Prenatal Exposure to Prescription Painkillers: Finding Solutions & Reducing Impact – Part 3

David Mineta: Great, thank you very much, Cece, and it's — I want to echo what the Director said earlier and thank everyone for being here, particularly after lunch right now, and I'm glad to be the moderator right after lunch (laughter) I want to just again specifically thank all of you who are here today, but also thank everyone who is watching and, you know, is a leader in this effort, and is going to be an integral partner as we move forward

There are many, many folks around the country: Researchers, community members, stakeholders, treatment folks, prevention folks, recovery support folks, families, who are very interested and are I think stand at the ready to help This afternoon we have two panels The first is going to be charged with discussing prevention, a topic that is near and dear to my heart And I'd like to first introduce the three speakers, and a little bit about what they're going to say, not to take any of their thunder, though First up is Sharon Amatetti from the Substance Abuse Mental Health Services Administration, SAMHSA, and Sharon is the woman's issue coordinator

And she will discuss the State responses to the problem Next will be Ralph Orr, from Virginia, who runs the State Prescription Monitoring Program And finally, we will have Dr Kimberly Kirby from the Treatment Research Institute, and Dr Kirby will discuss the Community Reinforcement and Family Training, or CRAFT, as a potential strategy for maternal addiction

I remind the speakers that we have, we're trying to, Cece's got us on a very, very tight schedule (laughter) And I just want folks to be reminded of that after lunch Anyway, first up I'd love to invite Sharon up and to talk about the State responses Hey, great seeing you again Sharon Amatetti: Yeah, likewise, thank you

Good afternoon, everybody Welcome back from lunch, and there was a lot of interesting conversations at lunch about what we heard this morning So I'm happy to continue this conversation I have been working on this issue on and off for much of my career Really, I think I've been thinking about it for all of my professional career

I remember that when I was a graduate student at UC Berkeley about 25 years ago, there was a woman who was walking up and down Shattuck Avenue there, and she was in the late stages of her pregnancy, very disoriented, clearly in need of assistance, and clearly under the influence And I remember how troubling that was to me, and I didn't know what to do I saw her on more than one day, and I was asking my classmates, I asked one of my professors, have you seen this woman, you know, what should we do? And nobody really knew what to do I think somebody suggested, well, you should call the police And that didn't feel right, to call the police, because I didn't know what would happen to her

And so I never did anything I never called anyone, I just worried about her, and I still think of her from time to time And I suspect that nothing very good happened to her and her child And you know, I sometimes wonder what would I do today if I saw that woman? What would happen if the police did pick her up? Would the response be different 25 years later? I don't know But, so, that's just by way of saying that I — this has been something that has, you know, been on my mind for quite some time, and fortunately I've the type of career that has enabled me to have some professional input on this issue

So I was asked if I would be willing to talk about a publication that we have developed through our National Center on Substance Abuse and Child Welfare The National Center is, well, it's one of those specialty type of boutique type of shops that Director Kerlikowske was talking about A center for excellence type of thing that's devoted to breaking down silos So here we have a silo trying to break down silos But it's really about working across child welfare substance abuse in the courts to help facilitate collaboration so that those agencies and organizations have a more comprehensive and well-thought-out response to families who are involved in child welfare because of parental substance use issues

And I just want to acknowledge my colleague Elaine Stedt from the Children's Bureau at the Administration for Children and Families who is my codirector for that center, and we fund it together and have done some, I think, good work together So we commissioned our National Center to develop this report And the report, what we asked them to do is to try to get a sense of what States are doing around substance-exposed infants on a policy level And so they looked at ten states in an in-depth kind of way, and what we had them do was really have a conversation with those State agency folks who had a hand in what they were doing around policy and intervention for this issue And then also looked more broadly to some other States as well to try and get a better handle about what we were learning and what we were seeing

So in order to even begin to do the study, we realized we needed to have some kind of framework to understand what it was we're asking about I mean, one of the things that people were saying at lunch is how this is such a nuanced issue, there's so many pieces to it, and once you think you've got a handle on one piece it raises another issue So we wanted to develop a framework for understanding what we were looking at when we were talking to these States And we realized that it really is much more than the birth event And I think all of you in this room know that it's much more than the birth event

