Thanks so much for joining early. We'll get started in a little under 10 minutes. Please take this time to introduce yourself in the chat. Please include your name, what county you practice in, and your credentials. Thanks. Hi, Dr, Mark, how are you? Good? How are you doing? Good CMS is going to join at the beginning and give a little bit of their spiel, but then I'll introduce you and give you a Q and it's your time. Okay, I never noticed how messy my desk is until I'm on. Yeah. Hi, everyone, we have just just about 5 minutes before we get started. Thank you for logging on early. Please take this time to introduce yourself in the chat. Please include your name, credentials, what county you practice in or what practice you work for just so we can get a better understanding of who's online with us today. And as you can see, our expert is online with us today. So please let us know if you have any issues. Thanks so much. Zach. It doesn't look like we have any questions just yet, but I'll let, you know, if anyone messages me directly. Appreciate it. Thank you. I've seen a few more people join, we still are going to give it about 1 more minute before we get started. Please take this time to acclimate yourself with Webex, be able to access that chat and take this time just to introduce yourself in the chat, including your name, credentials, county, where you practice or organization that you work for this just helps. Maybe you make professional connections, but also helps us understand who's in the audience today. All right, the time is now 12, I am going to get started with some housekeeping items. I know that this is a really popular time for people kind of switching over for morning patients. So I'm sure more people will trickle in, but this, this webinar is being recorded and the recording will be available within 1 business week on our website. I'll make sure that that information is included in any follow up messaging that you receive via email or via the Max portal, which I'll get into in a little bit as well. As you may have noticed, when you logged in, you are unable to turn on your camera or microphone, but we encourage you to communicate questions, comments concerns in the chat today. We will be having a designated Q and a time at the end of the webinar. So, if you are putting questions in the chat, just please make them as specific as possible. I know sometimes people refer to certain slides, and then once we get to the end of the webinar, we may not be able to know exactly what you're talking about. So please make sure that those questions are detailed and I'll be sure to relay them to Dr. Mark when it is time for Q and a. You will also have access to both the max slides and another set of slides that you will be seeing in just a couple of minutes. Those will both be available on the max oasis portal, which, if you signed up for today's webinar, you have already access. But if, for any reason, you are struggling with accessing that, or have any questions about how that works, please feel free to email me directly. I'll put my contact information into the chat that max oasis portal is also where you're going to access the evaluation survey after today's webinar. So, 2 things need to happen in order for you to get credit. I will 1st need to attest that you attended the entire webinar today, which may take up to 24 hours, depending on what mode you join the webinar. If you are a colon user, it tends to take a little bit longer because I do have to identify your phone number, but Webex does provide us with that information. Once I attest to your attendance and you have completed the evaluation survey that will be in the portal. You will be able to download your certificate directly from there. I know that this is kind of a new system for Max. We started in February of 2023 with this. So, once again, if you have any questions, please do not hesitate to reach out. I'm now going to give an overview of our Max for mom services. We offer similar to our Max program. Max for moms offers all of the same. Services, the only difference is we are funded through the centers for Medicaid and Medicare and our services include a free. Phone consultation, warm line open Monday through Friday, 9am to 5pm. And with that warm line, you can call in with as patient specific information as you'd like, or I'm sorry. De, identified patient information, but as case specific as you'd like, we'll gather some more information about what resources you're looking for and what questions you want to be answered and then we'll connect you to 1 of our expert consultants like Dr. Mark and they will follow up with you within 1 business day to kind of talk about what you're looking for. To talk through your questions and concerns and help you feel more comfortable and moving forward and treating that patient with substance use disorder or pain management. So, please take advantage of that warm line. We are here to support you and I'll be sure to include our contact information in the chat. We also offer training opportunities similar to today. We try to offer them during the lunch break 12 to 1 PM so that you are able to attend during your busy schedules. But once again, if for whatever reason, you can't, our past recordings are available on the website. I'm happy to send that link around as well. And today's webinar once again is being recorded and we also offer echo clinics, which is another unique training opportunity that meets once a month. I believe for moms. It is the 2nd, Tuesday of every month. A new cohort is about to start. So, I'll send that information as well. If you'd like to sign up, we're about to get started in September, but that's ongoing enrollment. So, if maybe you miss September, but you want to join in October, you are still more than welcome to. It's not. A prerequisite to attend every single session, but during tele, echo clinics, someone from the learning community, such as yourself presents a case from your own practice. Once again, with the identified information, but you get feedback from other members of the learning community as well as an expert panel of max consultants. So we like to call it in all teach all learn method, and it's a really great way to get feedback and once again, feel more comfortable in treating substance use disorders. I'm going to introduce our speakers shortly, but 1st, I am going to turn it over to Anna Perna who works at the center of Medicaid and Medicare are funders and they're just going to give you an overview of the services that are also available to you and a printer. Please feel free to get started. Hey, my name's Anna Porna coach Lakota. I actually work for Maryland Medicaid in the office of innovation, research and development. I'm here today to share a little bit about Maryland Medicaid's mom program. We will not take more than 3 or 5 minutes of your time. As we know, you're here for a really important presentation today. We've heard from the max team that many clinicians express concern over a lack of programs to refer patients to for help outside of their own settings. Medicaid operates a program specifically for pregnant and post part of individuals who have opioid use disorder. We would love your partnership and promoting and referring to this program. It's called mom. Next slide. Please. Oh, I'm sorry I did the whole thing without you see. Okay, I'm case management services. So, the mom program funds are Medicaid managed care organizations to provide enhanced case management services to pregnant and post part of Medicaid participants who have opioid use disorder. It's based broadly on 5 core case management pillars. So comprehensive case management care coordination. That's helping participants make and keep their doctor's appointments health promotions, which is HIV STI prevention, treatment, nutrition, family