Medication Assisted Treatment During Pregnancy, Postnatal and Beyond

Cathleen Otero: Good morning, or is it afternoon, depending on what time zone you're in This is Cathleen Otero, Deputy Director of the National Center on Substance Abuse and Child Welfare, welcoming you today, on our webinar session

Today's session, Medication-Assisted Treatment Series, Part 2 of 2, "Medication-Assisted Treatment During Pregnancy, Postnatal, and Beyond" Again, this is Cathleen Otero We are happy to have Karol Kaltenbach here with us, presenting To quickly review our agenda for today, we're currently doing just a couple of introductory remarks, and then we will move into the bulk of the presentation, "Medication-Assisted Treatment During Pregnancy, Postnatal, and Beyond" We'll touch a little bit on considerations for child welfare policy and practice

Again, if we don't get a chance to answer any questions during the course of the presentation itself, then we have some time slotted at the end for some discussion and questions and answers You may notice that your lines are muted You will not be able to ask questions, verbally, to the presenter, but again, feel free to ask any questions, at any point, using the question and answer dialog box on your right-hand side control panel A quick message from our sponsors The National Center on Substance Abuse and Child Welfare is funded by Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, and the Administration on Children, Youth and Families, the Children's Bureau Office on Child Abuse and Neglect

Our mission is to improve outcomes for families affected by substance abuse who are involved in the child welfare and family court system Just a quick touch on who is joining us today We always think it's interesting to find out who's participating, and of the registrants that we have for today's session, almost half are substance abuse treatment providers, about a third of you are child welfare workers, that is 25 percent of you indicated that you are from another system, and then we have about 6 percent who are from child welfare, I'm sorry, dependency courts or family drug courts Most of you, about 88 percent, indicated that you attended part one understanding medications and treatments for families affected by substance abuse disorders, the presentation that we did in July If you did not attend the first session, again, you can check out our Children and Family Futures website for the materials and handouts from that first session

A quick review from part one of "Understanding MATs for Families Effected by Substance Disorders," a couple of issues that we touched upon included medical marijuana, prescription medication misuse and abuse, MAT for co-occurring mental health disorders, and for substance abuse disorders We talked about use of MAT as an exclusionary criteria for child welfare programs, particularly family drug court Misunderstanding the use of medication-assisted treatment, particularly methadone treatment and substance abuse treatment and how it relates to child protection and child safety In particular on the agenda for today, and what Dr Kaltenbach will present, is addressing some of the issues that came up last time on the requirements of minimal dosing or titrating off of assisted treatment medications for pregnant women or as a term for reunification as well as the issue of positive toxicology resulting in a presumptive pos for a child, a newborn, in the case of methadone

Without further ado, I'm going to turn it over to Dr Kaltenbach to take us through the presentation for today Dr Kaltenbach? Dr Karol Kaltenbach: Thank you

I am delighted to be with you all today MAP, medication-assisted treatment in pregnancy, I'm going to talk about that specifically as to what it involves, the medications that are used, and why we feel it's warranted and so important to be used I'm also going to be talking about neonatal abstinence syndrome because that is one of the issues that always comes up when you're talking about opioid dependence during pregnancy specific to the opioids, the illicit drugs that are used, and the maintenance medications that are used We're going to spend a little bit of time talking about illicit drug use By illicit drug use, it's exactly what it implies

It's illegal drugs From that, we're talking about heroin, cocaine, marijuana, anything that is illegal is what comes under the terminology of illicit drug use Prescription misuse, again, is what the title implies It's prescription medication that is legal to use and that is an important medication but that has been either misused or is being abused For this topic, what we're usually talking about are medications such as Percocet, OxyContin where they are being abused and the women have become dependent upon them

We're also talking about benzodiazepine, which is a very highly prescribed medication, but it is also very much used and abused within this population Then we're going to spend a little bit of time talking about co-occurring psychiatric disorders, what you do about providing treatment to opioid dependent pregnant women who also suffer from a number of psychiatric disorders Then we will spend a little bit of time talking about breastfeeding because that's always an issue that comes to the forefront in this population I want to just emphasize the term MAT You see that throughout all the titles, medication-assisted treatment

Our language is very, very important It used to be when we'd give a talk about opioid dependence during pregnancy, you'd talk about Methadone maintenance treatment programs That nomenclature has been changed to medication-assisted treatment, and for two reasons One is now we have another medication We have methadone, and we have buprenorphine

I'll be speaking about both of those Also to emphasize that this is medication-assisted treatment, we're talking about treatment for substance abuse disorders, in particular opioid dependence We're talking about a medication We're not talking about misuse of a drug Sometimes you'll see even posters at scientific presentations where they'll identify drugs

They'll call them illicit, and they'll have methadone on there Methadone is a medication It's been defined by the Americans with Disabilities Act as a licensed daily medication It's used for a number of things other than just treatment of opioid dependence Certainly, buprenorphine is another one of those medications

It's very important that you understand the underlying principles We're talking about treatment for substance abuse disorders By that term, I mean the full complement of treatments Comprehensive services, we won't have enough time to discuss the array of services that are necessary for this population, but we're talking about extensive treatment services in conjunction with pharmacotherapy, medications I just want to make that point because that lays the groundwork for the rest of the talk

To talk about medication-assisted treatment, as I mentioned, we're going to be talking about methadone and buprenorphine Methadone has a very long history in the United States It has been recommended for the management of opioid dependence during pregnancy since the early 1970s It was approved for use in this country in the late 1960s We have a very long history of using methadone

Another important thing to understand is that in 1997, the National Institute of Health had a consensus panel that was to identify and look at treatment for opioid dependence In that consensus panel, methadone was recommended as the standard of care for pregnant women That informatur is very important If you go back to the two issues that we're going to talk about, the requirement of minimal "dosing of medications for pregnant women as a term for reunification" and talking about the presence of a positive toxicology as a presumptive cause for child removal That is inconsistent with the fact that methadone is a medication that's recommended by the NIH as a standard of care

We're going to talk about that and, hopefully, explain why it has that recommendation and why the idea of requiring minimal dosing or not allowing reunification with a parent who is successfully receiving methadone treatment is inconsistent Buprenorphine is the new kid on the block It's been around for a long, long time even though it's very new in the United States It's been used in Europe since the mid-1990s, so we have a long history of its use with pregnant women In the United States, it's not yet formally approved for use with pregnant patients, but its use in the USA is increasing

We have a large number of women who are being maintained on buprenorphine before they become pregnant, and then once they become pregnant, they choose to remain on buprenorphine We also have an increasing number of women who are being inducted onto buprenorphine during pregnancy They are not using treatment They choose buprenorphine over methadone We're going to talk about both of those issues