So we wanted to say, well, what are the main points of intervention? And so we framed it around five main intervention points And they really are the whole pre-pregnancy period, then the prenatal screening and support for the mother, then what happens at the birth experience And then what happens to the children afterwards, the services for infants, and then the services to parents So what happens with the family So that's how we framed this

It wasn't just one point in time, it wasn't just one issue, we tried to look in a more public health sort of way So another way for you to look at this and think about it is how this impacts the mother, the child, and the family through those different points of intervention And so you'll see that there's the pre-pregnancy awareness thing, experience going on; then there's the prenatal screening; and if a woman does screen positive for substance use, then we initiate some services there Now if she doesn't get screened for whatever reason or if she doesn't screen positive, then we go on to the birth experience And at the hospital, something might be revealed that was not otherwise known

And at that point, then you would begin some services for the parent and for the child Okay? And then for the families And throughout a trajectory of the child's, you know, early life there would be some types of services that we think about beginning or connecting the family to So this was, this was our organizing framework And just to show you about the importance, you know, of beginning before, before the birth experience, really, is the fact that we know through our national survey on drug use and health that the first trimester is when the greatest amount of exposure to children occurs for, you know, during pregnancy

So that first trimester, often when women or sometimes when women don't even know that they're pregnant is a very high-risk time So, and you know, I don't need to share, really, the details of these statistics with you Somebody else talked about it earlier, what sort of it looks like But that, of course, is the time when most women who are using are using And pregnancy is a very motivating period for women to discontinue using

So it's an opportunity, if not for herself, then she will discontinue because she is concerned about the well-being of her child And, you know, somebody talked earlier about the fact that most women and men who need treatment, who would be classified as needing treatment don't feel that they need treatment And that we know is true, because addiction is a disease of denial People often think that they can handle it, it's not that serious, you know, it's not the level of concern where they don't think they need treatment, even though it would be otherwise indicated So during pregnancy, a woman might think, well, I don't really need treatment for myself or for my own substance use, but this is something I know that would be healthy for my child

So it is a wonderful opportunity in that way, in terms of intervening and getting the attention of the mother So given the framework that I talked about, I think it's pretty clear that this issue doesn't belong to any one agency because it's a comprehensive issue, it requires comprehensive services It has to do with prevention and intervention and treatment, and at different developmental stages of the life of the child and then the family So one of the conclusions we certainly can come to is that no single agency can deliver all of these services And I think that depending on where you sit professionally, different types of agencies and organizations come to mind about who are the players

You know, some of the partners that we thought were important were, of course, hospitals and fairly qualified health centers, physicians, health care management plans, public health agencies, maternal and child health, children and adult mental health, child welfare, drug and alcohol prevention, treatment and aftercare, schools and special ed for the children, family dependency courts, child care and development agencies, family support agencies, and the list can go on And I know that you're thinking, oh, she didn't mention so-and-so That's exactly right I mean, there's a lot of other important partners who have a stake and a role in this issue So we did this inquiry with these States, as I mentioned, and we wanted to know what the States were doing

So all of the States have perinatal councils or some kind of coordinating body to address substance-exposed infant issues Sometimes they are through the IDEA interagency councils, women's treatment interagency councils, early childhood coordinating councils, and that sort of coordinating type body Several of the States have actually created working groups focusing on fetal alcohol spectrum disorders issues None of the States had an interagency process to monitor data and the effectiveness or outcomes on what they were doing across their efforts, and none of the States had developed policy at each of the five points of the intervention for mothers and infants and children Some of them were doing some pieces of it very well, and some others, but nobody really doing all of it very comprehensively

In terms of what they were doing at those different points, and again, none of the States were doing all of this, but this is the type of things that they were doing For pre-pregnancy they were doing things like working to provide health warnings about substance use during pregnancy, they were providing educational materials or doing campaigns, that sort of thing During the perinatal period there was an emphasis on screening, and some of the states using the four P's screening instrument There was move in some places to do universal screening Everybody's going to be screened, that way there's no bias

Brief interventions, of course, were part of the mix, as well as referrals to treatment At the point of the birth, they had to make decisions about what they were going to do, whether they were going to do — whether there was going to be — what kind of testing, if any, the hospitals were going to be encouraged to implement or be required to implement What they were going to do with the reporting of that And the reporting for services And we talked a little bit this morning about CAPTA, the Child Abuse Prevention Treatment Act, and the requirements of that Act