planning, individual and family supports as in with the permission of course, identifying and involving those who will serve as their support throughout pregnancy, labor and delivery, and postpartum care. As well as linkage to community supports, which is based on the participants response to social determinants of health screening. Next slide. Okay, so what's different about mom mom allows case management case managers to take their time based on the needs of the participant rather than a set script. It starts with a social determinants of health screening, which informs a discussion of the individual's own goals. The idea is that, for example, the case manager doesn't just provide the participant with a brochure, but they actually help them set up an appointment and sure they have a way to get there. Same goes for doctor's appointments. The case manager aims to ensure that the person makes and keeps their appointments, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual person, be it transportation, food, clothing, whatever that may look like for the individual please do not hesitate to contact us if you have any, if you'd like to access these marketing materials or with any questions about the program, and please fill out this prenatal risk assessments. Thank you so much for coming, for Max, for sharing your time with us this morning, afternoon, I guess. Thank you. Thank you so much, Ana Perna. Oh, sorry. Um, there were a couple of questions that came into the chat just for time sake. I'm going to feel free to reach out to them directly. I'll also send you their contact information. We just do have a lot to get through for our content today, but thank you so much for taking the time. As I said before, everyone will have access to those slides. Please feel free to reach out with any other questions. I'm happy to connect you directly with Ana Perna. But once again, thank you so much for taking the time today. Right before we get started, I am just going to give a brief introduction for our speaker today. Dr. Katrina Mark is an obstetrician and gynecologist who holds dual board certifications in obstetrics and gynecology as well as addiction medicine. Her research and clinical interests center around the intersection of reproductive health and substance use and abuse. She's the medical director of the University of Maryland Women's Health Center at Penn, and the director of the substance use in pregnancy and parenting outpatient recovery and treatment practice also known as support. In addition to her obstetric practice, she is an ambulatory gynecology practice at the University of Maryland, where she cares for people with gynecologic needs throughout their lifespans. She performs gynecologic surgeries at the University of Maryland, downtown and midtown campuses, as well as the Veterans Administration Hospital in Baltimore, Maryland. We're very lucky to have Dr. Mark as a consultant for Max for Moms. She is also a part of that tele-echo clinic that I mentioned. So please look out for that sign up information. But Dr. Mark, I will turn it over to you and I'll look out for questions. And once again, we'll have that Q&A at the end. Thanks so much for presenting today. Hi, can you hear me? Okay, it took me a minute to figure out how to unmute while I was on screen share. And you can see my screen that's just the slides, right? Okay, yes, this is perfect. Okay, fabulous. Well, hello, everyone. I, as Bridget said, I'm Katie Mark. I'm an OBGYN here at the University of Maryland and I'm going to be talking today about stigma and why the words that we use matter. There's a lot of literature on this. I've just hit the tip of the iceberg, but hopefully this is a review for some people and hopefully we'll talk about something new. So, zoom slideshow. This is not letting me go. Okay, so our learning objectives today, which I think that you probably saw in the email is to understand how language can positively and negatively affect patients, how to analyze, we're going to analyze historical terms that inhibit progress, and we're going to reframe care through patient centered, a patient centered lens. I like this quote, sticks and stones may break your bones, but words, words can break your soul. I think that we forget sometimes how much the things that we say can really have a lasting effect on people. Even if we just say them in passing, we didn't really mean them as negative. That doesn't mean that they don't have a really major impact. And this is positive or negative words. They both can have these types of impacts. So, first, what is stigma? Stigma is discrimination against an identifiable group of people, a place, or a nation, or it can be defined as a label with an associated stereotype that elicits a negative response. There are multiple different types of stigma. There's public stigma, which is driven by stereotypes about people with opioid use disorder, or I'm going to be referring to it a lot as opioid use disorder. And I hope everyone knows this is in general for all substance use disorders, but these stereotypes about people with use disorders can translate to negative attitudes. There's anticipated stigma, which is when the individual themselves are typically stigmatized, and then they're subjectively aware of those negative attitudes, and they developed expectations in society of being rejected. And this becomes important with access to medical care, because they have this anticipated stigma. They're assuming that they're going to be judged and mistreated, and so then they just sort of isolate and don't present for care. And then there's internalized self stigma. People with a stigmatized identity often accept their devalued status in society as valid, and they adopt for themselves the prevailing negative attitudes embedded in the public stigma. So they, society is stigmatizing them, they're anticipating that, so they're sort of isolating themselves from society, and then they're also starting to believe what people are saying about them and those stigmas that exist. There's also courtesy stigma, which can happen to family members and friends as a result of their affiliation with people from a stigmatized group, such as those with substance use disorder. And then there is enacted stigma, which is behavioral manifestation of public stigma, which includes discrimination and social distancing. So this means you, you know, society has these stigmatized beliefs, and then that makes us actually act different towards the stigmatized population. And I'm glad that you're all here today. I think, you know, in some ways, I'm probably preaching to the choir, because if you show up for a talk about stigma, you're probably aware of stigmas, and you're trying to work against this. But I just want to say that most people are, this is really very subconscious, and people aren't trying to isolate stigmatized populations, or they're not purposely being biased. But this is a very, there's a very strong sort of societal force here. There's also structural stigma, which is the totality of ways in which societies constrain those with stigmatized identities through mutually reinforcing institutions, normal policies, normalization policies, and resources. So these things become encoded in cultural norms, laws, and institutional policies. And the types of stigma, these types of stigma are all interrelated, they're reinforcing, and they result in poor health outcomes for people with substance use disorders. And then, of course, there's the intersectionality of stigma. People don't exist in a vacuum. They, all of these things sort of work with each other, and then the sum is great, the whole is greater than the sum of its parts. So when an individual or group experiences multiple stigmas that are not only overlapping, but they're also synergistic. So if you have a