Putting Harm Reduction to the Test

Episode 6: Putting Harm Reduction to the Test: Drug use, Pregnancy, and Parenting

Featuring:
Leah Warner, NP, MPH
Street Medicine San Francisco Department of Public Health

Simone Vais, MD
UCSF Department of Family and Community Medicine

Host:
Jamie Lang
New Beginnings Case Manager, Homeless Prenatal Program

Pregnancy and the postpartum period challenge our notions of harm reduction and force us to address fundamental questions: who is our patient, and who is the primary focus of our harm reduction efforts? Is it the birthing parent, the fetus, the baby, or the entire family unit? Join host Jamie Lang and presenters Simone Vais, MD, and Leah Warner, NP, MPH, as they navigate through two intertwined journeys—one of substance use and recovery and another of pregnancy, birth, and parenting. On this journey, we inevitably encounter values that might be in conflict with one another, such as the family unity, recovery, and safety. Episode six delves into these dilemmas, exploring the tensions that arise and examining various harm reduction strategies applicable at different points along the continuum.

Find us online at amersa.org, and see our tweets at x.com/AMERSA_tweets.

Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Learn more about PCSS-MOUD at pcssnow.org.

Transcript

Kinna Thakarar: 0:13

I'm Kinna Thakarar and welcome to the podcast series, Harm Reduction, Compassionate Care for People Who Use Drugs. Harm Reduction is a social justice movement started by and for people who use drugs, and it's a philosophy of care and practical set of strategies to optimize people's health, safety, and rights. We want to acknowledge and honor the long history of street medicine and healthcare developed by people with lived and living experience to keep one another alive and safe through community care. Whether you're a seasoned harm to the concept, we're glad you're here and hope you'll learn something new and are curious to explore seeing patient care through a harm reduction lens. This podcast series is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project, and AMERSA. This week, we welcome Jamie Lange in conversation with Dr. Simone Bays and Leah Warner to discuss putting harm reduction to the test, drug use, pregnancy, and parenting. Our host, Jamie Lange, is currently employed by Homeless Prenatal Program as a case manager supporting people in pregnancy and postpartum who are experiencing homelessness, substance use, and mental health challenges. She is also a passionate advocate with Homeless Emergency Service Providers Association, Treatment on Demand Coalition, and Housing Justice. She is formerly chronically homeless, used substances and found recovery in pregnancy. Most importantly, she is the dedicated mother of a six year old. Simone Bays is a family medicine physician and current addiction medicine fellow in the UCSF Primary Care Addiction Medicine Fellowship. Her clinical focus is perinatal substance use with a particular interest in the postpartum period and the gaps in care between pregnancy and primary care based services. She works as a primary care physician at the Family Health Center and in the Team Lilly Postpartum Clinic, a family based clinic for postpartum people and their infants impacted by substance use disorders. Leah Warner is a nurse practitioner in whole person integrated care on the street medicine team. Since 2014, she has worked on the street medicine team providing primary care services for San Francisco's patients experiencing homelessness. Other interests include understanding and improving homeless services through a lens of gender, pregnancy and substance use, intimate partnerships in the setting of substance use, and trans care at the intersection of substance use and homelessness. Prior to becoming a clinician, Leah worked in public health in the field of reproductive justice. The presenters reported nothing to disclose. Thanks for joining us, Jamie, Simone, and Leah.

Jamie Lang: 2:34

Greetings and welcome to this podcast. I'm very excited to be here with my esteemed colleagues to discuss a topic that's very near and dear to our hearts. The intersection of harm reduction, substance use, and the pregnancy postpartum period. So much of what we believe about harm reduction really gets put to the test when it comes to pregnancy and parenting because we're faced with the existential question of who are we reducing harm for? The birthing parent or the infant?

Leah Warner: 3:02

Now, why does it sometimes feel like harm reduction for one party can stand in direct conflict with harm reduction for the other? Are there cases where that's true? How do we practice harm reduction? We want to dig into all these questions, but first, let us introduce ourselves and lay out our learning objectives.