Some of you probably know that initially, when that Act was — the amendment was passed, there was a requirement around illegal substance use, is the way it was phrased And there was a lot of pushback after that because people thought, well, why are you just looking at illegal substances? What about alcohol, which we know has such a devastating effect and it was silent on alcohol So in 2010 that actually was added I think Lynn Paltrow mentioned that there wasn't a lot of discussion really about the language in that act, and I think that States have struggled to interpret that, and that struggle is still part of ongoing dialogue But the intention of the legislators who put this language in was really to trigger a helpful referral to services, and services attached to the IDEA services which are Individuals with Disability Education Act that provides referrals and services for children who have been neonatally exposed

And I see the red light going off, thank you I didn't know where that light was going to be So the intention was that it would be helpful Now, you know, sometimes intentions don't play out the way that you hope they're going to, but that was the intention So let me finish up here

We thought about how States could assess what they're currently doing, and they really, we suggested that they look at all the different five points of intervention, that they review the results in each of the areas to see how they're doing, to look for what's missing, what are we not asking, what are we not measuring, and really, you know, approach it that way And then just some important policy questions You know, can pregnancy screening, like using the 4 P's, be the trigger for upstream services and referrals to treatment? And we also talked about, this morning about Medicaid covering so many of the births, so is that a better — is there opportunities there that we're missing in terms of recommended policy And then also can the mandated substance-exposed birth reports to CPS be a trigger for the downstream flow of services to the child, children and parents which we talked about, and although CAPTA doesn't really talk about services to parents, we know that treatment is very often indicated So I want to thank you very much

This is my contact information, and also the contact information for our National Center on Substance Abuse and Child Welfare (applause) David Mineta: Well, thank you very much, Sharon, and it was great to hear our Berkeley connection Go Bears! Thank you, Sharon We were walking those same streets Up next I'd like to call up Ralph Orr from Virginia, who leads the State Prescription Monitoring Program

Ralph And just so you know, for speakers, the light is stage right, so it is over there Yeah, towards — yeah Thanks Ralph Orr: All right, well, good afternoon, and thank you for the kind invitation to come speak about prescription monitoring programs

We do call our program a resource for patient management We started out talking about a resource for patient management for pain with controlled substances, and we discovered, we were told very quickly that we don't only have issues with controlled substances when they're being used for pain, but we also have other issues such as for benzodiazepine as stimulants and all these other types of controlled substance issues, and they all get thrown in together So we changed our tune a little bit on that, based on that So basically, I want to really go in, basically a prescription monitoring program is a huge database Prescriptions are reported to the database, and then the information is made available to authorized users so that they can utilize that information

Our primary purpose is to promote the appropriate use of controlled substances for legitimate medical purposes, okay We want to try and prevent misuse, abuse, and diversion, okay So we're not out, the purpose of the PMP is not to prevent people from getting prescriptions, we don't want to decrease the number of prescriptions, we're not out to target patients, doctors or pharmacies, okay We're out there to promote appropriate use Okay? So, our next one

So what kind of drugs are reported? Now, every — I will say that there are 49 States with PMP legislation, 43 of those States are currently implemented, and States have different rules and different capabilities, but in Virginia, we collect information on Schedules II, III, and IV Schedule II's are the Oxycontins, the morphine, the Ritalin, those products Schedule III is Lortab, the Vicodin, the testosterone, and the codeine, Tylenol with codeine Schedule IV is your Valiums, your Xanax, Lunesta, and your Ambien Those are the top drugs that we collect

Some states collect Schedule V, which would include nowadays primarily Lyrica is the drug that they're looking for when they collect that The next one is who must report? In Virginia, all of our pharmacies that are licensed by the Board of Pharmacy must report, unless they're covered by an exemption Okay? We also require nonresident pharmacies to report That's like our mail-order pharmacies like Express Scripts or Medco or Anthem, and you would not believe how many nonresident pharmacies there are across the nation that report to our program And the last category is our dispensing physicians

We actually license physicians to dispense These are primarily physicians that work in urgent care centers, and so you go to the urgent care center and you might get a prescription for Vicodin or something like that, as an emergency issue And the other thing that is important to our program is that we now require the reporting of dispensing of those products within seven days of dispensing So we have a pretty, we started out with twice a month, but we've gone to within seven days And that really seems to help a lot of providers that were saying there was too big of a time lag, and if you were, for my SAMHSA friends over there, NASPER, if you were getting a grant from NASPER, one of the things in that grant was this seven days, within seven days of dispensing, trying to standardize some of those aspects of these programs