substance use disorder that's stigmatized, and then gender can add to that as well. And so pregnant women are, pregnant people are much more stigmatized than men who have use disorders. Women in general are more stigmatized than men with use disorders, because female presenting people, their role in society is to be a caretaker and a mother, and now you're unfit for that job. Because you have a substance use disorder. There's also racial stigmatization that happens, and so if you are a pregnant black female, you are one of the most stigmatized groups, and this intersectionality, all three of those things together make that stigma even greater than any one of those things separate. So, parenting people with substance use disorder report a 49% greater odds of experiencing stigma compared to non-pregnant or parenting people with substance use disorder. Again, because we change our expectations of people when they're parents. So, again, I said, as I said, if you're all here, I'm sure that you've thought a bit about bias and stigma before, but I want to just take a moment and do an exercise where I'm going to show you a series of pictures. I'll pause for a few seconds with each one, and I want you to just sort of sit with your initial reaction to these pictures for a moment. Think about your mental, physical, emotional response to these pictures and don't try to curate it. Just let yourself have the response that you're going to have. So I won't make anybody say what they were thinking as they were looking through these pictures, but I can say that some common stigma that happened towards patients with substance use disorder, some common thoughts are that they're dangerous people, that they're unpredictable, that they're incapable of managing their own treatment, that they've somehow caused or created this condition on their own. This is self-inflicted, that they can stop if they really want to, that we immediately assume they're going to be very difficult to work with. And then for pregnant people, it's often assumed that they don't care about their babies, or they wouldn't be using drugs. You may have had some of these responses when you looked at these pictures, and I will explain in a minute why that is not entirely your fault. So we would like to think as health care providers that we are a little bit less susceptible to stigma and bias, but it's really unfortunately not true. So this was a survey that was done of family practitioners, internal medicine practitioners, and pediatricians, and they asked about the beliefs of people with substance use disorder. And 66% of people, so two thirds of people said that people who are addicted to pain medications are more dangerous than the general population. And so, if we believe that people with substance use disorder are more dangerous, then we act differently toward them. We don't give them the same opportunities. We are more likely to criminalize their behavior or look at their behavior in a negative light. They get worse care in the hospital. We're more likely to call security on them. We're more likely to document in their chart that they're refusing care, things like that. Over a third of physicians, medical practitioners believe that landlords should be allowed to deny housing to people who have a use disorder with pain medications. Again, this is enacted stigma. This is a problem with, we assume these people are more dangerous. They're causing these problems themselves. Somebody needs to give them tough love, and they need to quit. And so then we don't give them housing. And how do we think that affects their use disorders? Then less than 70% believe that people who had an addiction to pain medication could, with treatment, return to a productive life. And so about a third of healthcare practitioners did not believe that even with treatment, these people could return to a productive life. And then when asked if there were effective treatment options available to help people with use disorders with prescription pain medications, only a little more than half said that there were effective treatments. And so this is upsetting, because if the healthcare community doesn't believe that there are effective treatments or that there's any hope of improvement for people with use disorders, how are they supposed to believe it? We're supposed to be the ones that are holding hope for them and showing them the path towards a healthier life. So this is upsetting. So here are some examples of how each level of stigma that we talked about before can impact the outcomes of pregnant populations who use substances. So individual stigma, a newly pregnant person can believe that they are a bad person because they used non-prescribed substances, and that delays them seeking prenatal care. And so delaying their own, you know, having bad feelings about themselves and that sort of personalized enacted stigma makes them have this anticipated stigma where they don't present to care, and that actually causes worse harm than the drugs themselves. And our personal stigma, a newly pregnant person who uses drugs loses their previous supportive friends and partners and family, and then that makes them more isolated and depressed. Of course, people who use in isolation have a higher risk of overdose and death. Organizational stigma is when healthcare institutions obtain a urine drug screen in newly pregnant people without their consent, which, by the way, is illegal, and they respond to a positive result by involving child welfare services, but they don't otherwise provide substance use treatment. And so this is sort of the idea that this behavior needs to be caught and criminalized instead of treated as a medical condition. And then community stigma is when substance use treatment facilities don't offer treatment to pregnant people. This comes into play for a lot of different reasons, but a lot of people, once they become pregnant, get destabilized because they're no longer able to access care that they previously were, which, of course, is very counterproductive. And then public policy stigma is the criminalization of substance use and involvement of child welfare services in pregnancy, which then decreases someone's engagement in medical care and, of course, increases their morbidity. And so these are all the different, you can see, the multifactorial, multilevel ways that stigma can play into negative outcomes for people who are pregnant and have use disorders. So why are people with substance use disorders so stigmatized? It's something that I think we all just sort of accept as reality, but why is it the case? When we've made a lot of progress with some mental illnesses and depression, there's a lot of campaigns and people viewing that now as a medical issue and not so much as weakness as it previously was viewed, but we really haven't made the same improvements in the substance use arena. We don't view that in society as much as a medical problem as it is more of a moral failing. And I think that stems a lot from the belief that addiction is self-created and that it's something that people could stop, people could change if they wanted to. And so compared to other psychiatric disorders, patients with substance use disorder are more likely to be blamed for their disease than any other psychiatric disorder or any disorder, really. So now I'm going to show you a few more pictures that I want you to respond to, and I'd guess that your response is going to be a little bit different. So with these pictures, my guess is that your response is a little bit different. You might have laughed, you might have, you know, thought that these were amusing in some way, but you probably didn't have the same sort of visceral or negative reaction that you did to the pictures of pregnant people who are using substances. So then why aren't these