I've got to go back My arrows on here are causing me some problems Just a second Let's talk a little bit about the benefits of using medication-assisted treatment during pregnancy They have some very, very strong benefits

When a woman is opioid dependent and she is using illicit drugs — heroin or even prescription drugs like Percocet — those are short-acting opioids They only have an effect for a short amount of time They wear off after four to six hours If she doesn't have another dose to take right away, another shot of heroin to take right away, she's going to start going through withdrawal Every time the mother goes through withdrawal, the fetus goes through withdrawal

It's those episodic episodes of withdrawal, repeated episodes of withdrawal, that are so damaging to the fetus That's when you're talking about fetal morbidity and mortality, most of the time that's a result of these repeated episodes of withdrawal Now, we're also going to be talking about the withdrawal that occurs when the infant is born, and there's a lot of focus on that But we also need to remember that we should be cautious about the fetus going through withdrawal When you have a woman on methadone maintenance or on buprenorphine maintenance, you're going to stabilize her, so she's not going to have the erratic, repeated episodes, and so you're going to have a very stable intrauterine environment for that fetus

Even though it's being exposed to an opioid, it's protecting it from more harmful effects of these repeated episodes of withdrawal That's the primary reason why medication-assisted treatment during pregnancy is considered the standard of care When we're talking about effective maintenance, and this is where we're going to get into the issue of minimizing dose, effective maintenance or a therapeutic maintenance, you prevent the onset of withdrawal for at least 24 hours If she can get medicated every day, she is never going to go into withdrawal She comes in every day or she has take-home medication depending upon her length of treatment and depending upon what medication she's on

But you're going to stabilize her so that she never goes through withdrawal If she's on an effective dose, a therapeutic dose, you're also going to reduce or eliminate drug cravings, so she's not going to want to seek the drug that she's dependent on It's going to block the euphoric effects of other opioids, other narcotics, so she's not going to continue to use That's what it takes to have an effective dose If you give someone, a pregnant woman, a low dose that's not really an effective dose, you're probably going to prevent the onset of withdrawal

But you're not going to reduce or eliminate the drug cravings and you're not going to block the euphoric effects In all probability, she's going to continue to use — and I'm just going to use heroin as an example — she's going to continue to use heroin, even though she's in a treatment program and receiving, and I'm going to use methadone as an example, because it's not an effective dose, it's not a therapeutic dose Remember again, this is a medication and we have to use the same principles that we use for any mediation that we're taking for any kind of illness or disease We do have to make sure that women are on effective doses Back to now, the benefits, as I said

It prevents the fetus from repeated episodes of withdrawal You also have indirect effects, because the only way a woman can receive maintenance medication is either through an opioid treatment program if she's receiving methadone or through a physician's office if she's receiving buprenorphine, or also through an opioid treatment program So she's engaged in a broader range of treatment She's engaged in treatment, so you're going to reduce the risk to the fetus of infection from HIV, from hepatitis and sexually transmitted disease because you're reducing those risk behaviors in the mother You're also going to reduce the incidence of obstetrical and fetus complications for two reasons

Number one, you've stabilized that intrauterine environment so that you don't have the repeated episodes of withdrawal Number two, she's getting prenatal care If she's coming in, if she's enrolled in an opioid treatment program, they're going to either provide the prenatal care or they're going to coordinate it That's one of the criteria of accreditation in the United States that, for any pregnant women enrolled in an opioid treatment program, you must either directly provide or coordinate prenatal care Certainly, if she's receiving buprenorphine from an office-based physician, he's also going to make sure that she has the appropriate referrals and that she's receiving the necessary care

Then I want to talk a little bit about withdrawal procedure, because this is also a question that always comes up People that are interested in not having women maintained on medication, women that maybe maintain their medication but who decide that they don't want to during their pregnancy — there's a lot of different reasons why that question of withdrawal procedures come up during pregnancy, so we need to talk a little bit about them and make sure that we understand both the procedures and what we have to do if we're going to utilize them, and what the risks are We're really talking about two terminologies When we talk about medication-assisted withdrawal, that's what's used to provide transition from an illicit opioid to a drug-free state If you have a woman who's abusing heroin, she's dependent on heroin, and she wants to go into treatment, she doesn't want methadone maintenance, but she certainly doesn't want to go through withdrawal in the classical cold-turkey kind of paradigm by just stop using heroin

Methadone or buprenorphine may be provided to transition her from that illicit drug use to a drug-free state so she doesn't have to go through withdrawal Then the other terminology that we use is the taper That's for someone that is receiving maintenance, who's been enrolled in a maintenance program, and who wants to transition from maintenance to a drug-free state That's what we refer to when we are talking about the taper Those are two very different kinds of situations to explore

If you have medication-assisted withdrawal, if a woman comes in and she says, "I'm using heroin I'm pregnant I don't want any kind of maintenance, so please help me go through withdrawal" You need to provide counseling and education on the risks and benefits of maintenance Obviously, it's the woman's choice

She has a free choice in this matter and her wishes need to be respected But we also need to ensure that she has adequate information to make an informed decision So, she needs to be provided counseling and education on the risks and benefits of maintenance Certainly, it's admirable to want to maintain an abstinent state, but she needs to understand what the probability of that is and what the risks are to her fetus if she's not able to do that The same way with a taper when a woman is already receiving maintenance and requests a taper

Sometimes it may be a personal request Sometimes it may be because she's moving to an area where she's not going to have access to a methadone maintenance program Although with buprenorphine, she can transition to buprenorphine if necessary But a taper is when she is in a program and wants to taper off the medication Again, a thorough assessment is essential to determine if the woman is an appropriate candidate

Some women may not really want to do this, but they're under pressure from their families Oftentimes, the families do not understand what medication-assisted treatment is They see it as simply an extension of the drug use Again, this comes back to some of our terminology where we talked about substitution treatment This is not substitution treatment

We're not substituting one illegal drug for another We're providing medication in order to assist the woman to get to a state of recovery Oftentimes, she's under severe pressure Oftentimes, she's under pressure from the department of health and human services also That you can't be receiving methadone

That's not seen as a positive in order for her to keep her children She may be under pressure there to taper But you need to have a thorough assessment to determine if she's an appropriate candidate, because motivation is not always the only criteria It needs to be conducted under supervision by a physician that's accompanied by fetal monitoring Because withdrawal can be a threat to the fetus, so it needs to be done very carefully and under the supervision of a physician

