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"Don't be mean."

That advice might be seen as unnecessary for most doctor-patient relationships, but not for treating patients with substance use disorder (SUD), especially pregnant patients, according to Cara Poland, MD, MEd, of Michigan State University College of Human Medicine in East Lansing.

"The bar is really low in addiction," she said Wednesday during a on improving access to pregnancy and postpartum care for patients with opioid use disorder. "You just have to not be mean, because so many of these patients, because of their past experiences with the healthcare system -- they're expecting us to not treat them nicely, not treat them well."

"You start by just being nice," she continued. "Be open to them. Ask them questions about their current use, and be capable and competent in terms of offering them medications to treat their opioid use disorder."

Patients Often Self-Stigmatize

Poland, who exclusively treats pregnant people with SUD, noted that the World Health Organization states there is nothing more stigmatized than illicit substance use. "When you add on the fact that we're talking about substance use during pregnancy, these individuals have so much stigma that's coming at them ... They actually self-stigmatize themselves more than anything that we say or do to folks. So when somebody comes in and they're actively using substances, my answer to them is often, 'Thank you for coming in and feeling like you could trust this to be a safe place to talk about what we can do to support you during your substance use and also on that road to recovery.'"

Our culture has a "deep sort of hatred" toward people who use drugs, especially pregnant people, said Kim Sue, MD, PhD, of Yale School of Medicine in New Haven, Connecticut. "That really sets us up as a society. As healthcare providers, we have to undo that. We have to recognize a lot of the structural racism of our drug laws, and really encounter people outside of the clinic. So this would mean things like funding drug user health programs and harm reduction programs, and training people in harm reduction centers, and doing syringe service programs [and teaching] how to interface with pregnant people who are using."

"I think it's really hard to unlearn what we learned in medical school," she said. "We really learn what we're steeped in, in our culture. For example, I was working on a report with the New York State Office of Drug User Health, and someone I was working on the report with was very critical of a pregnant person who was drinking coffee -- let alone if you're injecting fentanyl or heroin."

The American Medical Association (AMA) became involved with this issue because the organization "is deeply disturbed, frankly, by the data showing that so many pregnant people with a substance use disorder are dying of a drug-related overdose and just not getting the care that we know should be available," said Jesse Ehrenfeld, MD, president of the AMA, which co-sponsored the webinar. "We're tired of seeing families torn apart by policies that are punishing pregnant people because they have a substance use disorder. We want to put an end to that."

"We want to encourage every state to make sure that pregnant people in jails and prisons have access to evidence-based care for substance use disorders," he continued. "We want to support and encourage any policy and advocacy efforts that can protect pregnant people throughout pregnancies, as well as their entire family postpartum."

Should You Report to CPS?

Reporting a pregnant person with SUD to child protective services (CPS) is a fraught undertaking, according to several panelists.

"Different states have different Child Protective Services laws" regarding when clinicians are required to report SUD, said Poland. Such agencies were influenced by the federal Child Abuse Prevention and Treatment Act of 1974 (), and CAPTA "was created in an environment where there was this idea that people who use substances are inherently going to cause harm to their children. And that was not evidence-based," she said. "People who have a substance use disorder can be fantastic parents, and people who don't have a substance use disorder can be terrible parents. So knowing the historical contexts in which some of these things occurred is really important."

CAPTA's mandatory reporting requirements were "developed to respond to child abuse where a rapid response and potentially rich child removal from a dangerous environment makes some degree of sense," said Mishka Terplan, MD, MPH, of the Friends Research Institute in Baltimore. But then those same requirements were expanded to include situations in which parents had an SUD.

"The idea of mandatory reporting [to CPS] in many ways offsets responsibility for care for the family," transferring responsibility for their care "to the surveillance agency for family policing, which is not a service agency," he said. "They can mandate things but they don't in and of themselves provide behavioral health care, child care, much less transportation to said mandated services ... And so this whole paradigm of mandatory reporting is a way for us not to take responsibility as health professionals, and that's been highly problematic."

Rather than helping families, "we have now 20 years of policy research that shows that mandatory reporting and other punitive policies -- labeling drug use in pregnancy as child abuse, or coerced treatment in pregnancy -- are actually associated with either no change in neonatal abstinence syndrome rates or worsening rates of neonatal abstinence [syndrome] and, at the state level, less engagement in prenatal care and higher rates of preterm birth," said Terplan. "So we actually have evidence that these policies are harmful on the population health level."

The idea that clinicians might have to "play it safe" by calling CPS could result in "extraordinary harm in terms of that immediate family losing a child that could be with them, but also it's going to make people not come in [for SUD treatment] and it's not having any benefits," said Jocelyn Guyer of Manatt Health and the panel moderator. "So 'Let's play it safe' is actually an extraordinarily destructive policy."

Developing a Warmer Handoff

The handoff is another issue to consider, Poland said. "As we think about transitions of care and the pregnancy, perinatal, and postpartum periods, some of the highest risk time periods in a woman's entire life is actually in the 3 to 12 months postpartum," she noted. "And the vast majority of pregnancy-related care ends between 6 and 12 weeks, so we actually are transitioning patients right during this time period where they're high risk for substance use and negative outcomes, including death."

"So when we make these transitional plans, I like to tell people, "I don't want a warm handoff -- I want a 'I just put my hand in the 350-degree oven' handoff," she said. "So [that includes] ensuring that people have a safe place to land postpartum if they can't continue in that clinic, and ensuring that we look at the family structure as our nidus of support, rather than looking at the mother/baby dyad."

In addition, "who else in that family may have a substance use disorder that may need support? Can we make sure that whole family gets care?" she said. "We're really looking at how do we create healthier families, because healthier families are a healthier society."

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