pictures so upsetting? Because obesity, gestational diabetes, excessive weight gain, unhealthy eating are also very harmful in pregnancy, both to the mother and the developing fetus. So why don't we have a negative reaction to these things? There's a lot of reasons for this. Maybe it's because we can more easily relate to overeating and eating ice cream and pizza while we're pregnant. Maybe it's because it's more prevalent in society or more visible. Maybe it's because we've made some gains as a society in looking at things like obesity. But really, probably a lot of it has to do with the way that we've been programmed by media and by society in general. We tend to view drug use much more as a personal choice than things like overeating, obesity, even diabetes. We view those as something that are out of your control versus substance use as being something that is within a person's control. So I would propose to you that it's not entirely your fault if you had negative reactions to those pictures of people using drugs while pregnant. Society has conditioned us to have these negative responses to people who use drugs. And this all culminated in the 1970s. So there were, you know, this is since the history of man, things are going along as pleasantly until the 1970s when two things simultaneously happened. And one was the personhood movement, and this was related to the abortion debate. And it was the first time that we as a country really started to have a national conversation about when life begins. And this is when laws were first created to view the fetus or even an embryo as a person who had rights. At the same time, unfortunately, was when Richard Nixon was waging his war on drugs. And the war on drugs was when this language that we use about substance use and substance use disorders really began to be widely used, this negative language really began to be widely used and make it sound like we were under attack and there was an enemy that we needed to fight. And these two things happening simultaneously made it very easy for society and media to believe that babies were the helpless victims that we needed to save and mothers who were using drugs were the enemies that we needed to defeat. And of course, this led to the crack baby, quote unquote, crack baby epidemic, which caused media hysteria. The term crack baby was a weaponized term that was used to describe neonates born to mothers who use crack cocaine. And you may know that crack cocaine is more prevalent in lower socioeconomic communities. It's also more prevalent in Black communities. It's more highly criminalized, even though it has the exact same health effects as cocaine does. But cocaine is more common in upper middle class white people. And so it is less criminalized. So long story short, I could give a whole talk about the epidemic that wasn't, but it was later completely disproven that any of these effects that were being sort of blamed on crack cocaine use were actually really related to crack cocaine use. They were all much more related to prematurity, but it was it was too late. This society had already taken this term and run with it. And we believe that we needed to fight against mothers instead of for them to help save the innocent babies. So, unfortunately, history has repeated itself with the opioid epidemic, and you can see here headlines that are demonizing pregnant people who use drugs. We have not learned anything from history about criminalizing substance use and stigmatizing people who use drugs. And it's just basically continued with a new epidemic. And so I think that this fact is really important and necessary just to get its own slide and second for thought, that substance use disorder is a chronic medical condition. And that sounds so simple when I say it, but when you reframe your mind to think of it as a chronic medical condition, then often a lot of the stigmatized language, stigmatized, enacted stigma, a lot of these things can really kind of fall away when you view it as a medical condition. So just try to keep that in mind as you talk to patients, as you make policies and plans and think about how you treat people with substance use disorders. So what are the negative effects of stigma on people with substance use disorders? Well, it causes social isolation because of anticipated stigma, which we talked about before, which can lead to solitary use and increased risk of overdose. It leads to family and public desire to social distance from people with use disorders. People don't want to be associated with them because they can have this association stigma. There's a decreased willingness to seek and engage in treatment, which decreases treatment retention, and it decreases screening and prevention of things like HIV, avoidance of methadone treatment programs, because those are viewed as places where others go instead of legitimate health care facilities. It influences providers' perceptions, which impact care. Providers are more likely to dismiss patients presenting to the emergency room as drug-seeking and not really do appropriate workups. This serves as a barrier to evidence-based medications. We're less likely to prescribe MOUD and long-term MOUD. And there's a reluctance to make naloxone routinely available because, just like in the abstinence-only sex mind frame of, we shouldn't give people condoms because it's going to make them more likely to have sex, that has been wildly disproven, as has making naloxone readily available does not make people engage in more risky drug use. What it does is decrease the risk of fatal overdose. So let's talk through some ways that we should be talking instead of ways we shouldn't. We'll talk about that too, though. So we should all be using person-first language. So what is person-first language? It's language that maintains the integrity of an individual as a whole human being by removing language that equates the person to their condition or has negative connotations. It has a neutral tone, and it distinguishes the person from their disorder or diagnosis. And so instead of calling somebody a drug user, they're a person who uses drugs. Because when you call them a drug user, that's all they are. It's as if their only purpose in life is to use drugs. But really, they're a person, and they also happen to use drugs. And if you use this type of language, it's more likely to really reframe people's behaviors as well. Here's some other examples of terms that we should avoid and better terms to use and why we should use these other terms. So addict, user, drug abuser, junkie, alcoholic, drunk, these are all terms that are not person-first. And instead, if we use terms like a person who has opioid use disorder, alcohol use disorder, a person in recovery, or just a patient, these are person-first, and they show that they are a person who has a problem that is able to be treated rather than they are the problem. Habit is not a good word to use. Substance use disorder is better. Habit makes it sound like it's some sort of choice, and it undermines the severity and the medical nature of the disease. Abuse is a very aggressive term that sort of conjures up the idea of violence, which, again, may lead to the fact that people believe that people with use disorders are more likely to be violent and dangerous, which is really not true. So, for use of illicit or non-prescribed drugs, you can just call it use, because there's no non-illicit use of heroin. So you can just call it use, or for prescription medication misuse, you can call it misuse or use other than prescribed or unprescribed use. Those things all get across the same idea without sort of weaponizing it or making it sound like this more dangerous thing to society than it really is. It's more accurate terminology, and it has less of a negative connotation. Clean and dirty, this