So, exemptions Exemptions include the dispensing within an appropriately licensed narcotic treatment program Okay? So our opioid treatment programs do not report to the PMP The administration of a covered substance is not reportable, okay The administration or dispensing to an in-patient in a hospital or a nursing home is not reportable, okay

If you have an in-patient hospice program, that's not reportable If it's an outpatient hospice, that's reportable, okay, because those are being filled normally by a pharmacy that's an outpatient type pharmacy And then the other ones are the manufacturer's samples and the indigent patient programs I will tell you in my experience the indigent patient programs normally do not dispense controlled substances They normally, a lot of them give a voucher which they have to take down to the local pharmacy, and then that gets reported to us that way

Okay? All right So very quickly, who can get information for their — who may get the information? Well, prescribers and pharmacists for their patients I do need to explain the prescriber bit a little bit I talked to a group of our community service boards people last Friday, and we had a lot of people there that provide substance abuse counseling and social work type things, and I told them that if they were, if they held a license, certificate or registration from one of our licensing boards at our Department, we hold the Boards of Medicine, Pharmacy, Nursing, et cetera, they're eligible to get registered to use the program as long as a supervising prescriber authorizes them to be their delegate Okay? So that, when I talk about prescribers and pharmacists, I'm really talking about those delegates are included in there

Pharmacists cannot have delegates, though Investigators for licensing boards, if they have an open investigation, and certain law enforcement agents if they have open investigations Patients over the age of 18 may receive or request their own prescription history And just to give you an idea how much that's used, we've processed 15 requests so far this year for patients Okay

This next slide is our home page, and I wanted to point out something here real quick At the very bottom you'll see that there is a — well, maybe you can't see it, but on the handout you can There's a prescription pain management course offering which is available to all our licensees at the Department of Health Professions free of charge, and they can get up to six and a half hours of CME, it's a collaboration between us and the VCU School of Medicine Now, a couple years ago I talked to the Virginia Maternal Mortality Review Team, and one of their things was is that they were looking for in their 2010 report, they wanted us to continue our education, they wanted us to become interoperable with other States, because they were seeing a lot of cross-border traffic, and they also asked us to add a module talking about the use of pain medications or opiate controlled substances with the ladies that are pregnant or the babies, you know, what can we do The problem that we had with that, when I took it back down to my VCU folks who were doing the internal medicine, they didn't really feel that they had the expertise to develop that kind of information

So that's something that could be put on to the to-do list, because we'll certainly add it if somebody wants to try and work on that Okay This is our website, and you can always go to it We have lots of reports; we have lots of statistics, several studies, and all kinds of information Please feel free to take advantage of that

So, if you're a prescriber or a pharmacist and you're not registered, you can click on the "not a registered user," become a user, fill in the information, click the "submit" button, print it out, fax it to me, and we'll get you registered Okay? As simple as that No notary required in Virginia, okay If you are a registered user you can log in with your user name and password, and you'll get something that looks like that And this, I'm showing you the new request screen here, I hope

I can't really see it that well myself, so I apologize for that But in order to make a request on a patient, all you really need to do to submit that request is, one, put in the patient first name, patient last name, date of birth, you know, if you want to change the default date range which is set for one year, you may do so If you want to add an alias, you know, maybe I don't go by Ralph, maybe I go by John, you know, you can put that in, and put in that information, and then down at the bottom you have to certify that you've provided notification in some manner that you are going to utilize the Prescription Monitoring Program You can do that by putting a public sign in your public area, you can provide written material, or you maintain the actual specific consent, okay? Not all States require that, but we do Okay? And then you hit the "submit" button, and generally before you can even turn your eyes away from the screen, you're going to get a report back

And all you do is click on the patient name, and you'll be able to click on the PDF, or if you have to take your eyes away and go to something else you can always come back and you'll click on "view request," and you'll scroll down until you find your patient's name, and you click on that and you'll be able to pull up the report, which looks like that Now, there's some important — every State has slightly different reports, so you do need to look at them very carefully Please read them carefully Generally the basic items that you're going to have on the report are the fill date, the date it was filled The name of the drug and the strength and the form

