potency, higher concentration methamphetamine, and people use methamphetamine. And there's a term called over amping where really, as you continue to use, you get into a situation where that can lead to really cardiovascular and pulmonary collapse. And that is what drives really a pure sort of a purely methamphetamine looking picture. We don't see that that often in, in pregnancy, but certainly in the postpartum period, we've seen that where people just don't sleep for days on end, they get into psychosis, they're not drinking, they're not eating. And that can really lead to metabolic derangements, arrhythmias, heart attack, death. Okay, so pregnancy, let's switch to talking about pregnancy, lactation, and kiddos. So amphetamines and opioids are really increasing across the country. So as, as we are seeing the addiction, the epidemic, opioid epidemic, methamphetamine epidemic increase, we're seeing that increase on all segments of the population, including among pregnant individuals. We've seen this really rise and different areas of the country are affected differently. So here in the Intermountain West, we're really seeing a rise in methamphetamine related deaths. So this is a study that's, you know, getting, getting a little bit older, but really still relevant by Lindsey Edmond from University of Michigan. She looked at the national inpatient sample and there's a rise in amphetamine related deaths. 0.2% of all deliveries were associated with amphetamines and the thought that this is primarily driven by methamphetamines, 1% in the rural West and up to 5% in the highest use areas. And I tell you, based on a court study that we did here in Utah, that is absolutely what we're seeing here. So 1%, we did a study of courts looking at, we collected 1700 courts across the state of Utah and 1% of them were positive for methamphetamines. So we're really, we really are seeing that and in the highest use areas where we expected it to be, it was between three and 5%. So this study really is not that far off. What we see, the adverse outcomes that we see associated with methamphetamine use in pregnancy is more antepartum admissions, higher risk of preterm delivery, preeclampsia, placental abruption. I'll get a little bit more about severe maternal morbidity and mortality, and certainly a higher cost because of the associated complications that come with both maternal and neonatal and later on child effects. This is a, again, it's getting a little bit older, but a study on methamphetamine use during pregnancy. What I want to bring out, because it's not, you know, the slide right before told you all the bad things that happen. The one thing I want to bring out is that what we know about many of the pregnancies and what we know from chart reviews is that they're complicated by poor prenatal dating and poor prenatal care. And that is really a result of the way in which our system is set up. So there is a disincentive for pregnant individuals to disclose that they're using substances. So often pregnant individuals will delay coming into prenatal care because they are afraid that someone is going to take their infant from them when they have their baby. That is the question. And that delays presentation of prenatal care. It's not that they, you know, not that they don't care and they don't care about the health of themselves and particularly of their baby. It's that there's a strong disincentive to present for prenatal care. And often people are trying to stop using. And when they can't on their own, it's often when they finally finally come in to present for care or even wait until a little bit later. And the vast majority of individuals will obtain abstinence on their own without medical intervention. And often that is what pushes people. And this is all the methamphetamine use that we know about. So really the slice of the pie that we have are that we can say these are individuals that have used methamphetamine are really the most severe. They really have severe use disorder and have not been on a have really been unable to stop and then have disclosed. So this is the this is the administrative data that we have. That's what we know at least around severe meth use disorder. So this is a study out of the Utah population database that we did, which is a really unique database that we have available here in Utah where it links inpatient hospital days with birth certificates, death certificates. We really get a robust amount of information. And what we found was in in the state of Utah, when opioid use disorder and methamphetamine use disorder were combined, that more than one in five individuals experience severe maternal morbidity or mortality and severe maternal morbidity. To frame it, as many of you know, is this is bad stuff. I mean, the stuff it is. There are 17 codes that go into maternal severe maternal morbidity. And it is things like stroke. You got a cardiac catheterization. You needed a massive blood transfusion. I mean, these are very, very bad things. You were on the brink. You were essentially on the brink of death before you you you you you didn't die, but you almost died