one really gets under my skin. So people will often talk about a dirty urine, or they will say, even, you know, they'll say, like, this person has been clean for a year, which they view as a positive thing, like, she's been clean for a year. But the negative of that is that the alternative, the opposite of clean is dirty. And so even if you're saying someone's clean, which you think is positive, or that their urine was clean, which you think is a positive thing, really, that has a negative undertone, because you're saying that if they were using drugs, then they were dirty. And that, of course, is very stigmatizing. And so a better way to do it is just say the facts of their toxicology result was positive for, or if you're describing a person, instead of saying they're clean, you can say they're in recovery or they're abstinent from, or if they return to use, you can say a person who uses drugs or a person who uses whichever drug they use. Methadone clinic has a very negative association. The word clinic in general kind of has a negative association. Opioid treatment program has a much more positive and medical sort of terminology. Medication-assisted treatment we now refer to as medication treatment for opioid use disorder. Assisted treatment kind of undervalues the role of medication. I think more importantly is not to call it replacement therapy, because that implies that you're replacing one drug with another, but MOUD is the correct terminology that we use now. And then this is another one that really, really, really gets under my skin as an obstetrician, is saying that babies are born addicted. So addiction is a chronic medical disorder, and part of that chronic relapsing medical disorder is behaviors in which the person spends a lot of their time seeking out drugs, and they are neglecting other responsibilities in their life, their own health, things like that, in order to seek drugs. Babies are not capable of doing that. They can be born dependent on a drug. They can be born dependent on a lot of drugs, not just opiates, but a whole slew of legitimately prescribed drugs, but they absolutely cannot be born addicted. So calling a baby addicted is absolutely never the right thing to say. We used to call it neonatal abstinence syndrome, and now the correct terminology is neonatal opioid withdrawal syndrome, because specifically it has to do with the fact that they were exposed to opioids, and now they're no longer exposed to them, and they need to be weaned off of them. It's just a more medically accurate term. But I would forgive someone for saying NAS. Please, please never say that a baby was born addicted. This is a picture of an actual billboard that exists in the world, and I put this here to remind us that we have to remember that having a substance use disorder does not mean that you are unfit to parent. There's absolutely no evidence to say that people with substance use disorders are more likely to abuse or neglect their children than the general population. Pregnant people are often ashamed to come to care because most medical professionals view pregnancy in someone with substance use disorder as something that should be avoided, when in reality, healthy and safe pregnancies are absolutely achievable with the appropriate care. Implying that a person with substance use disorder should not become pregnant causes further divides in the doctor patient relationship and makes people less likely to seek necessary care, which is much more likely to end in negative outcomes than the drugs themselves. And so, while we should all be providing contraception to those people who do not want to be pregnant, the implication should not be, oh, you use drugs, what kind of birth control are we going to put you on to make sure you don't get pregnant because you're a drug user? Instead, it should be, what are your reproductive goals? And if you want to get pregnant, how can we get you as healthy as possible for that pregnancy? This table is from the Journal of Addiction Medicine study that just came out this month and JAM, and they used this natural language processing software to look through all of the different notes in an entire medical system to look for stigmatizing language. And they found a lot, unfortunately, about 80% of people with use disorders somewhere in their medical chart had stigmatizing language. The most common word that was used was abuse, substance abuse, alcoholic user, clean, polysubstance dependence, drunk replacement therapy were the most common things that were used. And this was across all different specialties. Actually, I saw that there are a lot of nurses on here. Nurses were the least likely to use stigmatizing language, but across all medical specialties, there was really just a very pervasive use of these very stigmatizing words. So, if someone were a skeptic, they may be listening to me and thinking, this is just like a bunch of woke snowflake left wing stuff that you just want me to talk in a certain way because you're trying to be controlling and people are too sensitive and like, really, isn't it all just the same thing? But it's not. It's actually been studied that our words affect our behavior. So, there was a survey that was done of 516 providers that were attending a mental health care and addiction conference. So, these were people that were like in it, right? Like, they already work in addiction. And they probably had some stigma training or some awareness of the stigmatization of people who use drugs. And they split them up into two groups, and they gave one group a vignette that described a patient as described a case and called the person a substance abuser. And the other one was the exact same case with the exact same medical information, and they called them a person with a substance use disorder. And lo and behold, when they then asked them what the next step should be for the person, the patient that they described in the vignette, the people who had the vignette, oh, I'm sorry, I didn't change this slide. The people who had the vignette, where they referred to the person with a substance use disorder as abuser, had a higher likelihood of saying, of perceiving, of placing blame on the patient, and a higher likelihood of recommending punitive action and punishment rather than medical treatment. And so, even among substance use treatment providers, they found that just using the word substance abuser, it made them more likely to frame that person in a negative light and more likely to place blame on them and not give evidence-based treatment. So, what should we do instead? We should focus on strength-based documentation, focus on what is strong instead of what is wrong. And I'm not telling you to lie or misrepresent things in the medical chart. I'm telling you to think about how you're writing them and not only how that will affect the patient if they were to read it, but how it's going to affect everybody else that reads it. You know, if you say, this person, this patient who's a substance abuser arrived 30 minutes late and was agitated, the next person that sees them is going to read that note and already walk into that room, assuming that this person is going to be combative and have a very negative view of them. And so, a better way to say it is, despite having transportation and child care issues, Ms. Smith attended her appointment today. So, that's true, right? It's an accurate statement. It's not that you're falsifying the records, but there's no point in saying those negative things that didn't really help anything in their medical care. Instead of saying, patient relapsed again, you can say, Ms. Smith presented today to seek care and reports that she is motivated to achieve sustained recovery. So, this helps with two things. One, it helps with other providers when they see the person to go in with more of a positive attitude and less stigma and less bias and treat them better. And the other thing that it does is now that there's this mandated law that patients have access to their medical records is it helps them see, that helps this sort of doctor patient relationship to see that you're viewing them in a positive light, that you're not documenting negative things or thinking negative things about them when they walk out. And it helps them feel more empowered and better about themselves too than if they were to read a negative note. There was a study that was done recently that showed that 30% of people that read their medical records found something in there that they found to be incredibly judgmental and upsetting. And that's not people with substance use disorder, that's just people in general. 