Partnering to Support Families Affected by Opioid and Other Substance Use Disorders

Partnering to Support Families Affected by Opioid and Other Substance Use Disorders


Dr. Nancy Young: This is Nancy Young. I’m the director of the National Center on
Substance Abuse and Child Welfare. Thank you very much for joining us today for
the webinar. Let me turn things over to Elaine Stedt. Elaine Stedt: Thanks, Nancy, and good morning,
good afternoon to everyone on the phone again today. Thank you, again, for joining us. As many of you are experiencing in your regions,
the opioid epidemic is affecting, and sometimes devastating, families and service providers
from virtually all of the health and human service organizations. I’m thrilled to see the number of participants
on the line, and we have a great turnout. We have representation from the Children’s
Bureau, from SAMHSA, from HRSA, MCHB, and the ACF regional office representation. I know that’s the alphabet soup, but I’ll
go ahead and say it’s the Children’s Bureau, Substance Abuse and Mental Health Service
Administration, the Human Services Research, and Maternal Child Health Bureau, and of course,
the Administration on Children, Youth, and Families and within ACF. We hope that when you leave this webinar,
you will leave with an invigorated sense of being able to do something about the opioid
epidemic in our country. We look forward to learning about and potentially
bridging the initiatives that are in your regions. I’d like to turn it over to Dr. Nancy Young,
who you just heard from, who is the executive director of the National Center on Substance
Abuse and Child Welfare. The National Center is co-funded by the Children’s
Bureau and SAMHSA, to address and provide technical assistance and resources to states,
tribes, and communities, and organizations working at the intersection of child welfare
and substance abuse disorders. I’d like to also just thank our colleague
over at SAMHSA, Sharon Amatetti, who is also on the line and has been a wonderful partner
in thinking through and organizing this webinar, and also has been incredibly supportive of
the work of the National Center, as they are the lead organization for it. With that, I turn it over to Nancy and look
forward to the discussion at the end. Thank you. Dr. Young: Thank you so much, Elaine. We’ll just spend a little bit of time today
talking about the numbers, and then the windows of opportunity, if you will. Both about advances in substance abuse disorders
treatment, and then specifically, about the Child Abuse Prevention and Treatment Act and
the changes that were made in that act as part of the Comprehensive Addiction Recovery
Act, or as commonly called, CARA. Then some lessons that we’ve been able to
gather at the National Center related to some technical assistance programs that we’ve been
conducting for the last few years. Hopefully, we’ll have some time for some discussion
and then open up for some ideas related to some next steps. As Elaine mentioned, the National Center on
Substance Abuse and Child Welfare is a program of the Substance Abuse and Mental Health Services
Administration and the Administration for Children and Families. Our direct contacts are in Children’s Bureau,
the Office on Child Abuse and Neglect, and the Center for Substance Abuse Treatment. We are in our 15th year, so we’re very happy
to be able to have gathered some knowledge over those 15 years about the various substance
use trends that we’ve seen over those decades. It’s also to make sure that we’re staying
current with what the knowledge base is about the impact of substance use on the child welfare
population. I see that there’s a little bit of a drag
from my screen to what you’re seeing. I’ll try and make sure that I’m timing this
a little bit better so that we don’t have too much of a drag. You’re all very familiar with the trends over
the decades of the heroin epidemic that we had in the 1960s, cocaine in the ’80s, methamphetamine
in the ’90s and now, the prescription drug and opioid crisis that our country is facing. I think part of the lessons from these prior
trends in substance use is that it’s so critical to make sure that we’re looking at the impact
on families in regard to what’s happening for the child welfare system, for income support
programs. We had a conversation yesterday about the
impact in child support and how substance use disorders may be affecting their programs
and the window of opportunity that they have, even in child support. We recognize that there are many lessons from
these prior eras that we need to bring into the programs that are being conducted across
the nation now. In 1997, as you are all very aware, the Adoption
and Safe Families Act has some new criteria, specifically about timing and many other aspects
of the Child Welfare System. Since that time, SAMHSA and ACYF have had
several initiatives that help us understand what the impact is. Then, I think, importantly, what kinds of
strategies, what kinds of programs, what kinds of approach is in play to improve the outcomes
for this particular set of families. You see the various grant programs that have
been funded all the way through February of 2017 and the Policy Academy that brought several