or death. And when we looked at just opioid use disorder and meth use disorder, it was more than one in 10 individuals experience this either in pregnancy or in the year postpartum compared to 3% of individuals with neither opioid nor methamphetamine use disorder. And there was a synergistic interaction of the effects from co-occurring opioid use disorder and meth use disorder, meaning when we add the two up, it was really greater than we would have thought from just the single condition. The other thing is this administrative database. So just exactly what I was just saying right before this slide was that these are the, this is the most severe. So we are biased in this situation where there is a lot there, certainly the people in that 3% are likely there are some that are going to be in more that likely belong in the meth or opioid use disorder category. So we have a little bit of ascertainment bias. And I think we are biased towards the nulls. We actually think that this could be, this is, this could be worse in reality than what we found in this study. This is a really nice case series about cardiac effects associated with methamphetamine, really methamphetamine associated cardiomyopathy. Stephanie Pierce from the University of Oklahoma and Marvin Williams and Dr. Phillips, all from the University of Oklahoma reported this. And we're, one of the most frequent questions that I get asked is, should we be doing screening echoes on our pregnant people? The answer to that is, I don't know. We don't have that data. I saw someday that that study will happen is we will do a prospective study looking at really what are the, are there heart conditions that we can detect in a pregnant and postpartum population? But we don't have that answer to that. What we do have is this case series. We have some case series that pregnant people really are at, when they present often have very dramatic presentations. And there's a little bit hard to tease out what is the pregnancy? What is the pregnancy and what is the methamphetamine? We struggle with this in the maternal mortality review committees. What is pregnancy? What is substance use related, particularly in that postpartum period? My guess, and this is another study that's going to be forthcoming is it's both. And it really is synergistic that when you have underlying and maybe subclinical diagnosis that you don't know about in terms of meth associated cardiomyopathy, meth associated valvular disease, and that you overlay the pregnancy physiology and the postpartum physiology onto that and potentially return to use that really, those are the things that exacerbate these conditions and lead to severe morbidity and mortality. This is a really nice study that I found very recently. It's trends of substance use per 100,000 delivery hospitalizations and the proportions of all delivery hospitalizations complicated by substance use. What you can see is that it's kind of going up and down in terms of that's the red line for substance use. But that gray is certainly going up. Gray is opioids. And then amphetamines is that dark blue. And you can kind of see that tip up right around 2010, 12, 14, 16, 18. We're really seeing that same line go up. What I loved about this paper was this graphic. And what they looked at is odds of adverse events associated with substance use during pregnancy. And so they divided this up by all of the substances that were available. So alcohol, cannabis, cocaine, amphetamines, and opioids. And really any substance use was associated with an increased risk of in-hospital cardiovascular events. There was more than a twofold increased risk in cardiomyopathy or heart failure. And again, a twofold increased risk in in-hospital maternal mortality. And then when you look over at the amphetamines, the acute cardiomyopathy and heart failure compared to individuals without amphetamine use, they have almost a 10, it's a ninefold increased risk of having acute cardiomyopathy or heart failure. So really what this, and that's higher than cocaine. I think that I bring this out because often people say, well, it's kind of like cocaine. And I go, it's probably worse than cocaine because of that long acting. So cocaine remember is out of your system in an hour. Methamphetamine, it takes 12 hours to get out of your system. So it really is harder on, on a system, harder on the heart, especially when it's complicated by that pregnancy physiology. So low threshold from the, for the clinicians, really any, any sort of shortness of breath, chest pain, any history of, of meth use disorder or meth use low, low threshold to do that cardiac workup. And so mortality, right? So this is the client, the ultimate outcome. This is Utah data. I want to emphasize this is Utah data, which I present because I think this is, because I know it the best, but this is Utah is not, it really isn't unique. It's a special place. It's got unique characteristics. But the, the, the, the patterns that we're seeing across the country are really similar. So when we looked at our, our drug related deaths in our maternal mortality review committees, which reviewed