There have always been recommendations going back to treatment being initiated with this population in the '70s The recommendation has always been that if withdrawal is necessary, it should only be conducted during the first trimester, because you may cause spontaneous abortion, and you don't even want to do it during the third trimester, because you may precipitate delivery prematurely That's been the clinical standard, and if you go back and read any of the publications, even up to today, it recommends that withdrawal be conducted during the second trimester You need to know that there are no systematic studies on whether withdrawal should only be initiated during this time There certainly is some evidence that the rates of spontaneous abortion or prematurity do not differ from rates in a general population among women that have gone through withdrawal

Most people would not question as to whether it can be done safely or not Again, as I said, if it's done very carefully, if the patient is in an outpatient program and so you have methadone You want to decrease the methadone very slowly, by 2 mg to 25 mg a week If the woman is inpatient it can be done more rapidly, 2 mg to 2

5 mg a day But again, fetal movement must be monitored and non-stress test performed, and it should be discontinued if it causes fetal stress or threatens to cause premature labor I've included a reference here This is a citation from the Center for Substance Abuse Treatment, which is their TIP on medication-assisted treatments TIP is the treatment improvement protocol publication that they put out that's developed by a consensus panel that gives you guidelines on the standard of care

We know that women can safely be withdrawn during pregnancy The question is whether it should be done It's not an issue of whether it can, but it's an issue of whether it should The reason it's an issue of whether it should is, because despite an individual's good intentions, there's a very high rate of relapse in opioid-dependent women during pregnancy Anytime you have a relapse, you're going to put the fetus at additional risk

Again, we're looking for both, to improve the health of the mother, and also to ensure that we have a healthy full-term baby born from this pregnancy That's what the goal of any discussion of medication-assisted treatment is — to ensure that we have the healthiest baby possible I just want to quickly give you some data that speaks to this This was a study that was done at Johns Hopkins It was published in 2008

It's not a randomized study or anything like that It was simply looking at available data that they had It was a retrospective study of maternal and neonatal consequences of withdrawal during pregnancy They had a natural kind of experimental design, because they had a specialized program for pregnant women, opioid-dependent pregnant women, or non-opioid dependent but substance-using women But they could come into their program, and they did provide methadone for opioid-dependent women

They also provided medication-assisted withdrawal if the woman did not want maintenance Then over the course of a number of years, they changed their protocol from a three-day withdrawal, which is a very quick withdrawal, to a seven-day withdrawal So they could compare the quicker versus the longer withdrawal also It was a very interesting natural experiment They had a group of women who came in and requested withdrawal, got withdrawal, and never went to maintenance

Then they had a comparison group that were the same type of women that requested withdrawal, but eventually decided that this was not for them, that they wanted maintenance, so they went onto methadone maintenance Then they had the same kind of comparison between the seven-day withdrawal, and then they had the ultimate comparison group of women who received methadone maintenance from treatment entry, who never had a medication-assisted withdrawal What they found was, without going through all of the different results was, that for women that were maintained, they did not, and this is from both the women who never had withdrawal, or the women who had withdrawal but went into maintenance But any woman who was receiving maintenance treatment, they remained in treatment much longer They attended more prenatal care appointments, which we know is critically important in terms of the outcome of the infant, and they delivered at the program hospital

You may say, "Well, what difference does it make what hospital they deliver at?" But it's extremely important that when you have a pregnant opioid-dependent woman, that she's delivering at a hospital that knows her if she's been maintained They need to know her so that they know to observe the infant and be prepared for the abstinence that may, the infant may undergo This becomes also an important factor in terms of improving outcomes But certainly the treatment retention, we had lots of data that show that this is one of the most important variables in good outcomes and obviously prenatal care is a primary factor The maintenance group did much, much better than the women who went through medical withdrawal

Obviously, no one is going to dispute that the infant, the delivery of the infant free of drug exposure is a universal goal That's all of our goals, when possible But in the case of opioid dependence, this must be balanced within the risk-benefits of continued medication This is something that is going to be the driving force between, throughout our treatment of women, both in terms of initiating medication-assisted during treatment and in terms of the outcome of the infants is looking at the risk-benefits of using medication as opposed to not using medication I want to talk just a little bit about the induction of methadone maintenance so that people are familiar with it, even though you won't necessarily be doing it

If you are providing services to this population, you need to at least be familiar with this to know what is required and what has to be undergone In terms of methadone, you need to be aware that it is governed by very, very strict regulatory issues Not everybody can be maintained on methadone You have to have a documented opioid dependence for a minimum of one year You also need to know that pregnant women are exempt from that

Again, that comes back to the reason that it seems so important to be able to stabilize that intrauterine environment They don't have to have a year of dependence, but you have to be able to document, to certify that they're pregnant if they don't meet the legal requirement The first dose is restricted to either 30 mg or less You can never give someone more than 30 mg for the first dose, whether they're in the hospital or not If you give them a 30 mg dose and their withdrawal symptoms persist after two to four hours, the initial dose can be supplemented with another 5 mg to 10 mg

But the maximum first total dose can only be 40 mg It may not exceed 40 mg unless it's documented by a physician that that dose was insufficient to control withdrawal This is the way the regs read In terms of the practical application, I don't know of anybody who would go over 40 mg in an outpatient setting Certainly, when you have a person inpatient in the hospital and she's being monitored very closely and carefully, you can go higher in the first day if the physician feels that it's warranted

That being said, one of the problems with induction is that people do not understand the pharmacology of methadone and its half-life is 24 hours, which means it takes that long in order for half of the medication to leave the body If you give a dose and then two or three hours give another dose, you've got a large accumulation building up in the bloodstream that's not been excreted You have to be very careful It takes about six to seven days with methadone in order to achieve a steady state, which means that it's a steady level between what they're taking and what stays in the bloodstream You have to be very, very cautious during induction

The rule of thumb is take it low and slow Certainly, the major difference in outpatient and hospital induction is that inpatient allows for medical monitoring and a much comprehensive approach The outpatient, though, is often a practical necessity because not a lot of programs have the ability to have an inpatient hospital induction If it is done on an outpatient basis, you need to have twice-daily observation until the patient is stabilized Again, because she takes the medication, that medication is not going to peak until about four to five hours

That's when she's going to feel the most of it, and then it's going to start to taper off and decrease over the next 24-hour period She needs to be observed In terms of methadone, the two areas that seem to raise the most concern are effective dose and the relationship of dose to neonatal abstinence syndrome But dose should always be used with the same criteria that is used for non-pregnant patients There should never, ever be a different dose regimen for pregnant patients as opposed to non-pregnant patients

The same criteria that for a therapeutic dose, that you're trying to prevent the onset of withdrawal, you're trying to reduce or eliminate drug craving and block the euphoric effects have to be used so that they should be on the type of dose as any other person Optimal dose, it used to be that it was suggested it was in the range of 80 mg to 120 mg This work was done back in the '60s when heroin was not very pure The heroin on the street was only about 10 percent pure Now, the heroin on the street is about 80 percent pure