30% of people that were able to view their charts found something that they thought was offensive and stigmatizing by their providers. And so imagine if all of our patients with use disorders were to read their charts, what they would think of what's in there and how that would affect their views of themselves, their individualized stigma. So now I'm gonna go through some misconceptions about people with substance use disorders. So the first is that using medication for opioid use disorder is just trading one, it's just trading an illegal addiction for a legal one. And this stigma, I actually get from patients probably more than from providers. The patients will frequently tell me like, I don't wanna just be addicted to another medication, I don't wanna be addicted to something else, I wanna be free of all of that in my life. And so starting on MOUD is just trading one addiction for another, which is really not true. So addiction is a brain disease and its symptoms are visible behaviors. So as we talked about with babies not being able to be born addicted, you can be dependent on a lot of things and people can be physically dependent on medication for opioid use disorder, but that is not the same thing as an addiction. There are many medications that cause physical addiction. People are, I'm sorry, physical dependence, people are physically dependent on insulin, people are physically dependent on antihypertensives. But saying that you're addicted to it really implies that you are misusing it and that there's a pattern of behaviors related to your use that is not consistent with the prescribed use. Taking medications for opioid use disorder is just like taking medications to control heart disease or diabetes and it shouldn't be looked at any differently. And oftentimes my patients are on MOUD or on other medications and I'll say, okay, so you're pregnant and now you wanna stop your suboxone. Okay, do you also wanna stop your nifedipine, your insulin and your metformin? Of course not, because those things are helping you and you can see how they're helping you be healthy. But for some reason this MOUD is really looked at as a crutch, which is harmful because MOUD is the only thing that's really shown evidence in helping people stay in recovery for a prolonged period of time. So taking MOUD is not substituting one addiction for another and that's important why we don't call it replacement therapy anymore, because we don't want it to be viewed as just switching from one to the other. These negative effects of stigma on opioid use disorder, media representation adds to public stigma by instilling fear towards people with opioid use disorder. It contributes to the underinvestment and addiction treatment and infrastructure. People don't want their tax dollars going to this because these dirty drug abusers chose this themselves and why would we want our public dollars to go to that? They should all go towards nuclear weapons instead. So this really kind of undermines the ability to provide infrastructure and opportunities for people. It results in discrimination in insurance benefits and employment and housing. Again, even doctors said that they thought that landlords should be able to refuse housing to people who use drugs. So all of this really just compounds on itself and then makes it even more difficult for people to be in treatment and recovery. And it shapes public opinion in favoring punitive versus health-oriented management. The next misconception that I want to address is that people with opioid use disorder are difficult to work with because they're always drug seeking, which is another term that I think is very pervasive and unfortunately very negative. So everybody should be familiar with the term and the idea of hyperalgesia. So hyperalgesia is a state of nociceptive sensitization caused by exposure to opioids. So what does that mean? That means the people who have chronic long-term exposure to opioids actually feel pain different than those who do not use opioids chronically. It presents as an exaggerated response to painful stimuli due to changes in receptor activity because of the chronic stimulation from opioids. This is reproducible in laboratory animals. So if you give laboratory mice, rats, guinea pigs, opioids for a prolonged period of time, and then they have the same painful stimuli as another animal that did not have those chronic opioids, it will react more dramatically because it feels it more dramatically. So this is not drug seeking. This is something that is actually physiologically based. And this, I find, causes some cognitive dissonance for people because physicians and medical practitioners often have a hard time prescribing opioids to people who have an opioid use disorder. And I hear all the time, like, I don't wanna just become their legal drug dealer, right? But if you don't adequately treat pain of a person with a use disorder, they're gonna leave the hospital and go use more, which is much more harmful to them. And then you feel like your hands are clean that you didn't cause their overdose. But in a way, you actually did contribute to it by refusing to care for them in an appropriate way. The next misconception is that people with opioid use disorder never get better and that they don't wanna get better. And so why bother treating them? But the truth is that substance use disorder, again, is a chronic medical disease. And when we compare it to other chronic diseases, diabetes is treated, if somebody comes in with DKA, we treat them with more insulin. Even if the person went into DKA because they weren't using their medication or they were eating cake, right? Like somebody comes into the emergency room with DKA and you ask them what they ate, and they said, I ate a whole cake and I didn't take my insulin before I came in. You don't say, well, this is your fault. You better leave. I'm not taking care of you right now because you caused this problem. Of course not, we give them more insulin. Substance use is the only medical disease where people's reflexive response is to take away treatment when somebody's disease is clearly getting worse. The same thing would happen with asthma. Somebody comes in with an asthma exacerbation, even if they were not using their inhaler, they were smoking, and that's what caused their asthma exacerbation. They didn't get a COVID shot, so now they have COVID and an asthma exacerbation. We're gonna give them more medication. We're gonna treat that flare up. But for some reason, we don't really view opioid use disorder in the same way as when somebody starts using again or using on top of their MOUD, we all of a sudden wanna withhold all of their treatment, which really doesn't make any sense. One of the hardest parts about caring for people with substance use disorder, again, is falling into this trap of just feeling like relapse is inevitable and there's a low likelihood that they're gonna get better or that there's gonna be any sort of success. But really, if we reframe it as a chronic