Jamie Lang: 3:24

I'm Jamie and I'll be your host. I currently hold A client facing role at a local non profit supporting people in pregnancy and postpartum who are experiencing homelessness, substance use, and other various adversities. I also advocate with various coalitions related to homelessness and treatment on demand. I lived on the streets of 10 years. I'm a former drug user. I used substances and found recovery during pregnancy, and I'm a parent to a happy and healthy six year old. Now, I'll send it over to my co host, Leah.

Leah Warner: 3:57

Thank you, Jamie. I'm a big fan of yours. I'm Leah. I'm a nurse practitioner with a background in public health and I work on a street medicine team in San Francisco. So what that means is my patients are adults who are experiencing homelessness. And what that means is that I see a lot of extremes. I see extreme poverty. I see really extreme substance use. Unmet mental health needs and some very extreme wounds, but no matter all the extremes that I see, it still really challenges me to see people in their reproductive and pregnancy stages of life while they're experiencing homelessness and using substances. So I am so excited to be here and talk about this very topic today.

Jamie Lang: 4:49

Thank you, Leah. Welcome, Simone.

Simone: 4:52

I'm Simone. I'm a family medicine doctor by training, and I'm currently finishing up my addiction medicine fellowship at UCSF. My clinical work is at San Francisco General, where I primarily work at a postpartum clinic for people with substance use disorders and their children, which means that my patients are birthing parents and their babies and can I just say how grateful I am to have Jamie here to not only ask Leah and I questions, but also to check our assumptions as somebody with lived experience in this realm.

Jamie Lang: 5:19

Thank you, Simone. It's great to have you both here. Could you tell our listeners about the learning objectives of this podcast?

Simone: 5:26

Our learning objectives for this episode are firstly to identify the harms that we're scared of when pregnant and postpartum people use drugs. Like, let's just name it. What are we actually afraid of? Two, talk about what are the harm reduction strategies that we can use at each stage in the reproductive cycle? So preconception, pregnancy, and then postpartum and parenting. And then three, to analyze the barriers to healthcare during pregnancy and postpartum for folks who are using drugs. and a brief disclaimer on language. Throughout this episode, we're going to use different pronouns to refer to people who give birth. Sometimes we'll use gender neutral pronouns, sometimes we may use male or female pronouns. We just want to acknowledge here that there are a diversity of people who can and do give birth.

Jamie Lang: 6:08

Thank you, Simone. Simone and Leah, as medical providers, what scares you the most about caring for pregnant or postpartum people using drugs? Can you describe a time when you felt overwhelmed by a patient's substance use?

simone--she-her-_1_04-26-2024_131209: 6:20

Thanks for asking this, Jamie, because I think, if we don't clearly enumerate like what exactly are we afraid of, it's difficult to come up with solutions that are right size for our fears. So my clinical work, like I said, focuses primarily on postpartum people. And so I'm going to focus on that time period for a moment, also because I think like societally we focus so much on pregnancy when we think about this topic. And so, so much of people's recovery actually happens in the postpartum period. Just to name some of the things that I'm afraid of in no particular order at all. And ask also to add the caveat that when I do this clinically, like I do try to outline what I'm afraid of, but I also add how likely are each of these outcomes, because I think it's important when you're trying to right size your solution to not only name your fears, but also say, okay, but how likely are these to happen? With no order at all. I'm afraid of a postpartum parent using fentanyl while solo parenting like a newborn and getting so sedated that they either inadvertently drop a baby or just aren't watching while a baby crawls into something dangerous. I'm afraid of babies ingesting fentanyl, which is something I've had happen. to several patients. I'm afraid of having babies removed from their birth parents and placed in foster care where we know the outcomes are not good. I'm afraid that if I, for example, call CPS on a family that I will break my trust with them and with the healthcare system. I'm afraid that if a dyad is separated, then what might have been a brief slip in a parent's recovery will become like a long term return to use and will kind of end the chances of reunification. obviously, a lot of these fears are in conflict with each other.