states specific to this topic. We’ll talk a little bit into the webinar,
into the session, about some of the lessons that the National Center is learning from
the work of the states that participated in the policy academy. I’m telling you the summary of these data
slides that I’m going to show. What we know is that there are more children
that are recorded in the data system that are removed from principal care when substance
abuse is a factor. There is an upward trend in children in out-of-home
care. Disturbingly, more infants that are entering
out-of-home care than any of the other age groups when we look at entrance into out-of-home
care by age. Then also, that the impact for extended family
members who are caring for the children who are affected by substance abuse, it looked
a little different than perhaps what we even thought in the cocaine or the methamphetamine
epidemics. Some data to get started with. These are probably data that particularly
those of you who are the program managers for children’s bureaus are very familiar with. Perhaps our colleagues in other agencies may
not be as familiar with. These are the AFCARS population on September
30th of each year. After many years of this downward trend, that
was very effective in reducing the numbers in out-of-home care as was once a primary
goal of the Adoption and Safe Families Act, we began to see an uptick in 2013 in that
population. As well as when we look at the data that are
recorded in the CWA system, the Child Welfare Administrative System. There are optional items for case workers
to enter if the parent’s alcohol or drug use is a contributing factor for the reason for
the removal. You see even during the time period that the
overall were going down, more children identified as being with a parent with an alcohol or
drug use issue. Most times, when we present these data in
live audiences in states, we tend to ask, “Does this look like data that are reflective
of your state’s experience?” Typically we get a lot of no’s. That’s not what they experience. The reason why that overall data looks that
way on that about one-third of cases is the wide variability from state to state. We think there are two things going on with
this. One is the system that the state has to screen
and to identify parents with a substance use disorder. Then secondly, the system to actually record
that in the information system is wide variation from state to state. You can see the states that are in your region. Probably, there are not huge prevalent state
by state differences in your region, but if you look at differences from state to state
in what actually gets recorded in the information system. Some of the work that the National Center
has been doing over these years, how will they have a standardized screening assessment
protocol to identify families who are in need of services as well as that second component
of the information system. We’d be happy to follow-up with any of you
that would like other data related to this, but we encourage you again to look at data
from your states and just stay in touch with does that seem like what you’re hearing from
your state leadership. I mentioned already that one of the aspects
of the opioid crisis is the impact on multi-generational families. We certainly saw that in a cocaine epidemic. We certainly saw that in the methamphetamine
epidemic, but we haven’t seen the number of overdose deaths that were really in our country
before. While extended family have always stepped
up to provide kinship services, kinship care for the children with parents with a substance
use disorder, this is a larger increase than we’ve seen in the past. We look, again, at those AFCARS data about
children who are placed in kin providers, that they tend to be a higher percentage of
those that were noted in the case records that they had substance use disorders. Again, those are secondary analysis that we’ve
conducted based on the AFCARS data set, but it may be something that you’re hearing from
your state leadership about the impact on extended families. I mentioned this one already. In terms of this, these are children who entered
out-of-home care during the fiscal year, and the increasing trend for younger population
that’s really being driven by infants. Less than one year, about 47,000 infants in
the country who are placed in out-of-home care based on the safety and risk factors
that are evident in their family while this child is an infant. Let me back up. We get the question a lot. What do the data say about the impact of,
currently, opioids on the foster care system? Running through those data, you can understand
why we have to say we don’t really know that direct connection. One of the things that we are certainly aware
of in infants are the percentages and the numbers of infants who may have potential
effect from prenatal exposure. These are simply the national estimate of
substance use during pregnancy applied to the four million annual births. It’s not precise to say that these are other
than these national estimates that are applied to the annual births. You see that about 15 percent of women continue