medical illness rather than a personality or moral failing, it starts to look a lot more like other medical conditions. So the rate of relapse of other chronic medical illnesses is just as high, if not higher, than substance use disorders when appropriately treated. And again, we wouldn't withhold antihypertensives or insulin or treatment for asthma just because somebody's disease was worsening. And so almost all medical diseases are chronic and relapsing, and we don't blame those on the patients as frequently. Another misconception is the people with opioid use disorder are always noncompliant. And if they really wanted to get any better, they'd keep their appointments and they would seek care. So the truth is that three quarters of pregnant people who use drugs are afraid of their drug use being identified by their provider. They're trying to hide it from us, which of course is doing no good for anybody, but they're afraid, this is that anticipated stigma, that they're afraid that they're gonna be treated differently, that they're not gonna get appropriate care for their pregnancy once you find out that they're using drugs, and that potentially this is gonna be criminalized and their baby's gonna be taken away from them, someone's gonna press charges on them, and they're not out of line for thinking that. There have been many cases across the country where this has happened, where people's babies have been taken away, they've been put in jail because their provider realized that they were using drugs. And over half of recently pregnant people with SUD admitted to skipping their appointments or delaying care because they were afraid that someone was gonna find out their substance use disorder. And so this is so harmful because it really, I think I say it on a slide coming up, but it's really harmful because what actually hurts the pregnant person in their developing baby the most is the lack of care. And so by us making people feel unwelcome and helpless when they come to care, and then them not coming to care, that actually is the thing that's, I mean, they could continue to use drugs and come to care, and they would turn out much better, the health outcomes for them and their baby would be much better than when they avoid coming to care. There's also racial discrimination in pregnancy, and this has to do with that intersectionality of discrimination, racial stigma, and people with use disorders stigma. So there was a study in Florida where they collected urine samples from all delivering pregnant people and sent them for drug testing. And the rates of positive drug testing by urine analysis were about the same across the different races, but African-American women were 10 times more likely to be reported to social services. And so you're afraid to come to care anyway, and then you know, if you do come to care, it depends on how you look, how you're gonna be treated. And so this intersectionality of stigma causes the most vulnerable people to really avoid coming to care. So this is just showing the sort of watershed effect of barriers to disclosure and treatment of substance use in pregnancy. As we talked about in previous slides, it really happens at all levels. It's also important to know that two thirds of pregnant people with substance use disorder have co-occurring mental health disorders. And so they are not only not getting treatment for their substance use disorder, now they're not getting treatment for their mental health disorders. 50 to 90% have experienced childhood trauma, including physical or sexual abuse, which can also make it incredibly challenging for them to present to care for GYN and OB issues. And then 60 to 80% have experienced IPV in the last year. And this can worsen during pregnancy. And so they may be in a controlling situation where they're not able to come to care or that someone's forcing them to continue to take drugs. And all of those things need to be handled with care and we need to screen for them and help people with all of these different comorbidities. There are higher than average rates of housing instability, transportation issues, childcare issues, and all of these things can seem very overwhelming and make people wanna avoid taking care of people with use disorders. But I hope that presentation at the beginning, talking about the Maryland Moms Program that can really help with a lot of this will inspire people to be more likely to screen for these things and help manage them. So the take home point is that people with substance use disorder face more barriers than the average patient. Many have guilt and shame and have had many negative healthcare encounters in the past. And so we really need to be the new and fresh start for them. It's our job to make care as accessible to them as possible in a nonjudgmental and supportive environment. The assumption that people with substance use disorders do not want to access care is a self-fulfilling prophecy. We assume they're gonna be noncompliant. We assume they're gonna be combative. We assume that they don't wanna get better and that those stigmas and that those assumptions are very easily related to the patient. And then they think those things about themselves too. And then they don't wanna come to care because they don't think that we believe in them or that we're gonna treat them well. And so then that just becomes this spiral of, oh, well, now they've just confirmed my bias that I thought they weren't gonna come. And of course they didn't show up to their appointment. Well, they didn't show up because you treated them like they weren't gonna show up or that they shouldn't show up. So we really need to be the first step in helping them access care. And hopefully everybody has heard Amanda Gorman's speech but try to remember that there's always light if only you were brave enough to see it and if only you were brave enough to be it. So we really need to be the light for people with substance use disorder, particularly in pregnancy because they often have just been treated so poorly by society and by themselves that they need someone to help them see that there is a path forward. So what can we as providers do? We need to be aware of stigma and available of the resources. We need to use patient-centered language, patient-first language, recovery-oriented language. We need to listen without judgment, evaluate our own biases and humanize people's experiences. We need to recognize that use disorders are chronic relapsing brain diseases. We need to use appropriate medical language instead of stigmatizing language, both when we talk to patients, when we talk to our colleagues and when we document. We need to assess patients using criteria for opioid use disorder defined by DSM-5 and not use judgment, just use accurate medical information, prescribe evidence-based medications when warranted, understand the duration of treatment is very patient-specific. We need to be clear about screening and testing policies, the patient's rights and our reporting mandates. We need to emphasize that patients with opioid use disorder do respond to treatment and can lead productive lives, but it can take time and they need to be patient with themselves and we need to be patient as well. And then we should all be using strength-based documentation. So another amazing quote is that people will forget what you said and people will forget what you did, but they will never forget how you made them feel. And if you make them feel comfortable and welcomed in your practices, they will remember that and they will come back. And all it takes is one experience where they feel that they were judged and not taken seriously and they will then just avoid care in general. So this is, I think you all know because you're here, but this presentation was from the Maryland Addiction Consultation Services