pregnancy, all deaths within pregnancy and up to a year, postpartum more than a quarter of our deaths were drug related. We are still waiting for our legislature to approve our newest numbers so that I could report to you even the most up-to-date data. I was really hoping it's going to be any day now. I was really hoping it would be this week, but it's not. So you get this, you get this table, but it's actually, it's much so spoiler alert. It's higher than a quarter. So we're really approaching more like 40% of our deaths are drug related. And amphetamines are polysubstance use. When we looked at our desk was the name of the game. So 83% of the deaths that were drug related had polysubstance associated more than two thirds or two thirds had three or more substances and a quarter of our deaths were related to methamphetamines. The other thing that I will draw your attention to is that other graph on that bar chart bar graph is the deaths happen really postpartum. So it is at 43 to 365 days postpartum. That's when 80% of deaths happen that are drug related. And that is not, that's all substances. And that's what we're seeing across the country. So wherever you are, that is the pattern that we're seeing across the country as we're meeting as maternal mortality review committees. I mean, this is a pattern that was just being replicated across the country. We have rising, rising rates of drug related deaths in pregnant and postpartum individuals, polysubstance use often opioid and some stimulant and depending on the community methamphetamine related or cocaine related along with other substances and really driven by that postpartum period. So this is a, this is a, an abstract that we presented in 2022 at the society of maternal fetal medicine. It is currently languishing in the place where abstracts go to live before they are published or they die, whichever one happens. But the point of it, this one I hope will not die and will actually get published. So we talked a lot about maternal death. So there is also an increased risk with, with opioid use disorder and methamphetamine use disorder for neonatal death. The numbers are, are get pretty small, but there is an increased risk of being an abstinence syndrome, preterm death and or preterm birth and neonatal death. And in the population with opioid and meth use disorder, it was approached 4%. So one, one baby died, but it was 4% of the population. One baby died in opioid use alone. And that was 1%. And when we come and when we looked at just meth use disorder, it was two infants and 5% primarily driven by prematurity, but not entirely. Okay. So I'm going to switch over a little bit to, you know, some practical questions that I get asked a lot. So what about lactation? Lactation, I think is an important question. So this is not maternal morbidity and mortality. Because if we're talking about lactation, you're probably not in the ICU on a ventilator or, or death or dead. But the question is can, when, when is breastfeeding okay? And so the Academy, American Academy of Pediatrics, the American Academy of Breastfeeding actually had recently looked at their data. The older guideline said, and there shouldn't be any, any substance use for 90 days. I think that we're really moving away from that. And certainly the Academy of Breastfeeding Medicine has moved away from that and recommended that it really screened for the recommendations are really driven by no active use and really driven by infectious disease and screening for specifically HIV, but it can screen for other infectious diseases as well. If there's active use, which is good for both the maternal, the, the parental individual and the infant. And then for the baby it's of course, we are, we care about exposure, but when can in terms of when can someone breastfeed after, after a recent use, the idea based on these case series is likely once the urine clears is likely when the breast milk has, has cleared as well. So that is not, that is all based on case series data. But that's really where, where the recommendations are shifting. And the reason those recommendations are shifting is if somebody is motivated to breastfeed that can really leverage the breastfeeding and, and utilizing that dopamine signaling that is involved in breastfeeding to help the brain recover from an, a substance and prolonged exposure to a substance that really infects dopamine signaling. So that's just some practical advice. I will skip over these case series so we can get to everything, but you'll have these slides available. Yes. I see that there's probably a question. Yep. There's a question. So it goes back to the slide before the breastfeeding and it says, are the postpartum deaths from opioids at 365 days actually postpartum which usually ends at least by six months. So that's the definition of pregnancy associated deaths. So pregnancy associated deaths as an epidemic, either pregnancy associated or pregnancy related. So if you're seeing that reported by the CDC, it's pregnancy through a year postpartum. So that is, that's the, like the CDC epidemiological tracking definition is it's always