The quantity The days' supply, okay The Rx number The date written in many cases Some kind of way to tell what the patient is or who the patient is

And remember, each — we do not collect Social Security numbers or driver's licenses The patient IDs that are in the system are generated by the pharmacy systems So that's why you might see five or six different patient IDs on a patient report because they go to different pharmacies Okay? Now if you see 20 or 25 or more patient IDs on your report, that's probably — that's a red flag, okay? Also you'll have an anagram for the prescriber, so you can get the prescriber name and address, and the address is based off of the DEA registration, and you'll also get a number for the pharmacy which tells you what the pharmacy name is, the address, and in most cases the phone number You'll also get whether it's a new prescription or a refill, and the method of payment

So if you see a hydrocodone or Oxycodone paid for by Medicare, and then two days later you see one written by cash, there's a red flag for you Okay? So, use of the report I'm going to just skip over this real quickly because I think I'm out of time, but basically, we do want to make sure that practitioners know that they can talk about this information with other health care providers That's the important thing And we encourage them to put it in their charts

And please be aware that we are interoperable and have been for over a year now So thank you very much, and I look forward to answering any questions later David Mineta: Great (applause) Thank you very much, Ralph And next up I'd like to invite Dr

Kimberly Kirby from the Treatment Research Institute And we will be — with time, we will have questions after Dr Kirby Thank you Dr

Kimberly Kirby: Thank you, David It's really a pleasure to be here today Cece asked me to speak with you today about Community Reinforcement and Family Training, or CRAFT, as a potential intervention strategy to deal with some of the problems that we've been talking about in terms of engaging women in treatment And before I move on, I just want to acknowledge my colleague, Dr Yukiko Washio, who's here today, who has experience in maternal health and has joined me recently, so just recently gotten us interested in these issues

I also want to acknowledge Robert J Meyers Dr Meyers is the person who initially developed the CRAFT approach And finally, I want to acknowledge the National Institute on Drug Abuse, who has supported our Parents Translational Research Center at TRI and most of the work that I'll be presenting today

So, CRAFT basically was developed to help family members deal with a treatment resistant substance using loved one I'm going to briefly describe CRAFT It basically has three goals First, to engage the IP, or the identified patient, the person who's drinking or using drugs, to engage them into treatment Second, to reduce that person's substance use

But third, also to improve the functioning of the family member And I'm going to be referring to the family members as CSO's, Concerned Significant Others In most CRAFT studies they are family members, but it doesn't have to be a family member, so we use that term So you get a sense of CRAFT sessions, generally there's 12 one-hour sessions, they're very problem focused during the session, the family members train in specific skills that they can use to deal with those problems It's a very active session, there's practicing the skills and giving feedback during the session

And also it's active between sessions because family members are told to go home and practice this at home as well CRAFT has many components; I just want to touch on a couple Components 2, the functional analysis; component 4, positive reinforcement; and component 5, allowing natural consequences These form the basic behavioral strategies behind CRAFT, which is to help the family member recognize situations where drug use might occur, to understand what the IP is getting out of the substance use, what's reinforcing them for that, and then to provide reinforcement for the things that the IP is doing well or, you know, at least not — or not destructively And then allowing natural consequences, that's basically training CSO's how to deal with the enabling kinds of behaviors

Most enabling is protecting the person from negative consequences, so we train family members not to do that The other component that I want to talk about is communication training, which is component number 3 Basically family members come in with patterns of nagging, begging, and pleading, which are not effective So we try to give them some communication skills that are more effective And the seventh component is basically when to recognize opportunities for suggesting treatment entry to this person and exactly how to make that suggestion

There have been five randomized trials at CRAFT that I'm aware of; four of them are published, and the last one we're currently writing up What I want you to notice on this slide is that CRAFT has been used to address a wide variety of substances, including opiates And the last line in there shows what CRAFT has generally been compared against And for the most part it's been compared against 12-step approaches such as Al-Anon, and that's a logical comparison, because that's generally what's out there and available to people I'll talk about exceptions as I go along

And I'm going to really blast through these, so I'll let you know what you need to notice in the slide, and if you want to later you can go back and look at your printouts So this was the first study of CRAFT It, I mean, you can see it They're incredible results Eighty-six percent of the individuals that received CRAFT training got their substance using loved one into treatment, and in the 12-Step approach nobody did