for Maternal Opioid Misuse, which is abbreviated MACS for Moms. And I know Bridget talked at the beginning about all of the different opportunities that we have, phone consultative services for providers, education and training, assistance with resources, and then our Tele-ECHO session, which I would encourage anybody to sign up for. All right. Thank you so much, Dr. Mark. I know we are down to the wire with time, but I only saw a couple of questions come in in these last couple of minutes. So I will read this out loud to you. If anyone does need to hop off, please feel free. This recording will be available on our website once again within One Business Week, and you will have access to the slides by the end of the day today. The first question I'm seeing here is, are hospitals allowed to turn patients away who are experiencing withdrawal? I've heard clients mention that they went to a hospital and were treated badly or not at all because they found out they were using drugs. So based on EMTALA, it is illegal to turn anybody away from the emergency department. But probably what actually happened was that they were treated so poorly that they left, which again is an enacted stigma, right? That they don't get the treatment that they need, and they just sit in the room with no withdrawal treatment, with nobody caring for them as a whole person, and then they get upset and sick and they leave. And then the way that gets perceived to people who are stigmatizing is, oh, these people who use drugs never even say they just wanna leave and go get high again, which is exactly the opposite of the case. They came there because they wanted to get better and nobody treated them and nobody helped them, and they had no other option. Because if you've ever seen somebody who's in the throes of opioid withdrawal, it is brutal. And if you don't treat it, they really don't have many options other than to leave and treat it themselves. And so the short answer is no, it is not allowed for people to be turned away, but there's a much more passive way that it happens and it's not really able to be legally acted on in that way. Because again, it gets blamed on the patient. Thank you so much. This next one, I feel like it could be a whole talk in and of itself. And I also pointed this person to other resources we have on those old webinar recordings, but they asked based on this, how do you recommend talking about and screening for SUD in pregnancy? Okay, yeah, agreed. It could be an entire talk in its own. But what I will say is that I recommend screening as early as possible in pregnancy because a lot of places screen or do drug testing at the time of delivery, which at that point it's too late to intervene for in utero exposure. And so oftentimes it really just turns into punitive action at that point. So if you screen as early as you can in pregnancy, then the idea is to connect people with care, make sure that people are being consented for the screening, they understand what's happening, particularly if you're doing urine testing, they absolutely need to be consented for that. But then more importantly, is the screeners like the 4Ps Plus and all of these written screeners that you can use and explain to the person why you're screening, right? I would say we give this to all of our pregnant people because oftentimes people use drugs and they haven't really had any access to care or they haven't really thought of their use as an issue until they become pregnant. And so we just wanna make sure that we can identify any issues that there are and provide resources to you. Because if people don't understand why you're screening, they're gonna assume that it's a negative reason, that it's to get them in trouble and they're not gonna tell you the truth. And so having a good provider patient relationship, explaining to people why you're doing it and what you're gonna do with the results, also being clear about what's mandated to report and what's not. I tell all of my patients at the first visit, nothing that you tell me during this visit is going to be used against you. It's all going to be used to help you in your treatment. And the goal is to get you as healthy as possible for your pregnancy and get to the goals that you want, which most of the time their goal is to keep their baby. Sometimes that's not their goal, but their goal is to keep their baby. And so we talk about a plan to help work through the pregnancy to get to whatever their goal is. And so really the survey-based screeners are the way that I would recommend to do it and do it as early as you can in pregnancy. There's a lot, I mean, I could give a four hour talk on urine drug testing, but I would say it never should be your first line and it has to be consented if you're gonna do it. Awesome. Thank you so much. Those were the only two questions I saw. All the other comments were singing your praises. Thank you for a great talk. As always, if more questions come up, please call our warm line. You would be connected with Dr. Mark. Keep us in mind as a resource, look out for further communication and thank you all for your time today. I just want to say one more thing before we leave. I thought I had the slide in my presentation, but it must have come out. One of the frequent questions that I get asked is how do you respond when patients use stigmatizing language, when they call themselves an addict or when they say they had a dirty urine, things like that. I never correct a person because it is their right to use, I never correct a patient. It is their right to use whatever language they want, but I don't mimic that language back. I respond with the language that I think is empowering and non-stigmatizing. So if somebody says I relapsed and I had a dirty urine, then I will say, well, and since the time that you've returned to use, we did have one drug test that was positive for opiates. And this is a hiccup in your recovery. Let's talk about how we're gonna move forward. But I would never repeat that language back to them. But I don't say, don't call yourself an addict. It's their experience and they're allowed to call themselves, they're allowed to use whatever language they want. But I often find that once you start to use this more empowering language, they will start to use it as well. I absolutely correct my colleagues when they use wrong terminology. I think that we need to model good behavior. We need to face these things head on. And if you don't wanna have confrontation, then my best advice is to act curious. And if somebody says, this addict's in triage every week, she just comes cause she's drug seeking and she never actually wants care. I'll say, oh, well, what makes you think that? Why last time she came, it seemed like she was in withdrawal and didn't get treated. So what makes you think that she's drug seeking? What's the difference between drug seeking and withdrawal and just sort of play dumb or politely inquire. And then oftentimes once people start to talk through it or think through the things that they're saying, they recognize the error in their own ways. So there are lots of different ways, you can address it head on, you can be a little more passive about it and try to help the person come to that conclusion themselves, but we shouldn't be allowing inaccurate and stigmatizing language to occur in our healthcare systems. Awesome, thank you so much again. I think that's a great stopping point. So once again, thank you everyone for being on today. Keep us in mind and thank you, Dr. Monk. Feel free to lock off. Thanks everybody for staying with us a couple of minutes late. Thank you. Thanks Bridget.

stigma

substance use disorders

pregnancy

person-first language

understanding

empathy

stigmatizing language

misconceptions

addiction

medication-assisted treatment

healthcare encounters