through 365 days from the end of the pregnancy, whether the pregnancy was a miscarriage, a termination, a stillbirth, a live birth. So it does not matter what the outcome of the pregnancy was. It's always from the end of the pregnancy to 365 days postpartum. Okay. Thanks for that clarification. Really good question. I think that's a, um, it's a, when you live in this world, you forget that postpartum means different things to different people. Often six weeks, right. You're like, okay, bye. You're not, you're, you're, you're good. Right. Um, or even six months. And I think that that's a, um, to pontificate just a tiny bit, right. We often think about six months is like, that's, we're starting to disentangle from the physiology or even things that, um, related to pregnancy. And I think this is a highly controversial thing, even in, within, um, maternal mortality review committees. And the more that we look at the effects of child removal, the more that we look at the long-term effects of postpartum depression and anxiety, and the physique, like when does return to use happen? We're seeing that postpartum, it really is probably much longer than that. Six months. We're really looking at that longer. Um, in that, that, that six months, that six months to 12 months postpartum is we're kind of that perfect storm of things have, have been circling for long enough. And that's where we're seeing the spike in these postpartum deaths. Well, there's my pontification on that. Okay. So there's the lactation stuff. Um, you guys can look through that as well in terms of fetal effects, um, methamphetamine is neurotoxic. So neuro it is neurotoxic to an adult. It is likely neurotoxic to a fetus. Um, and there is preferential concentration of the metabolites in the fetal brain. And there is the earlier exposure is associated with interestingly, um, longer lasting alterations in the serotonergic pathways, not necessarily in the dopaminergic pathways. And there are sex differences. Um, so if you are a male fetus versus a female fetus, and you were supposed to methamphetamine, the exposure and the brain changes that are seen later on are different. What does that mean for functionality? We don't know the answer to that question. Um, but we can see that there are at least some sex differences in fetal exposed, um, both in animal models and in, um, the limited human data that we have. So, um, in, um, reaction actually to some of the, um, the, the false and, um, really highly, um, problematic, um, studies that were published about cocaine exposure, um, in the nineties, um, the ideal study, which is the infant development environment and lifestyle study, um, what follows 412 maternal child pairs, 204 of which were methamphetamine exposed and 208 were unexposed, um, from both the United States and New Zealand. And this is an ongoing studies where we are continuously getting data. So in the neonatal period, um, what they saw is in, in the methamphetamine exposed infants, there was increased risk of, um, or increased admission to the NICU and decreased arousal and increased physiological stress that was improved at one, um, month. And there was more neonatal abstinence syndrome. Um, but that was rarely required medication and there was less breastfeeding, although that may truly be driven by policy and not so much that, um, that they couldn't breastfeed or that the infants weren't able to breastfeed. It's more that if you were bred, if you had methamphetamine exposure, maybe you were told you couldn't breastfeed, um, which is a frequent thing. Um, the child effects, um, in general are, are overall quite reassuring in the sense that there are differences in cognitive behavioral language and emotional outcomes, but those were much more correlated at age three with adverse social, uh, um, environments and not prenatal methamphetamine exposure at age three and five years, really heavy prenatal exposure, meaning, um, three or more days per week of use increased. Um, there was an increased, um, risk of, uh, anxiety and depression and intention problems, um, compared to unexposed infants. And then at seven and a half years, there were four cognitive function on the Connor parent, um, rating behavioral scale or the Connors parents rating scale, but not behavioral problems. And I think, so that sounds a little bit doom and gloom, but honestly, when I read these and I, um, encourage you to read, um, these studies, the ideal study, there are many, many publications. Um, the overarching pattern is that the there's much more correlation with adverse, with the way that postnatal environment is, uh, which says to me, the more we can support postnatal development, the more we can support families, um, staying together, or if, if that's not the choice that people have made that, um, that we support the adoptive families or foster families that are caring for, for these infants along with supporting, um, the, the parent. Okay. So I'm going to switch a little bit to use disorder and treatment, um, with, with the lens of pregnant and postpartum individuals. So many of you may know this, this is the NIDA, um, principles