Now I mentioned there's three goals of CRAFT The last two goals — the first one was treatment entry; the last two goals are to reduce the substance use; and to improve the CSO functioning And I'm just going to quickly show you that in this study, they actually got significant differences where CRAFT reduced drinking and instances of intoxication But this is the only study that has found these kinds of significant differences Not only in substance use, but also subsequent studies have shown no differences in family member or CSO functioning

This is another study that was done with the family members of alcoholics, and the only point I want to make here is, once again, you see the effective of CRAFT relative to — AFT is Al-Anon Facilitation Training But, you know, people have argued Al-Anon's not a fair comparison because they're not trying to get the person into treatment So in this study, it was also compared to the Johnson Intervention So that would be like the intervention that you may see on the television program where family members get together and try to convince the person to enter treatment, and you can see that CRAFT is doing significantly better than that as well This is another study that we conducted, it was the first one that was applied to the family members of illicit drug users, and again you can see very similar effects of CRAFT relative to Al-Anon

This is another study that was done by Bob Meyers, and again, you can see a difference between CRAFT and an enhanced CRAFT relative to Al-Anon And this is the study that we're currently writing up, and in this study what we did was we again compared CRAFT to Al-Anon Facilitation Training, but we also looked at a shorter version of CRAFT that we called Treatment Entry Training, which is the third bar there It was a four to six session intervention, and you can see that it produced the same treatment entry results as the CRAFT intervention So what I'd like to do is really talk a little bit about how you would apply this to women, you know, pregnant women with substance use issues The studies that have been done so far have not excluded pregnant women, but we've not had a lot coming in

When we recruit for these studies, we ask family members if they're worried about somebody and to come in to treatment It's not easy recruiting these people, so one question would be would you be able to recruit family members to come in and help doing, you know, approaching it this way Many women with serious addiction problems are somewhat isolated from their families So that could be — it currently is a challenge, and it could be a challenge here as well This just shows you the basic characteristics of the Concerned Significant Others that have been in the previous studies, and I think sort of the most relevant features are that the person needs to have frequent contact with the IP, and another critical thing is that they cannot have serious substance use problems themselves

We, a number of years ago, tried an approach where we recruited in women who would mentor other women who are in substance use treatment We call these community anchor persons The recruitment was done through religious communities, and so we recruited well-functioning women that were affiliated with some community and we matched them to a client of the same religious denomination And we asked them to touch base with the women regularly, and encourage them to continue in treatment Now these women were already in treatment, so this is really looking at a retention issue

And we tested it in a residential treatment program, and this is the only slide I want to show you for this one Basically what you see here is that at three and six months, the retention is significantly better in the intervention with the mentors We called this intervention Community Reinforcement Employing Spiritual Teams, or CREST Can you advance me to the next slide? Okay You can go past that, just keep going

All right The next one — okay I've got it, thanks We did another study that was residential treatment, we did another one in intensive outpatient treatment, and in this one we're just showing that when the mentors had contact with the women in the week prior to the next session, they were much more likely to show up at the — the women were much more likely to show up at the session And so then another issue, moving on, is would CRAFT be as effective in increasing treatment engagement as it is with treatment entry

And I think maybe treatment entry for opiate addicted women is probably the critical issue If you can get them in to treatment or get them — yeah, get them in earlier, the better it is But some of the data from our recent trial also suggests that we're seeing increases in treatment retention And finally, the last issue is having these family members, sometimes they're not all that invested in making sure that they, you know, attend all the sessions and do all the work that they need to do So the question we asked is would the four-session strategy work equally well

It would put less demand on the concerned significant others Okay So, basically, that's it I think my main take-home message here is that CRAFT is a very promising, you know, approach for this, but it hasn't explicitly been tested with this population, and so that kind of work is needed Thank you

(applause) David Mineta: Thank you, Dr Kirby We are — I think we're at a point now we're probably so close to break I think we're going to go ahead and take the break now What we'd like to do, though, is we're taking the break five minutes early So my hope is that we start five minutes earlier on the break

So if we could, we are scheduled to come back at 2:20 We have a 15-minute break, so 2:15 we're going to try to get through And again, speakers on the second panel, if you can, make sure we stay to time because we are then going to try to take questions for both panels as we come back Because I think in fairness to this first panel, it's not very long, not very much time that they have to actually present So they did a great job keeping it to that and getting the information out

Please give them a round of applause (applause)

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