Leah Warner: 7:58

Yeah, the thing I'm most afraid of is my own bias and agenda. Think there's really good national meta analyses describing the prejudice that people who use drugs feel when they access healthcare, and if you add reproductive health and pregnancy, postpartum and parenting to that conversation, that prejudice only increases. And I think there is a lot of provider bias and prejudice out there. I think it's very real and it comes from a lot of places. But if I'm speaking for myself personally, my bias really can come from fear. So I'm grateful for this question. I fear all of those bad outcomes that Simone listed. And I fear that in trying to prevent them, trying to prevent these bad outcomes from ever happening to my patient, that I will turn into a biased provider and that bias will really guide how I talk to my patient. So that's. Pretty abstract, so I'm going to give a real example. I had a patient once who really had me scared. She was in a really abusive relationship, she was very deep into her substance use, and she had a lot of medical, kind of dangerous health problems going on that were unstable. And when she shared with me that she wanted to get pregnant, I spent the visit trying to convince her not to do that. And I'm someone who has seen the research that describes the prejudice that patients can feel discussing reproductive health with providers like me, like pressure to use long acting contraception. But in that moment, I was only thinking about what I was afraid of for her. And I was also thinking about this abstract pregnancy that didn't even exist yet. And the fears I had for her turned me into this provider that I don't want to be. The one who gives her patients the message that their substance use defines their reproductive goals and that a bad outcome is already written in stone.

Simone: 10:05

I think like my biggest takeaway from my experiences, in this realm so far has been, you know, pregnancy can be so incredibly motivating for people and we never know what's going to happen. And so all we can do is offer people and surround people with the support they need and kind of let them write the rest of the story.

Jamie Lang: 10:22

I definitely identify with that. Becoming pregnant was complicated for me and the first interaction I had with a healthcare setting was a male doctor and his recommended treatment for my situation was an abortion. He told me that since I was a drug user and I was living in a tent, it was probably the best decision for me. I wish he would have helped me get into treatment. I tried getting into treatment on my own, but they sent me away and said I had to come back in three days. Treatment is ultimately what I wanted. This was the first time I realized that the systems in San Francisco were not going to support my needs with this pregnancy. became highly motivated to start detoxing on my own without any support in the streets. I came in contact with the healthcare system three times in my early pregnancy wanting treatment and was discharged to the streets with nothing each time.

leah-warner--she-her-_1_04-26-2024_131536: 11:11

See, hearing that story, Jamie, it really makes me of course, judge this provider, right? Who recommends that you go and get an abortion when he hears that you're pregnant. I think it's important for me personally to remember that I can be on that side of health care where I can let my own bias start to guide how I'm talking to the patient in front of me. So I appreciate that story.

jamie-lang--she-_1_04-26-2024_131209: 11:43

Absolutely, Leah. Simone and Leah, can you give examples of harm reduction approaches through the stages of preconception, pregnancy and postpartum, and the stage of parenting that work, and any that were not as effective?

Simone: 11:56

Oh yes, I love this question! Here come four soap boxes from me. Strap in everybody. First and foremost, as we all know, the, the best thing that we can offer any of our patients with, let's just talk about opioid use disorder, the best thing that we can offer any of our patients with opioid use disorder is access to life saving medications on demand. So, methadone and buprenorphine. And then, specifically, in the pregnancy and the postpartum period, those medications dosed appropriately, right? We know that the metabolism of methadone and buprenorphine are increased tremendously in pregnancy and in the early period, which means that people need both higher doses and more frequent doses. And, and they need that for those medications to be therapeutic and to actually work. Not only do people need their doses to increase when they're pregnant, they also, will have their metabolism change again when they become postpartum, and a dose that was previously therapeutic for them might become super therapeutic and now causes them sedation. And we need to tell people about this, and we need to monitor for it, and then when we see this over sedation, which is an expected outcome of metabolism changes, we need to treat it not like a failure, but like a natural history of medication metabolism. I think so often when we, when we in different spaces encounter folks who are on methadone or buprenorphine, particularly methadone, and are over sedated on their methadone, like, There are so many questions that arise patients are accused of using, and it can be incredibly triggering for patients when all they've done is get pregnant, get postpartum and keep taking their methadone as prescribed. And then we're just accusing them of doing things wrong. So dose it appropriately, both while you're up titrating and down titrating.

Leah Warner: 13:42

Here here. Get that dose right. I love that. I think it is also important to educate not just providers who are prescribing the methadone But also all the frontline healthcare providers who will see that patient, that sedation, over sedation can be a thing in the postpartum period.