of effective treatment, um, for adults. What I think that is so, so, so important here, um, is treatment needs to be readily available, which I know I'm preaching to the choir here. Um, but that just the fact of being pregnant and postpartum, um, or parenting really creates, um, enormous barriers, um, for individuals seeking treatment in part, not, um, not exclusively because of a childcare, this, um, uh, addiction providers, um, feeling nervous about taking care of pregnant individuals or lactating individuals. And really what I encourage you as addiction specialist, um, to look as individualizing, um, the treatment, we're going to live in this in an evidence informed world. It's not going to be evidence-based probably for a very long time and really looking at risks versus benefits. So benefits versus risk always never, um, but never out, never losing sight of the fact is in comparison to what, right. So in terms of, for example, medications, we always want to make sure that we're looking, we're thinking about it as well. It's, you know, what is, for example, what is the risk of, um, Vivitrol in a pregnant person? Well, I would rat I, I have limited data, but I have reassuring data that tells me that the, um, at least short-term outcomes look very similar and in comparison to continued methamphetamine use, right? So there are real risks, both, um, biological and also social, um, that result from that. So in comparison, always asking ourselves in comparison to what, um, the one thing that's not on here, um, is number 13, um, testing patients for the presence of not just HIV, hep B, hepatitis C, um, tuberculosis, but also syphilis. So let's not forget that we're in a syphilis epidemic. Um, and I will, here is my fluffy syphilis. So it looks very cute, but don't forget about it. Um, harm reduction is a really important, um, framework. It works in pregnancy. So one of the best resources that I send people to is pregnancy and substance use a harm reduction toolkit. It's very, very important to think about, even for an individual, of course, we want all pregnant, um, and postpartum individuals, um, to abstain from use, but that's not always possible. And that's not always the goal of, of that individual. And we can't have goals if they're dead, right? So we really focus on what it, how can we prevent overdoses, particularly in that methamphetamine group where they're not using opioids, um, regularly talking about fentanyl, having the lock. So, you know, I've had people be like, well, I don't use opioids. I'm like, well, and in salt Lake last week, 10 to 20% of our methamphetamine was, well had fentanyl in it. And as soon as you see that you were like, Oh, okay. And then fentanyl, again, this is the addiction, um, medicine groups. You probably know this, but one of the ways that I like to explain fentanyl test strips and I go, don't, don't forget fentanyl test strips were, were designed by a man. Every woman on the planet knows that two lines is positive. One line is negative, but it is the opposite in a fentanyl test strip. It is one line positive, two lines negative. So that is how that is literally the way that I explain it. And usually people remember that. Um, and talking about overdose prevention, particularly for pregnant and parenting individuals, because they are often hiding their use. Um, talking about using, you know, not using alone is really, um, that's, that's hard. It's hard because there's a lot of shame. Um, there are real consequences for disclosure. Um, there are real consequences with family and partner and child protective service involvement. So saying it out loud and coming up with creative strategies of not using alone or doing a check-in or saying, Hey, I'm going to call you back in five minutes. If you don't hear from me, call me back in five minutes, those types of, of, um, strategies for really reducing harm. Um, this is, um, a slide, um, that I kept in here. I have not personally done this, but I think this is fascinating. This is a group out of Australia. They used listexam methamphetamine for the treatment of acute methamphetamine withdrawal. Um, this had, there were 10 men involved in this, um, in this study, there were certainly no pregnant or postpartum individuals, um, but there was minimizing, they were minimizing, um, that the results showed, um, that they were able to reduce withdrawal symptoms, um, and reduce return to use. And I think that's a, a really, um, creative way of thinking about getting people through that initial withdrawal period. That is not for long treatment. We know that getting through just the, the, um, initial physical, um, and psychological withdrawal symptoms isn't enough. Um, but certainly I think it's, it's, it's worth talking about, especially for a person that's really struggling, even in a pregnant or postpartum individual. And these were all hospitalized individuals. So this was not done on an outpatient basis for pregnant and postpartum individuals. We have to, have to, have to, have to, have to talk about child removal is the thing that really drives, um, individuals, um, actions and behaviors, um, and