The current data indicates that most patients are maintained on dose between 100 mg to 200 mg You need to know that others may require significantly higher doses You also need to be very cautious and know what other medications they are taking, because some medications interfere with the metabolism of methadone, either speeding it up or lowering it Some mediations, such as benzodiazepines, can have a fatal interaction You have to be very cautious about what other medications that they are taking

If you have an opioid-dependent women who became pregnant while receiving methadone, she should be maintained on her pre-pregnancy dose There should be no changes simply because she has now become pregnant There's also continued debate regarding the relationship between maternal dose and neonatal abstinence syndrome This is one of the reasons why there have been, even though this has been the standard of care for almost 40 years, why there tends to be continued resistance to the use of methadone Because the infant will go through abstinence and there has been a feeling that the higher the dose, the worse the abstinence

The data for this is inconsistent There're about 33 studies to data The majority of them show that there is no relationship between maternal methadone dose and the severity of abstinence There're a lot of factors that go into the severity of abstinence in addition to the medication The genetic host, the metabolism system of the infant, the gestational age of the infant — there're many, many things that go into it

You can take a scatter plot and look at a hundred women who are maintained on methadone You can have a woman who's maintained on 40 mg and her infant has withdrawal that has to be treated You can have another woman who's maintained on 200 mg and her infant is discharged on four days because the withdrawal does not have to be treated You should never reduce the maternal methadone dose to avoid NAS Again, if you reduce it so that you're not giving a therapeutic dose, you may promote supplemental drug use and increase risk to the fetus

Again, we've come back to this risk-benefit Yes, the infant will go through withdrawal, but it's not a direct linear relationship between the maternal dose and the withdrawal You want to make sure that you can address all the other factors that put the fetus at risk, but you should never lower the maternal dose simply because you want to avoid withdrawal I'm going to talk about buprenorphine a little bit, because it is out there A lot of people are using it

For those of you who are not familiar with it, it was approved in 2002 by the federal drug administration It comes in two sublingual formulations By sublingual, we mean it has pills that have to be placed under the tongue and they dissolve One of those formulations is Subutex, which is buprenorphine, and Suboxone, which is buprenorphine plus naloxone We are one of the few countries in the world that use Suboxone and that's primarily only to reduce the diversion of buprenorphine

Because, as you know, naloxone is an antagonist, and if you are using opioids and you take naloxone, it will put you in withdrawal It's what's used if you have an overdose of opioids But when it's taken sublingually mixed in this tablet, it has no effect on you so that you can take the medication effectively The naloxone has no effect unless you take the tablets and crush them up and try to inject them Then the antagonist will have an effect on you that will not be pleasant

It's a diversionary control tactic, and that's why we have Suboxone That's the most widely prescribed prescription in the United States Subutex is not used on an outpatient basis The whole focus of the Drug Addiction Treatment Act of 2000, which allows buprenorphine to be prescribed in physician offices, was to improve access to treatment, because we have many opioid-dependent patients who need medication-assisted treatment who there simply are not available slots for This is a Schedule III medication, and this legislation specifically stated that these Schedule III, IV, and V medications can be used for maintenance

Right now, buprenorphine is the only medication we have in that category Methadone is a Schedule II medication so the only way you can receive methadone for maintenance is again through a licensed and accredited opioid treatment program In terms of pregnancy, the current guidelines recommend that buprenorphine be prescribed to pregnant women only when the benefits outweigh the risks and the patient has refused methadone This again is the current guideline, but the reality is, as I mentioned earlier, a lot of pregnant women are being maintained on buprenorphine It's also recommended that if the woman chooses to be maintained on buprenorphine that she be transitioned back to Subutex and not be maintained on Suboxone, but we also know that that is not happening

That if a woman is successfully maintained on Suboxone and wants to stay on it, that most of the time she continued to be maintained on that during her pregnancy In terms of induction, the issue for buprenorphine is dependence on short-acting opioids or long-acting opioids If you're talking about someone using heroin or OxyContin prescription, Percocet, those are short-acting opioids, so you have to have between 12 and 24 hours between the use of the drug that they're abusing They need to be exhibiting early signs of withdrawal before you give them buprenorphine administration because the buprenorphine will precipitate withdrawal Long-acting medications, such as methadone, it's more difficult to transition from methadone to buprenorphine

You have to taper the dose down to less than 30 mg for at least a week and you have to wait 24 hours from the last dose of methadone before you can administer buprenorphine The patients need to be uncomfortable They need to be in withdrawal so that you don't participate withdrawal It's very difficult to go from methadone to buprenorphine You can go from buprenorphine to methadone right away

You can take a dose of buprenorphine one day and a dose of methadone the next day We just went through this Go ahead Buprenorphine also does not have the same regulatory restrictions as methadone There's no regulatory restriction in terms of how much dose can be given initially and what the first day's dose can be

Typically, the first dose is 2 mg with the initial dose supplemented up to 4 mg Most patients are stabilized on 12 mg to 24 mg per day But like methadone, it also takes a number of days to build up a steady state But buprenorphine does not have the same depressant effects of methadone, so you don't have to be concerned for causing respiratory distress if you provide it too much, too quick I want to talk about neonatal abstinence syndrome very quickly

Because this is, again, what causes so much resistance to the use of treatment during pregnancy When we have abstinence syndrome and maternal drug use, it's usually an opioid abstinence, either from heroin or oxycodone and buprenorphine There are other non-opioid drugs that can cause behaviors consistent with withdrawal, such as benzodiazepine, cocaine, alcohol, methamphetamine But these, the last three are usually do not require treatment We really don't talk about an abstinence syndrome, they just have some symptomatology

This is what we mean by the neonatal abstinence syndrome The top picture shows an infant going through withdrawal That's what neonatal abstinence is The bottom picture shows an infant who is treated, so that any infant whose mother has been using opioids, any infant whose mother has been maintained on methadone or buprenorphine will exhibit some withdrawal symptoms Not all babies will have to be treated

The severity of withdrawal varies for, as I mentioned earlier, a number of reasons Certainly, it's very disconcerting to see an infant going through abstinence, but it is a temporal phenomenon If it's assessed and treating immediately, as you can see, the infant is very comfortable Then you wean the infant gradually There are no data that show any long-term sequelae from infants who have to be treated for abstinence

I just want to take a minute here also to discuss the difference between a baby going through withdrawal, being physically dependent on the drug, and being addicted Oftentimes, in the press on the news stories, you see the term addicted baby used all the time These babies are not addicted Addiction is a psychiatric diagnosis that requires a lot of factors to be present in addition to being dependent on a drug These babies are physically dependent on the drug, because that's what opioids do, the same way that alcohol, you become physically dependent on alcohol