Simone: 14:02

Okay. So box number two, are you ready? So first, you're going to get people on life saving medications, and you're going to dose them correctly. Second, we need to have frameworks that guide our conversations around Child Protective Services, or whatever it's called locally for you. The decision to call Child Protective Services, has a profound impacts on patients lives. Appropriately, it is therefore a very stressful and overwhelming decision for providers, and we never make our best decisions when we're stressed, overwhelmed, and scared. And so, in any way, a decision this big and with these profound impacts should never be made by one person. At San Francisco General, where I work, we, we've instituted this, it's called the Dyad Care Coordination Timeout. Basically, on labor and delivery and postpartum, if anybody thinks that Child Protective Services is going to need to be called, we have a multidisciplinary meeting where The inpatient team is present. The continuity outpatient team is present. And we sit down together and go through like this set of standardized questions, including what are the patient's strengths? What are the challenges they're facing? What are the biases that we have about this patient coming in? Who is not in this room that needs to be in this room for us to have this conversation? And then after we go through this entire conversation, only then do we actually make the decision about whether or not to call CPS. even if we don't, If we decide to call, we also talk about, like, how can we minimize the harm even having made this decision? Like, who's going to tell the patient? How are we going to tell the patient? What do they need to feel supported? we do this for every patient with the hope that by standardizing the process, And including as many voices as possible, it increases our chances of making equitable decisions. Obviously, we're not perfect, and obviously it is, it's always an incredibly painful decision, but hopefully by trying to be more equitable and thoughtful about it, we're at least minimizing the harm that we're causing.

jamie-lang--she-_1_04-26-2024_131209: 15:53

I've actually been in timeout meetings before, and it definitely does feel like the people supporting the birthing parent are up against the pediatrics team from the NICU.

leah-warner--she-her-_1_04-26-2024_131536: 16:03

What do you mean by that, Jamie? What does, what does it mean to be up against the pediatrics team?

jamie-lang--she-_1_04-26-2024_131209: 16:09

Well, the pediatrics team usually supports a CPS referral and welcomes the idea of a separation. It's like if the parent is not visiting the NICU enough or not doing everything exactly how they want them to do, they start to judge them.

Simone: 16:24

I think you can definitely, It can definitely feel like that. I think an important, like, I think this all comes back to the point they were making earlier that, when you focus exclusively on the needs of one entity within the dyad and focus on like what is best for baby in a complete vacuum where they are not part of any family unit, it can really change what you think might be best. But when you kind of zoom out and think this is a family, this is a dyad, what is best for this dyad, right? Is that they are together. In a loving and supportive environment that kind of meets both of their needs. And I think we can make better decisions. And that's why it's so important to have these meetings where lots of people are in the room coming from lots of different perspectives, so we can kind of compromise and come to a shared decision. Okay, that's the end of that soapbox. Let me go on to my third soapbox. Three of four, everybody. That Soapbox was about decision tools about calling Child Protective Services. Soapbox number three is about decision tools about urine toxicology. So, urine drug screens are a clinical tool and should be used for clinical purposes. shout out to my residency friend, Noelle Martinez, who has a recent paper with a helpful framework around this. The TLDR is that, urine drug screens should be used when you have a clinical question. So a clinical question in the postpartum space might be this person was using stimulants up until the time of delivery. She delivered yesterday and she wants to breastfeed. We know that stimulants are not safe for babies and breast milk, and so she consents to giving a urine so that we can appropriately time when she's going to start giving the baby the breast milk rather than pumping and discarding it. That's a clinical question. But at the end of the day just to say, these are tests that need to be obtained with consent. And should not be randomly gotten as a screening tool. If you want to know if somebody uses drugs, you should ask them. And if you want to use a urine drug screen, you should have a clinical reason to do so.