avoiding care. And we also have to acknowledge that child removal is not, um, equitable. So if you are part of a historically marginalized community, a black or brown community, or a socio, uh, socioeconomically disadvantaged, um, community, you are much more likely to have your child, to have a report to DCFS and to have, um, children removed either temporarily or permanently from your custody. Um, and so we have to acknowledge that this, this slide is not specific to substance use removal, but this is the pattern that we see across all things. And it was exacerbated by substance use, um, related, um, removals. So what I encourage, um, folks to do is really to talk about it, even if they're not talking about it, they're thinking about it. So I will, in my, when I am counseling, uh, you know, first time pregnant person, I say, I'm going to speak to the elephant in the room. This is the, these are the legal policies in the state. This is how we interpret those legal policies. And we're going to be honest and straightforward with you with what we, what we have to do. Um, and, and I think that that is very helpful. And the other thing that I encourage people to do is to really, um, work with policymakers. If you were in a position to do that in your, in your hospital, in your County, in your state to change laws, um, that really disincentivize people to treatment. So for example, um, we were able to change the policy here in, um, in Utah, what, that, what used to be, um, three and a half years ago was just any substance use, um, was a mandated report. So we were kind of caught in this like, well, does that mean that we're, you know, we're reporting first trimester use that people didn't know that they didn't even know they were pregnant or they used, and then they stopped using, um, and they've disclosed like, where, where do we fit in that? Um, and our legislature and our policymakers, um, were really open to it. And they, we, so we changed the policy to, um, substance use, um, where there is evidence of compromise to the ability to care for self and independent other, um, which was really allowed us to say, to, to, to move away from, as soon as you use, you, you get a DCFS referral. I'm really to say like that, if you're able to get in the treatment, if you are enabled, able to get into recovery, then that DCFS, um, call does not need to be made. That's a child and I'm using DCFS and that's department of child and family services here, but it's child protective services, whatever the acronym is in your community. Other, um, so other, um, treatments are really the mainstay are, um, behavioral health, um, interventions, um, contingency management. I always, um, mentioned cause it really has the best evidence, um, for methamphetamine use disorder, um, in, in all kinds of individuals, the hard part, um, for contingency management that I find not practical is no insurance company covers it. Um, there is, um, California Medicaid is looking at pilot programs and we're really eagerly awaiting those to see, you know, if insurance companies and specifically Medicaid will, will, and we'll cover, um, I, I, an evidence-based approach that really has shown really robustly over and over and over again, that the, that this can work. Um, we are also working, um, the ORN is actively working with SAMHSA to remove, um, what used to be a 70, what is well, and it's still a $75 limit on the ability to get, um, contingency management for things like methamphetamine use disorder. The problem is that's not enough money. Um, there is a dose amount and it's probably closer to about 200 to $300, especially with inflation, it may be a little bit higher, especially in higher, um, in, in, in places where, um, cost of living is higher, it may be even higher than that because you do have to make, you know, you have to, to the time of all individuals is valuable no matter who they are. Um, so those are the limitations of contingency management. Um, one of the medications that many of you may, um, use is, um, is naltrexone and then bupropion extended at least 450 milligrams. The analysis is that ADAPT2 trial that showed modest effects for, um, reduction of methamphetamine use. Again, this was, um, this is certainly not evidence-based for pregnant and postpartum individuals. This is absolutely evidence-informed, but when I am talking to my pregnant and postpartum individuals, I am talking about like, I have very little to offer you in terms of medications and naltrexone will, if you have, excuse me, uh, please. Thank you. Um, if you are using methamphetamine, even from a harm reduction perspective, it'll reduce the overdose risk. You have some opioid protection. So even if it doesn't help with methamphetamine cravings, um, it might, um, help with overdose protection. And then the bupropion, um, or what market is well, butren, um, really helps with, um, often there's nicotine use disorder and there's depression. So we are really kind of killing a few birds with one stone. Um, and we ought, we certainly offer it to our pregnant and postpartum individuals within the counseling of the limited, but really reassuring