You do not become physically dependent on cocaine But the physical dependence means that when they are born and they are no longer receiving any supply of it through the uterus, they go through withdrawal But they are not addicted We should not use that term We should not refer to them as addicted because that's a very pejorative term

It sets up a whole host of expectations that are not appropriate These are babies that are passively dependent on a drug that has crossed the placenta They can be treated for it if the withdrawal is severe enough Again, our language is very, very important The symptoms that you see are neurological excitability

These babies are very hyperactive They're irritable They have difficulty sleeping They have difficulty eating They do, as I say, if the withdrawal is severe enough, then they're treated with an opioid that they're gradually tapered off of

The majority of the infants exposed to opioids undergo withdrawal But, as I said, they don't all need to be treated The issue of severity and the need for pharmacological intervention is another issue People tend to get very upset about infants having to be treated Again, it comes back to the risk-benefit

If a baby is born to a mother who uses heroin who has not been maintained on methadone, that baby may have a very short abstinence, may not have to be treated But that baby has, in all probability will be born very early in gestation and will have a number of problems associated with the morbidity of withdrawal in the uterus Again, it's a risk-benefit Would you rather have a full-term, healthy newborn who has no other problems other than that's going to have dependence that has to be treated with a medication that can be done very successfully with no sequelae from that, or a baby that's born very premature with all of the problems concomitant with prematurity Again, those are the risks and benefits that have to be balanced

I want to talk very briefly about the MOTHER study, because that's something that has made the news This was a study that was conducted at eight sites throughout, six in the United States and one in Vienna, one in Canada where we were evaluating the possible differential impact of buprenorphine and methadone Because we know that the withdrawal syndrome with methadone is much more severe than with heroin Buprenorphine causes much less withdrawal in adults, so we're assuming that it would cause less withdrawal in infants That's what this study was designed to evaluate

It's a randomized clinical trial It's a very complex, rigorous study It was published in December in the "New England Journal of Medicine" We certainly don't have time to go through the study, so I'm just going to give you the take-home message of what the findings were We didn't find any difference in the number of infants that had to be treated whose withdrawal was severe enough for treatment between methadone and buprenorphine

Just as many buprenorphine babies had to be treated as methadone babies did But among those infants that had to be treated, there was significant difference in the course of their abstinence They required 89 percent less morphine to treat NAS They spent 43 percent less time in the hospital, and they spent 58 less time in the hospital being medicated for NAS Both medications, be it buprenorphine or methadone, in the context of comprehensive care for the mother, produced similar maternal treatment and delivery outcomes

The biggest impact was on NAS I also need to just highlight for you that even though this was an extremely important study and has received a lot of attention, it was designed to rigorously evaluate the effect of buprenorphine and methadone on NAS There are a lot of unanswered questions One of them importantly is what is the best induction procedure for pregnant women onto buprenorphine? This study did not answer that In fact, it raised some questions about it

We also used Subutex, so we don't have any data on the safety and efficacy of Suboxone exposure during pregnancy Again, very importantly, this was a very rigorous trial so that these infants' mothers did not use alcohol, they didn't use benzodiazepines, and these are two drugs that have a very significant impact on NAS and the management of NAS so that we don't know what's going to happen if these differences with buprenorphine are going to be maintained when it's confounded with alcohol and benzodiazepine exposure Now, let's go to illicit drug and prescription misuse, talk about that briefly Cathleen: Karol, this is Cathleen Real quick, before you move onto that, we had a question that came in about, what about the impact of cigarette smoking on methadone and or buprenorphine dose? Dr

Kaltenbach: Cigarette smoking impacts NAS Whether the mother is being maintained on methadone or buprenorphine, that doesn't matter But cigarette smoking does impact on not whether the infant will have to be treated for NAS, but it does impact on the length of treatment Cathleen: We also had another question that just came in Why would a pregnant woman be prescribed Subutex versus Suboxone? Is one better than the other for pregnant patients? Dr

Kaltenbach: Subutex and Suboxone are exactly the same in terms of buprenorphine But Suboxone has naloxone added to it in order to control for diversion The naloxone has no effect at all when it's taken sublingually, so it becomes like a placebo part of the drug, except if they try to abuse it by crushing it up and injecting it In terms of the medication, there's no difference in the buprenorphine The reason that we use Subutex and the reason that Subutex is recommended for pregnant women is because there are no data on the effect of naloxone on the fetus

That's the reason for the guidelines that recommend that pregnant women be maintained on Subutex It's just a conservative approach, since we have no data on naloxone in fetal development Cathleen: Thank you, Karol Dr Kaltenbach: What's also important to remember is that methadone or buprenorphine has no direct pharmacological effect on non-opioids

If you have a woman in treatment who's abusing alcohol, who's abusing cocaine, the fact that she's being maintained on methadone or buprenorphine is not going to impact her use of those drugs It has to be treated as clinically a separate problem That's why it's so important that you have comprehensive treatment services that can clinically address the use of other medication As I mentioned earlier, benzodiazepine misuse is the most difficult problem of all It's very difficult to control, and it does have a significant impact on the length of treatment for NAS, for both methadone and buprenorphine

Well, at least methadone we have the data for We don't have the data for buprenorphine, but we assume that it's also going to have an impact of the length of stay for buprenorphine It's a very difficult problem to treat because, as we'll talk about now, women have a high prevalence of anxiety disorders and they've been prescribed benzodiazepines for a long period of time, and then has come to abuse them I want to quickly also talk about co-occurring psychiatric disorders, because this is something that's extremely prevalent in this population The prevalence of depression is very, very high

For non-abusing pregnant women it's reported between 9 and 16 percent, but for women with substance use disorders, it's between 40 to 70 percent, so it's an extremely high co-occurring morbidity in this population We do have some data on that The center for substance abuse treatment funded 50 programs in the mid-1990s They were residential treatment programs for women and children, and they were pregnant and post-partum programs, and they published their evaluation results They had over 5,000 women who received services in this initiative, and 50 percent of them had mental health disorders

Again, it's extremely high There's another publication that I just referenced for you that was published in 2007 that looked at 106 opioid-dependent pregnant women, and 37 percent had a primary mood disorder, and of those a high percentage of them also had an anxiety disorder Conversely, 36 percent had a primary anxiety disorder, and of those, they also had a concomitant mood disorder This is something that's extremely present, and it raises the question about what to do with treatment Because SSRIs, which are selective serotonin reuptake inhibitors, that's the most widely-prescribed antidepressant medication in the country