Leah Warner: 18:14

Pause on urine, pause. That's wild. I honestly, since I don't work in a hospital, have it in my mind that. If you're in a hospital, you can get a urine on anyone at any time, no matter what, without their consent. And it was not long ago, I think the late 1980s, that there was a federal law that passed out of South Carolina that did enable hospitals to obtain non consensual urine drug tests on any pregnant person and then report a positive drug test to law enforcement. Now, this law has since been repealed, but I think this sentiment of like, you have to catch people who are using, is still a very strong belief held in our society and, and in our healthcare system. And I think it's important to ask, is a punitive approach the way to support someone's health? Now shout out to jail health, because at least in San Francisco, that can be a positive health touch for people. And there are people with stories of recovery through. Jail and the penal system. But I think in general we move towards this punitive approach because we think we need to protect the fetus. What you were talking about, Simone, kind of evaluating whose needs are most important in this vacuum. Instead of thinking about this is a dyad. If we care for the patient in front of us, which is our job, that is our job. That that will then support the fetus or the baby that is inside of it. So just like to bring it all back to urine. I think there is good reason for why patients are scared to go into a hospital or to give us urine because it can feel like a way people get in trouble rather than support it.

Simone: 20:07

Oh, 100%! And I still have patients, I had a patient like last month, Go into a different hospital for a viral gastroenteritis and without her consent, got urine drug tested and she is somebody who's very engaged in recovery, goes to the methadone clinic, gets urine drug tested all the time between methadone clinic CPS. She has not used in months and she had a false positive at this outside hospital, which acute cause, like, tremendous upheaval until. Until we got confirmatory testing that was negative and like that can be incredibly triggering for somebody in early in recovery. So yes. We're up to my last soapbox people. I can't believe we got to just like talk and give my soapboxes out loud. My fourth soapbox is about safety planning before a crisis. Early in my postpartum visits, I tried to have a frank conversation with patients about how in recovery, and we know this for all people, it's not different because people are postpartum. In recovery, return to use happens, and we need to plan for minimizing harms. And so what that looks like in this time period is to talk about like, if you are ever on the precipice of a of returning to use, who are you going to call, right? Who can you give the baby to? Because it is not safe. You cannot use while with your baby. So who can you give your baby to? So that if you have to use, you can use. And if ever there is a CPS removal, do you have a family member who could take the baby for a couple of weeks at a time so that, you know, it can remain within the family? These are questions that can be really painful to ask, but also can in the future prevents so much harm. Also, like, naming for people that when your baby starts to crawl and become a toddler, toddlers put things in their mouth. So if you have drugs in the house when they're a baby, you really need to rethink that when they become a toddler. Like, put things in a lockbox so the babies can't get to them. Anyway, that's what I say, Jamie. What do you say when you safety plan?

Jamie Lang: 21:53

I safety plan in a very similar way. I try to be very real with them in a non judgmental way and just say, hey, return to use is a normal thing. It's not your fault, it's just a part of recovery. The thing to consider is where are your kids when you're doing it. Make sure they're with a safe and sober grown up. And do what you gotta do. Sharing that information with a parent gives them so much power over how they navigate parenting and recovery. While also ensuring the safety of the children.

Leah Warner: 22:22

Do either of you have an example of actually doing safety planning? I'd love to hear it.