data that we have specifically around naltrexone. Um, this is, um, a, um, a great, um, evidence-based guidelines for pharmacological management of methamphetamine dependence. What I'm going to, um, uh, draw your attention to is that many of these things don't work all that well. Um, the things that really do work, um, that there's, um, evidence for are these two, mirtazapine and the injectable naltrexone NP program. Um, what I, um, will say is that, you know, this is going to, if you, if you look at the pregnancy, um, information on this, you know, uh, we don't really talk in categories anymore. That is pretty outdated. Now it's really longer, um, benefits versus risk. And the reason for that is, again, we want to couch this in what Bennett, what could the possible benefits be? What could the, the risky, you know, as your friendly neighborhood, MFM and addiction medicine specialist, I say, I absolutely offer these things to individuals. Mirtazapine is something we absolutely offer, um, and can help, um, with a lot of things, especially appetite. Um, I would see that really, um, be a very helpful tool. Um, and we've had some people really respond super well to it. Um, what about stimulants? You know, this is not something, this is a, um, again, way we're way outside of pregnancy and postpartum here, definitely not studies that, um, that have included pregnant or postpartum individuals, but this is not something that, um, that we typically offer because there just doesn't seem to be, um, much benefit in terms of methamphetamine use disorder. So the reason that there is a picture of a toddler peeing in the ocean is that Justin Alba is really gives a great talk. If you ever have an opportunity to see him talk, he really explains this fall. So I'm stealing this from him that if you are using stimulants because of the way that stimulant that methamphetamine work, you're really not able to get that sort of replacement, um, effect. You can't get to a physiological level with, um, prescribed, um, stimulants like, um, amphetamine that would really be able to, um, to replicate what methamphetamine does. So it's, it's essentially the proverbial peeing in the ocean. And so we have not offered that, um, caveat to that is if someone does meet ADHD, um, criteria and has been on stimulants for, for ADHD, even in the presence of methamphetamine use disorder, that's absolutely something that we offer to our pregnant and postpartum individuals within that shared decision-making model. Um, if they, if, if that's something that is helpful to them and certainly from a harm reduction perspective. Sorry, you guys are getting to hear me, um, talk through the coughing. Um, uh, finally, um, transcranial magnetic stimulation is a really promising, um, intervention, um, that has, has really has shown, um, some evidence in, um, decreasing cravings and decreasing, um, return to use among individuals with methamphetamine use disorder. Um, we have a psychiatrist here at the University of Utah, um, who is looking at, that's really something that she's, um, looking at, and I'm going to be doing a research, um, project on doing a case series of, of the experience of pregnant individuals with transcranial, um, magnetic stimulation. So more to come on that. And then finally, this is a study, um, that just, um, we just completed enrollment actually yesterday. Um, we finished our last, um, study visit. So we're looking at the prevention of return to methamphetamine use among postpartum women, um, with meth use disorder. And I am a self-respecting MFM. So what do I do? I throw progesterone at, um, at, at individuals. So we are, um, you are using a micronized progesterone 200 milligrams place a day versus placebo among, among postpartum individuals with the idea that that, that progesterone level drop that people experience in that postpartum period, um, can increase the likelihood that the dopamine, um, signaling and certainly craving signaling that happens, um, through the amygdala may be, may be rearing its ugly head in that postpartum period and to stabilize, um, that experience. So we just concluded, I have no results for you other than we were successfully able, um, to complete the pilot. Um, and hopefully I'll have some data for you. Um, and I am fingers crossed, um, that we see a signal in that, um, there may be, um, there may be a decrease in cravings, um, or in return to use. Um, this study was really based on, um, a study on cocaine, on similar, um, return prevention of return to use in postpartum individuals with cocaine use disorder. I have a group, um, Kim Yonkers and Ariadne Foray, um, at Yale. Um, so hoping that we're, um, that we can stand on the shoulders of those, um, pioneers in our field. Okay. Let's sum it up. Um, so meth use disorder is increasing, um, particularly, um, with co-occurring opioid use disorder. So we're really trying to address both of those, um, both of those, um, conditions at the same time. Um, methamphetamines are certainly associated with both adverse, um, maternal and perinatal outcomes, including severe maternal mortality and death, uh, morbidity and death. Um, and