But in recent years, there have been reports describing neonatal complications associated with SSRIs, especially cardiac malformations In 2004, the US FDA required warnings on these perinatal complications Physicians were advised to taper their dose during the last trimester so that the fetus was not exposed to it at least 7 to 10 days before delivery That's raised some concerns There are also concerns that it may cause a type of abstinence syndrome

It's been referred to as a poor neonatal adaptation rather than an abstinence syndrome, but it has a lot of the same symptoms as neonatal abstinence syndrome There's been some concern about that, whether SSRIs cause a withdrawal or just a serotonin toxicity We need to make sure that we don't confuse them We need to not confuse what may be SSRI symptoms with NAS symptoms We need to remember that the number of data is quite small

The number of studies is small The occurrence of any kind of an abstinence syndrome is no higher than 30 percent Paxil and Prozac are the SSRIs most commonly reported with these abstinence-type syndromes It may be related to the pharmacology, or it may be the fact that they are the most widely used Also, I just want to mention that in response to the FDA call, there also was an article, a study that was conducted and was published in the "New England Journal of Medicine" in 2007

They looked at and found that paroxetine, Paxil, and Zoloft had the most common associations with any kind of congenital anomalies They weren't looking at an abstinence syndrome, but they were looking at the incidence of congenital heart anomalies and some bowel anomalies, some abdominal wall defects They found that most were associated with these two medications, but even then the association was extremely rare Again, you have to look at the risk of untreated disease with the benefit of avoiding a rare complication We know that untreated depression is extremely risky

You have suicidal ideation, you have hypertension, you have a lot of prenatal problems with low birth weight, pre-term birth, spontaneous abortion, these are all associated with untreated depression So you have to make, again, a value judgment of do you want to have the risk of all of these problems, or do you want to treat the woman knowing that you may have a very small risk of a problem associated with the medication Again, it comes back to looking at a risk-benefit model In terms of breastfeeding, and this is a question that always comes up Can mothers who are maintained on methadone or maintained on Buprenorphine, may they breastfeed? Opioid-maintained mothers can breastfeed if they are not HIV positive, if they are not using illicit drugs, and if they do not have a disease or infection in which breastfeeding is contra-indicated

This is for both methadone and buprenorphine medication We have a history of recommendations regarding methadone for a long time the American Academy of Pediatrics supported it, but recommended that women be on no more than 20 mg of methadone, which was an absurd recommendation, because that's not a therapeutic dose In 2001, they eliminated the dose restriction on methadone making methadone maintenance compatible with breastfeeding regardless of dose The publications that we have that have looked at the amount of methadone in breast milk, they don't find any relationship with higher doses We have limited evidence with buprenorphine, but the evidence indicates that only small amounts of buprenorphine pass into breast milk, so the consensus panels that looked both at medication-assisted treatment and looked specifically at buprenorphine, both of them recommended that mothers that are maintained on buprenorphine can breastfeed

In terms of medication-assisted treatment, it's the most effective when it's provided in appropriate doses Going back to one of the initial issues that we started with, dose should never be controlled or minimized to avoid NAS or because of protective custody issues, or placement of the child This is a medication, and the mother needs to be provided with what would be a therapeutic dose It needs to be provided in the context of prenatal care Treatment for pregnant women who are receiving medication-assisted treatment has been shown to be extremely effective in reducing both prenatal and neonatal problems and having positive outcomes for babies

But it has to be done within the context of comprehensive care You have to be providing prenatal care It's not the medication that is doing it all Obviously, it's helping because the fetus is not subjected to stress of withdrawal, but it's not sufficient It's necessary but not sufficient

You have to have comprehensive care where you're able to provide prenatal care, you're able to improve nutrition, you're able to stabilize the woman's home environment, you're able to get her into treatment where she can begin a road to recover from her substance use disorder That's when it's provided as a woman-centered treatment That does not mean it has to be a specialty program for women only, but it means that the treatment has to be women-centered It has to focus on the needs of women, understand their needs, and understand all of the complexities that they bring to treatment I guess the take-home message is medication-assisted treatment has to be evaluated within a risk-benefit model

Even when you do that, it needs to take into account what is best for both the mother and child I'll use the example of the findings from the MOTHER study There's a lot of emphasis now on the fact that if the mother is maintained on buprenorphine that the NAS for the baby may be much, much less, which is certainly an extremely positive thing If you have a mother that can be effectively managed on either methadone or buprenorphine, buprenorphine would certainly be the medication of choice However, buprenorphine is not appropriate and not effective for all women

It doesn't make any clinical sense to mandate that a woman be on buprenorphine when she's pregnant if that's not going to be the effective medication for her We need to understand that there's a group of women that are going to require methadone in order to be effectively treated during pregnancy We also need treatment programs that have to better understand the complex needs of opioid dependent women and employ models of care that address their multiple issues because this is a very complex population We haven't had time to talk about all of the issues that they bring to treatment, all of their bio, psychosocial histories Just looking at their psychiatric comorbidities, you know that this is a very vulnerable population

We also have a population of women that have a high history of physical and sexual abuse, of having intimate partner violence history, and so they need a lot of support and a lot of services if they're going to be able to effectively engage in recovery I think that's the end of what I want to talk about I guess the next step is to go to Cathleen, or are we going to take some more questions now? Cathleen: OK, one question What is neonatal serum? Dr Kaltenbach: Pardon me? Cathleen: Neonatal serum

Dr Kaltenbach: I don't know I've never heard that term You take serum blood levels to see the amount of medication, a drug, in the blood system There's tincture of opium which is a medication used to treat neonatal abstinence, but I've never heard of the term neonatal serum

Cathleen: OK, for that individual who submitted that question, if you have any additional context or explanation that you would like Dr Kaltenbach to address, please feel free to submit an additional question set The next question that came in is, "Should babies exposed to SSRIs in utero be scored using the Finnegan NAS tool? Dr Kaltenbach: No It wasn't designed to score SSRIs, and a lot of the symptoms of SSRIs are the reverse of the opioid abstinence symptoms

SSRIs, it's been pretty much agreed that they don't go through withdrawal That you see some of these behaviors that are similar to some symptoms in withdrawal, but it's not really a withdrawal It doesn't need a treatment For an infant that has not been exposed to opioids but is having some of these behaviors because the mother has been on SSRIs, the infant is usually not going to be treated for that, so it wouldn't need to be scored for that But it's certainly important to observe those behaviors and be able to determine that they're probably related to the SSRI exposure and not so some other disease condition