simone--she-her-_1_04-26-2024_131209: 22:29

Oh yes. And I would love to tell you. Okay, I'm gonna tell you about a patient of mine who, this is a story from about a year ago when she was five months postpartum. She was 26 p one five months postpartum. She has a history of opioid use disorder and stimulant use disorder, and I get a call from her incredible patient navigator who shares with me that the patient has disclosed that she had this one time return to fentanyl use. And part of what's triggering her is her knee pain. And so the navigator is wondering if I can see the patient in clinic. So patient comes into clinic with her five months old. And in the course of her visit when I ask about her recent use, she shares that actually she's been using fentanyl several times a day, including while parenting her baby. She stays with her mom, so with grandma, and that can be hard because grandma doesn't know that she's returned to use. Actually this patient never had a CPS case open because she was in recovery significantly prior to delivery. Putting myself back where I was in that moment, right, like, I'm in clinic, it's a busy primary care clinic, and now this patient is disclosing to me that she's using fentanyl multiple times a day while solo parenting her baby. Basically all the fears that I listed at the top of this episode were in conflict here. I'm afraid that, while she's intoxicated, is she providing adequate supervision of this baby? Is this baby at risk of, like, getting into her supply and ingesting something? But what am I going to do if I call CPS? I've never met her before. This is our first time meeting. If I call CPS and they immediately remove this baby, like, this return to use can spiral and that might be the end of her recovery. And certainly it will break her trust with me and with our clinic. And so in the long term, how does that serve us? I felt overwhelmed. I stepped out of the room, And called my colleague Dana, and we try to have this like rule within our little cohort that does this work of like never deal with the return to use alone, because sometimes you need somebody who can see the forest and somebody who can see the trees. So I called Dana, who is a public health nurse who is honestly at the core of all perinatal substance use in San Francisco, and Dana helped me game plan and so when I returned to the room, this is how the conversation unfolded. I asked the patient if she'd be willing to share her return to use with her mom, because her mom is a sober grown up that lives in the same house as this baby, and maybe could help us. The patient said she was not ready to tell her mom that she's returned to use, but she was willing for us to share it with her mom. And so, that night, our patient navigator called the patient's mom, called grandma, and disclosed this return to use to grandma. And grandma agreed to step in and take care of baby while we found mom a higher level of care for her substance use. Ultimately, we were able to get mom into a withdrawal management facility for a little bit, and then after withdrawal management, she moved into a residential treatment program with her baby and now her and baby are living together in residential treatment. And I love this case because one, it is just like really highlights how indispensable the multidisciplinary team is in taking care of, of our patients. I didn't have these difficult conversations with the patient's mom, with grandma, like that was a hundred percent our patient navigator. There's so much of like the real work of taking care of these patients does not happen by providers and does not happen in the clinic room. Also because it really highlighted for me like there are options between the binary of CPS is evil. Never call CPS. I'm never gonna call them and I'm just gonna have to live with the anxiety that this baby's gonna ingest fentanyl on one hand and call CPS and have the baby removed every time on the other hand, neither of those extremes really serve our patients, but there are options in-between but those options they require a lot of work a lot of frank and difficult conversations and a robust team to do the work, I am so eternally,.of work this patient and for teaching me about this work.

Leah Warner: 26:15

I love that case. Simone. I do feel like you're right. It highlights how non binary actually harm reduction is because on, I think oftentimes when we are really worried or fearful for our patients, we think, okay, there's only two options here, call CPS or do nothing and never sleep again. But actually harm reduction shows us that there's so much in the middle between those two choices. And it does sound like it takes not only a really good team multidisciplinary approach, but also a lot of creativity and time, which isn't something the healthcare system always gives us, but is probably the better outcome in the long run for our patients. And we really do need to take that time to see all the choices in between the binary.

Jamie Lang: 27:05

Okay, Simone and Leah, question three. One thing I encountered during my pregnancy was barriers. Health insurance, prenatal care, treatment, housing, clothing, shower, food, you name it. How would you change the current health care system to reduce barriers and improve health care access for pregnant or postpartum and parenting people using drugs?

Leah Warner: 27:28

Okay. Thank you. I am so excited to step on my soapbox now, because first let me say our public health system. And healthcare system can be very complicated to navigate. You need tenacity and a lot of interpersonal skills to talk to the various offices and services that don't always talk to each other. And this is important because the clients this system is designed to serve are people like my patients, people experiencing homelessness or living in poverty, who have a lot of substance use, unmet mental health needs, but also a lot of physical disability, like bodies that are in pain. And have to walk back and forth between these various places to get the services they need. And a surprising incidence of cognitive dysfunction from brain injury, either acquired or traumatic. So already there's a huge barrier here between the system design and the client complexity. So, to bring it back to pregnancy and parenting, let's take my pregnant patient, for example, and let's say she needs to come into health care because she needs to get a form signed. I cannot tell you how many health care visits I have for people who bring me a form that they just need signed to get through the system of care. To get to me. She has to leave her stuff, right? She, she may be sleeping on the street. She may have like the tent she needs, the equipment she needs. It took her a while to get that stuff, all her precious belongings. She has to find someone she can trust to either watch it or leave it during a time where she thinks it's not going to get swept away. She also has to find a good route to get to my clinic. One that won't be super distracting or that feels safe to her. Then once she gets there, she has to take her pregnant body through the gates of health care, maybe presenting as a person experiencing homelessness, maybe getting dirty looks, or even just more attention than she's used to being pregnant, and get through Registration, show her ID. I don't have an ID. Okay, what else do you have? Give me your social security number. She has to shout why she's there. I'm here to get a form signed for my housing. You know, all of these things that she has to get through in order to see me. So, while I can't really talk about what we could do to reduce barriers en masse, for our healthcare system. That's probably like a different podcast, but just on an individual level as a provider, I really try to keep all of these various barriers in mind so that by the time I'm sitting face to face with my patient, I'm giving a very wide margin, not just for error, but for frustration, for irritability, for just discontentment. I really do try to honor that people have had to go through a lot. To Just get to a provider visit and lo and behold what if it's the wrong form that case manager Printed out the wrong form, you know It takes me probably ten extra minutes to figure out what form I actually need to print out for this patient So she can connect these dots, but I I'm holding all of this in my head I'm going to help reduce those barriers. And I think other ways we can really reduce barriers is to have options where appointments aren't a thing. You know, not just a drop in clinic, but really a comprehensive set of services like primary care that don't have appointments. So we call our clinic open access. People never have appointments. They can just show up. In the times that we are there and get pretty good comprehensive care. And that takes away a lot of the shaming around. You missed your appointment. Sorry, I can't schedule you an appointment. You've missed too many appointments. And then finally, I think we can also think about putting healthcare in very creative spaces. There's healthcare on the street, like street medicine, but there's also healthcare that could be found in syringe access or drop in centers. Mostly I think about putting health care in spaces where people experiencing homelessness are welcome is there aren't a lot of those spaces and where they are welcomed is where the healthcare should be. Simone, your thoughts?