harm reduction is something, and you've been talking about that, is an intervention and it is important and it is something that can really steer the course, um, of that, of that individual's, um, course. Long-term, um, childhood outcomes are more strongly associated with adverse social settings than with, uh, methamphetamine exposure alone. So with treatment, certainly all is not lost. And then treatment mortality, mortalities are limited in general and are especially poorly studied in pregnant and postpartum individuals. So do the best you can with the tools that you have. Okay. Questions? Thoughts? Concerns? Yes, we do have one question. So do you feel free to put more questions in the Q and A? So the first one is, are there any contraindications to using Rimcozol, um, in pregnant women in attempts to antagonize the Sigma-1 receptor and reduce cravings for methamphetamine and cocaine? Oh, I am not familiar with that intervention, so I don't, I have, I have no thoughts on that. Um, but I am certainly interested in that, um, would love to hear more from your experience because I, I have, I have not used it, um, but would love to hear more about it. Okay. Oh, we just have a funny, uh, comment about, I hope the women aren't hurt when you throw progesterone at them. Metaphorically. Throwing it at their problems. Any other, oh, here's another one. Let's see. Oh, okay. And if you can, uh, put them in the Q and A because I've been monitoring that more than the chat. Um, somebody said excellent presentation, very current information and very comprehensive. Um, Oh, the, um, I think the person who mentioned that about the medication said I'm just a first year medical student and we learned about craving antagonism in a recent lecture. I'm by no means an expert. That's great. Well, good job being here. Any other, uh, questions, comments? Okay. Well, I guess then that way we, um, we have a little bit extra time to our day. So we'll wrap up. Um, this is going to conclude today's webinar. Um, thank you so much, Dr. Smith for your expertise and you're sharing your insights with us today. Thank you so much for the research contribution that you're making to our field as well. So make sure that you, as the participants in the webinar go to our webpage and then complete the survey so you can get your CME certificates. So, okay. Thank you. Thank you. I forgot to say, join us next week. We have, you know, five more weeks of these webinars next week. It's going to be Dr. Justine Welsh speaking on opioid use disorder and youth. Okay. Uh, there are two questions. Okay. Now they're open. So I'll, I'll, I'll quickly answer those. Um, sorry. I know we've concluded, but that's all right. Feel empowered to go home. Melinda asked, um, in general, would you say it's okay to have a patient start breastfeeding after five days with a negative UA? Yeah. I mean, I think it's once the UA clears, that's often what we use is once the UA clears. Now that's going to be problematic for things like cannabis and fentanyl, right? So that can may take a very, very long time to clear. So you like, but certainly with methamphetamines, with stimulants, um, with cocaine, um, that's, that's the approach that we've used. The important part is do you think we're, you know, we often do it when the plan is like, you're going to go to a residential treatment program, right? You're, you're, you're setting people up for success within that, um, within the framework. Um, yeah, certainly fentanyl is given for surgery and they can still breastfeed. Um, we certainly, we give a whole lot of fentanyl in, in obstetrics. Um, so I'm not suggesting that, um, I'm just suggesting that using that for UA, if they're using illicit fentanyl, um, it's, that's not going to be as, as useful of a tool, um, to say like when they have cleared, but I, you know, I think that that's really needs to be individualized. And certainly if you can leverage breastfeed, you know, breastfeeding and the bonding, um, I'm, I'm very pro that, um, please comment on meth use disorder and premature birth leading to increased needs for IEPs and 504 plans. Um, I think potentially, I mean, any, um, methamphetamine use disorder is certainly associated with preterm birth. Um, and preterm birth is associated with need for, um, individualized education plans. Um, so by extension, but I think the, the, the jump of like, is it the math? Is it the preterm delivery? Um, was it math that led to preterm delivery? There's often you can't disentangle the stress, poverty, poor nutrition, other, um, comorbidities that are happening, um, from the meth use. Um, and you know, what is the quantity? When was it? So it's, um, that is, you know, it's hard to really disentangle those things. Um, what is frequency of UA testing after starting breastfeeding? Um, good question. Um, all made up. We do it once a day, totally made up. Okay. Thanks everybody. Okay. Thank you. Bye-bye. Bye.

maternal morbidity

maternal mortality

methamphetamine use

substance use disorder

perinatal period

harm reduction strategies

contingency management

pharmacological interventions

individualized care