For instance, that mothers are maintained on either buprenorphine or methadone and who are also taking SSRIs That's important for the treatment staff at the hospital to know, because it may well in fact influence the length of NAS treatment Cathleen: Great, thank you We have a couple more questions Next question is, "What is your advice for mothers who are smoking marijuana and want to breastfeed?" Dr

Kaltenbach: That they shouldn't breastfeed The recommendation that has always been out there is that any use of illicit substances, and marijuana is an illicit substance I don't know of anybody who recommends the use of breastfeeding if the mother continues to use illicit substances In the same manner, if a woman is maintained on methadone but continues to use some cocaine or continues to use heroin, she would not be permitted to breastfeed Cathleen: Thank you

Next question "Can a breastfeeding mom take Suboxone? Does the naloxone [indecipherable 1:05:52] the breast milk?" Dr Kaltenbach: I can't answer that definitively I can just tell you what the recommendations are that women can breastfeed if they're taking buprenorphine, if they meet those criteria that they're not using any other illegal drugs and have HIV If they meet those criteria

The problem is the recommendation is that if women are to be maintained on buprenorphine, that they take Subutex That being said, we know that a lot of women are maintained on Suboxone, which contains the naloxone The issue with naloxone when it's taking sublingually is that very little of it gets into the bloodstream There shouldn't be much, if any, in the breast milk, but we don't have any data on that I don't know of any data that's looked at Suboxone

As I said, we only have a few studies, and that's looked at pure buprenorphine, Subutex, in breast milk But theoretically there shouldn't be much if any naloxone in the breast milk That's the same question that comes up Sometimes physicians will say, "Well, why isn't it all right for pregnant woman to take Suboxone?" Because if they're taking Suboxone, very little of the naloxone gets into the bloodstream That's why they're able to take it

The answer is yes, very, very little gets into the bloodstream, but we don't know how much gets into the bloodstream Again, because we don't have any studies on fetal development in naloxone, it's recommended that the safer course is to take Subutex To breastfeed and take Suboxone is just going to be, again, a personal decision There aren't any recommendations on it Cathleen: Thank you

Next question "What do you mean by there are some women who are methadone who should not be on buprenorphine? What would disqualify a mother to switch to buprenorphine?" Dr Kaltenbach: There's nothing that would disqualify her, but buprenorphine may not be the most effective medication for her Buprenorphine is a mixed agonist, whereas methadone is a full mu agonist Methadone does not have a threshold

If 80 mg doesn't work, you can increase it to 90 mg If 90 mg doesn't work, you can increase it to 100 mg Buprenorphine is a partial agonist, so it doesn't have the same properties, and it has a threshold effect Meaning that when you get to, right now the cutoff is 32m g, although there are some people that will say it really should be 22 mg to 24 mg where you've reach a ceiling effect Where no matter how much you increase the dose, you're not going to get any more effect from the medication

So, even though we don't have a lot of data on it, the assumption is that people that have very long-term chronic histories of opioid dependence require very high doses of methadone Say they require 200 mg a day to be effectively maintained That the buprenorphine medication is not going to be effective, because 32 mg of buprenorphine is roughly equivalent to 140 mg of methadone Cathleen: Next question "Can you talk for a minute about what treatment programs should do if they have a pregnant woman on medication-assisted treatment before she delivers so that the baby isn't removed by child welfare upon delivery?" Dr

Kaltenbach: Thank you, I think that's a very, very important question There's a lot that she can do There's a lot that the hospital can do Part of it depends on the history of the program and how much experience they have with pregnant women I'll use our program as an example not to tout our program, but just to identify it as a model

Because we specialize in the treatment of pregnant, opioid-dependent women, so we're well-known in the city The hospital at Jefferson is known as the place to go if you're opioid-dependent and pregnant As that's the case, we also have a very strong relationship with the Department of Human Services in town They know that if a woman is receiving treatment at our program, that she's receiving extensive treatment She's just not going in and getting a medication and not much else

We have a working relationship with them We also work very hard, and, of course, we obviously have a relationship with the hospital so that our nurse coordinator is involved in all of the deliveries and in the treatment of the neonates in the hospital What we do with the women is that we give them a lot of support and help them understand what neonatal abstinence is They feel very guilty that their child is going to go through withdrawal We try to educate them about what the symptoms are, what to expect

We show them the scoring tool that's used to determine whether the baby will be treated or not so that they understand, so that they do not think it's capricious judgment on the part of the nurse or a physician We talk about what's going to happen if the baby has to be treated and how she's probably going to be discharged ahead of the baby The baby will have to stay in the hospital We talk about how important it is for her to come in and visit the baby We help educate about the behavior that's expected in the hospital if her baby is being treated

We talk about the symptoms and especially sleep, how hard it is when the baby is first being treated to establish a normal sleeping pattern She doesn't want to go in to see the baby and think, "Oh, I'm here I'm going to wake my baby up and hold him" That's extremely disruptive and harmful for her baby We try to educate her on all the things to expect and understand and familiarize her with the hospital where her baby is going to be, help her to understand that even though her baby is going to go through withdrawal that the baby will be treated and will be comfortable

Again, we help her to understand that there's no relationship between what her dose is and whether her baby is going to have to be treated or not and also especially help her to understand that she is moving forward She's coming to treatment What she has been doing and is doing is for the healthy outcome of her baby We try to put it in a positive frame so that she sees how important and how positive steps she's been taking are rather than feeling guilty and upset about what's going on Cathleen: Thank you

One last question before we move towards wrap-up It's sort of related "How do we consider relapse in medication-assisted treatment when child welfare has to maintain the ASFA timeline, the ASFA timeline being 12 months to a permanent plan or 6 months in the case of very young children" Dr Kaltenbach: Relapse is an important issue

I think the issue is that women often come into treatment when they're pregnant They're actively using You get them into treatment They're not necessarily going to stop using overnight It may take them a while to get on an appropriate dose

It may take them a while to eliminate their active drug use Where that is in her pregnancy depends on when she comes into treatment during her pregnancy Certainly, if she's still actively using at the time of delivery, Child Protective Services are involved It may be that she's made enough progress in treatment that she can still maintain custody even though there's an open file As long as progress goes forward, there's an endpoint

If she's not engaged in treatment and not making progress in treatment, then the relapse is going to be an issue, and she's going to be at risk for losing her child I think most child welfare departments who are in areas that have very active treatment programs for pregnant women have worked out a relationship where they understand the issues a lot better, understand what the treatment program is trying to, and have worked out a supportive, mutual relationship where they each can attend to what their mission is in a productive way They're not necessarily at odds with each other Cathleen: Thank you, Dr Kaltenbach