simone--she-her-_1_04-26-2024_131209: 32:09

Just to add like very briefly on something you already said, which is that, I like cosine 1000 percent that would need to move away from a traditional appointment based system. And that is a system that was never created with the needs of the marginalized in mind. Just imagine you're a brand new parent, with a brand new baby, you're learning to parent, while also kind of still on an unstable methadone dose and feeling like you're in withdrawal all the time, and CPS mandates that you go to like, this therapy, and then this NA group, and then this court appointment, and like, it has a thousand hoops for you to jump through, and you also have to make it to your Doctor's appointments, but also your baby vomits everywhere every time you leave the house and also you have to walk there with your stroller. And so, with all those things in mind, like, of course it was never going to work for you to have a 15 minute window to show up at this clinic. We need to get away from that if we're going to try to take care of our patients. Jamie. Leah and I have rambled for 34 minutes now. I'm going to flip the table on you. As someone with lived experience, what do you think that pregnant and postpartum and newly parenting people who are using drugs perceive to themselves as the most harmful to their health during this time? I'd love to hear both like your thoughts from your lived experience and also from your just immense experience working as a case manager for these folks.

Jamie Lang: 33:22

Thank you, Simone. The first thing that comes to mind is a child separation. They're going to take my baby, that adds a whole extra layer of accessing care and being honest about my situation. for me living in the streets at the time, there was also the constant fear or threat of intimate partner violence and community violence. when I say community violence, not just the community of my peers, but community providers like the police department or department of public works, who were also very harmful and dangerous. I also think the constant stress of being in survival mode was a concern towards the pregnancy, specifically around housing and shelter and the mistreatment I experienced due to stigma and judgments when I tried accessing the systems.

Leah Warner: 34:11

Wow, talk about barriers. Those are some pretty insurmountable barriers. I want to pause on intimate partner violence, which is something we see very often in our clinic and is not easy for us to talk about with our clients. How do you talk to your clients about intimate partner violence?

Jamie Lang: 34:31

They usually come in wanting support around it. I don't have to pry it out of them. They're usually forthcoming, and I think there's an urgency around intimate partner violence when there are children involved versus maybe someone who is in the preconception or pregnancy stage.

Leah Warner: 34:48

I think that's a fair point. If you had to think back to the time when you were accessing care, what do you think the role of a provider is when bringing up intimate partner violence, or supporting somebody who's in an intimate partner violence situation?

Jamie Lang: 35:05

The role of provider should be whatever the patient wants. I was not looking for support around that. I was still very much living in street culture, where you don't talk about that type of thing unless you're ready to completely leave the situation or suffer the consequences of speaking out. What I really needed support around was the community violence, the police telling us to constantly move our tent or calling to have it taken away. Department of Public Works sprayed me with a pressure washer when I was sleeping one time. This was actually a barrier to getting care because I would have to leave my tent and all my things behind and if they come while I'm not there to move my tent. They'll take the whole tent and everything inside.