Your information has been valuable and critical The number of questions and comments that we've gotten throughout the course of this session, I think, reflects the amount of interest and need for this kind of information I'm going to go ahead and move into the next part of our session and do a quick review of some considerations for child welfare policy and practice In thinking about considerations for child welfare policy and practice, I want to take a step back and look at the needs of infants exposed to methadone, buprenorphine, or any substance in the context of any infant exposed to substances, whether illegal, illicit, or legal like alcohol, tobacco, or prescription drugs and to look at that in the context of the Child Abuse Prevention and Treatment Act The 2003 amendments, for those of you who may be familiar with the CAPTA amendments, provided that any infant born and identified as affected by illegal substances or withdrawal symptoms resulting from prenatal drug exposure, the CAPTA amendments indicated that these infants should be reported to Child Protective Services but that this is not intended to be a definition of child abuse or neglect or to use that report for any sort of illegal action

It was left to the child welfare agencies to develop a plan of safe care for these infants Then recently in the 2010 reauthorization of CAPTA they added addressing the needs of infants born with and identified as being affected by fetal alcohol spectrum disorders including the appropriate referral to child protective services systems for other appropriate services as well The states who receive CAPTA funding are required to provide assurances that those identification and reporting processes are in place In considering overall child welfare policy and practice with respect to infants born exposed to methadone or any other medication through medication-assisted treatments of the mother, we want to put these in the context of any infant who is exposed to substances and look at the overall child welfare policy and practice in responding to infants in general It's not necessarily looking at one particular substance or pulling out one particular substance but looking at the overall screening assessment and referral to service process that occurs in the child welfare agency and in connecting infants and their families to needed services

Part of that policy and procedure includes looking at the multiple stakeholders that are involved Obviously, if you have a woman who is on medication-assisted treatment, then coordinating with the substance abuse treatment providers and, if she's involved with the courts, to coordinate with the courts is essential I think, Karol, you indicated in some of your comments in response to the questions about ensuring that the child welfare agency is involved so that way there's some communication that happens back and forth about the woman's status in her treatment program, the type of medications and treatment that she's receiving, and the communication that needs to happen between the treatment provider and the child welfare system to make sure that, if at all possible, the family can remain intact and that she can be supported through her treatment program along with her child and being supported through the child welfare system as well That relates to identifying what kind of information needs to be released between those agencies There is, obviously, the need for communication to go back and forth between agencies

The more specific you can be about what kind of information is intended to be released between agencies and how and when that information needs to go to ensure that agencies and parents are aware of what information is being shared so that the providers, the child welfare agency, and potentially the courts are all mutually informed of, again, the status of the woman in her treatment, the mediations that she's receiving, and how that's impacting the safety of her child It's not necessarily about the one particular type of medication that she's receiving but, again, about the overall safety of the child and looking at the safety of the child in the context of the overall family, not just with respect to any one particular substance or medication This also goes to looking at role clarification, again, in terms of identifying the kind of information that needs to be shared between the child welfare agency, the substance abuse treatment providers, and the courts, identifying what sort of role each plays in supporting the infant, in identifying needed services, and making referrals for services for both the infant and the family Then, obviously, the more clarification that can be provided in written policies and guidelines for clients and staff is important We have a publication that's available through the National Center on Substance Abuse and Child Welfare, "Substance-Exposed Infants, State Responses to the Problem" where we provide an overview of nine states and their programs that are in place to address the needs of substance-exposed infants and their families

This monograph lays out a framework for identifying the needs of substance-exposed infants across a variety of time frames from both pre-pregnancy to the prenatal period to the time of birth, immediately following birth for infants and toddlers, and then later in life as school-age children and adolescents Again, the overall message that we convey through this document and in our others about substance exposure during pregnancy is that during the pregnancy period as well as for infants and toddlers, screening is not a one-time event It's an ongoing process for screening infants and children for their developmental and other needs that may be related to their exposure to substances It's an ongoing process for identifying and referring them and their families for services Another resource that's available to you is through the Guttmacher Institute, "State Policies in Brief Substance Abuse During Pregnancy

" The Guttmacher Institute provides an overview of state statutes in response to use during pregnancy and the kinds of laws that are in place in a variety of states If you look at the Guttmacher Institute, you can take a look at your own individual state and find out some of the laws in place regarding prenatal substance abuse in your state In wrapping up for today, ending right on time, as you close out of your webinar session, you will be prompted to complete an evaluation That evaluation is a very brief eight questions just to give us some feedback We welcome your feedback, and we certainly use it to enhance the programming that we provide on these webinar sessions

In summary, I just want to thank everyone for the time today I hope that you found this presentation informative and useful Again, I want to sincerely thank Dr Kaltenbach for her time and effort in putting this presentation together and for spending the time with us today Thank you, again, Dr

Kaltenbach Dr Kaltenbach: Can I just make a statement about the disclosure of information, the communication that you were talking about? Cathleen: Absolutely Dr Kaltenbach: It's important to understand that although both systems should and need to collaborate and communicate, it needs to be understood that treatment programs are extremely restricted as to what information can be released under the federal regulations of Drug Treatment Confidentiality Act

That often is misunderstood by child welfare agencies because, obviously, we all want the same thing Treatment programs are not permitted to provide any disclosure of information without the client's consent and are extremely limited as to what information they can disclose That needs to be understood and respected Obviously, there are ways that you can sort of convey information without disclosing information, but you can't just call up a treatment program and say, "We have your patient and we're making a determination as to whether we should take her child or if she should be reunified We need to have X, Y, and Z information regarding her drug use and her history

It can't be given Cathleen: Thank you I think that point is what leads to quite a bit of frustration and miscommunication between child welfare and treatment providers in attempting to gather the kind of information that's needed to make appropriate determinations about the permanency of a child while at the same time protecting the rights and confidentiality of the parent that's in the treatment program This points to the need on the agency level for there to be a very in-depth conversation that needs to happen between the child welfare agencies and the treatment providers about what kind of information is to be shared, how that information will be shared, and how the appropriate releases of information will be ensured so that, again, the child welfare agency has the information they need to be able to make appropriate determinations and, at the same time, protecting the confidentiality of the parent in their treatment program Those kinds of conversations are long, in-depth, and difficult, but that's on the ultimate end goal of improving outcomes for children and families and keeping families intact

Those conversations need to happen in order to be able to identify what they as a collaborative can do for a family Dr Kaltenbach: Absolutely Cathleen: Again, thank you all for your time today I think we have another question that came in about getting a copy of the PowerPoints and handouts

Those are available on the Children and Family Future's website that is provided in your packet in the PowerPoint slide Again, you can feel free to contact any of us or visit our national center website for additional information We look forward to hearing from you Thank you all again for participating Fill out the evaluation as you log off today

Thank you Have a good day Bye-bye

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