Leah Warner: 35:46

Jamie, Were there any signals from providers that made you feel like you could be safe with them? I mean you really mentioned like what's on your mind is child separation, the community violence you're experiencing, coming in with all of these things. Were there signals from health care providers that made you feel like yes, this person is here for me.

Jamie Lang: 36:09

I first met my midwife, Mary Mays, and she was just like, cool, how can I help you? What do you want to talk about today? Like, it was so normal for her, and learning to trust her opened the door for me to trust other providers, like nurse Dana, who would come and see me at my tent sometimes. Her support really changed my attitude and the trajectory of my life.

Leah Warner: 36:31

I think that's It's sort of the definition of harm reduction right there. It's hearing a patient's story, maybe feeling inside very overwhelmed by all that your patient is going through, all of the factors pressing down on them and remembering that you're there to support their health and moving forward and saying, okay, what can we do today? How can I meet your needs today? It takes a wizard like Mary Mays to pull that off.

Simone: 37:07

I really could not agree more that we should all just end with acknowledging that Mary Mays is a wizard. But I also want to just Bring us briefly back to our learning objectives to kind of recenter us where we started. We started off talking about, like, what are the harms? What are the harms that we are afraid of in pregnancy and the postpartum period? And to list them out, we're afraid of not doing enough about our return to use, that that will lead to parenting while intoxicated, inadequate supervision of babies, and potential ingestions. But we're also afraid of doing something and our intervention being harmful. So, calling CPS, that leading to removal, and that leading to a to sustained return to use. And then we talked about like, so what are some harm reduction things that we can try? And in that, we mentioned appropriately dosing people's MOUD. Noting that metabolism changes in pregnancy in the postpartum period. Having frameworks for more thoughtful and more equitable decisions around calling CPS and using urine toxicologies. And having honest conversations about safety planning that acknowledge that relapse is a part of recovery even when you're postpartum And as jamie brilliantly said what you have agency over is where your child is during those times And then finally we talked about the barriers to health care access for pregnant people and honestly all marginalized people. Which is that providers are not in the places where patients who are Living outside, feel safe and comfortable. And we need to get ourselves to those places. And we need to do away with this appointment based model that completely is based on the needs of the clinic and has not at all centered the needs of our patients.

Leah Warner: 38:43

What a beautiful summary. I want to add to that and say that when we are thinking about our greatest fears, we also have to acknowledge that sometimes that fear can easily turn into a bias. And that bias can really guide how we're talking to our patients and that it's okay. It's okay to feel that fear. It's okay to feel overwhelmed by what you're seeing, but remember our patients can pick up on bias and discomfort. And so it, It is important to use your multidisciplinary team, your resources in the community, and to make sure that, just like Jamie said, you're like, cool, well what can we do for you today? And make sure that you are really seeing what your patient, who overcame a lot of barriers to get to you, is there to talk about that day. And actually, it's a lot easier said than done. Like it does take wizardry.

Jamie Lang: 39:37

I think that's great. Thank you, Simone and Leah. I think this was a really great conversation.

Kinna Thakarar: 39:43

That was Dr. Simone Vays, Leah Warner, and Jamie Lange in conversation on harm reduction compassionate care for people who use drugs. Thank you for listening. Be sure to tune in next time when we welcome Dr. Joshua Lynch, Shelby Arena, and Dr. Shoshana Aronowitz to the series to discuss innovative access to harm reduction support and linkage to treatment. Please take a moment to complete SAMHSA's post event evaluation survey on the AMERSA podcast page at www. dot AMERSA dot. Org forward slash harm reduction podcast. We welcome any comments, questions, or other feedback for presenters. You can send those directly to AMERSA through the contact us form at AMERSA. org. To learn more about the provider's clinical support system, Medication for Opioid Use Disorder Project, and AMERSA please visit our websites at PCSSMOUD. org and AMERSA org. Funding for this initiative was made possible by Cooperative Agreement No. 1 H 79 TI 086 770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U. S. government. Thank you for listening.