to smoke during pregnancy, use of alcohol at 9 percent, illicit drugs at 5 percent,
binge drinking, which can be particularly concerning in the first trimester at a much
lower number, and heavy drinking at a smaller number. Then these are the data of infants that were
diagnosed with neonatal abstinence syndrome. Those are from the Medicaid data that have
been published looking at the increasing trend of NAS in Medicaid claims. Then again, the smaller percentage of infants
that are diagnosed with fetal alcohol spectrum disorder. Part of the reason for putting these data
out is that it relates directly to the Child Abuse Prevention and Treatment Act. There are three populations that are identified
in CAPTA for CPS to be aware of and for hospitals to take action regarding. That first is this potentially affected by
prenatal exposure. When you apply those percentages to the births
in any one state, you begin to get at least a feel for what the potential population is. These are obviously not direct consequences
but a way to at least look at what is that potential population. Then that second category in CAPTA, we’re
going to get into that in a little bit of detail in a bit, are those infants who experience
withdrawal symptoms. This narrow population of actually being diagnosed
with neonatal abstinence syndrome, or infant withdrawal syndrome, and then infants who
are diagnosed with fetal alcohol spectrum disorder. Just some ideas about ways to look at the
data to get a little bit of a handle of what’s going on in your own region. I mentioned that the data on neonatal abstinence
syndrome, or NAS, come from the Medicaid claims data. The most recent is a study that was done based
on 2013 claims. You see over the past almost 15 years, this
increasing trend on the rates of NAS over time. The same researchers have looked at the regional
variation from the hospital rates to establish the rates by region in the country. This is directly from their study that you
see the citation for, if you want to get further information on that for your own particular
region. Knowing that there are the infants that are
going into out-of-home care, we use the same regional breakdowns that these researchers
did and looked at the rates of infants that were placed in out-of-home care. It’s fairly interesting that it doesn’t overlay. We did this in part to try and understand,
is there a relationship between the higher rates of NAS and infants that are going into
out-of-home care? For those of you that are in the region from
Montana to Arizona and New Mexico are probably very aware that, that part of the country
is still experiencing more methamphetamine use disorders than opioid use disorders. While we certainly have reports that opioids
are affecting those regions, not in the same way that they’ve continued to experience the
methamphetamine challenges. In addition, and one of the things you may
be monitoring, we have more anecdotal reports from some of the northeast corridor and the
region from Michigan down to Alabama, that they’re seeing increasing trends again in
methamphetamine use disorders, even in the throng of the overdose death crisis that particularly,
the Appalachian states are experiencing. When we turn our attention to NAS, or neonatal
abstinence syndrome, I think many of you are very, very aware of what this looks like,
that the symptoms began after birth and what that may look like. We do know from the mother’s study, that was
conducted some time ago on pregnant women with opioid use disorders, that some of the
onset is related to the characteristic of the drug use and the timing of the last dose. We also know that most opioid-exposed babies
are exposed to multiple substances. We also know that there’s this wide variation
in the experience of NAS or the diagnosis of NAS among exposed babies, and that medication
is required in about half of those that expressed those symptoms and are diagnosed with NAS. We have this wide variation among pregnant
women who used opioid, of what percentage actually would be identified with an infant
with NAS, and then the requirement or the need for medication for those infants. This is a study that’s very new in the literature,
just actually last month in pediatrics. It reports on researchers at the NICU at Yale
University and hospital. Over a decade, they set out to try and reduce
the NICU stays and the impact of NAS on infants, and over that decade, conducted a series of
mini rapid-cycle testing series to try different kinds of approaches about what they could
do to decrease the NICU stay and the impact on their hospital as well as to increase the
outcomes for the infants and their families. You see the kinds of interventions, that non-pharmacological
treatment while giving morphine as needed, but the rooming in with the parent, the quiet
environment, not immediately placing the infant in the NICU, that the infant was roomed in
with the parents whenever possible. They stop the immediate, all these babies
go to the NICU and did some very focused parent empowerment about how the parent could soothe
the baby first. Then the changing a bit of the way that they
were assessing for the symptoms, and teaching parents how to assess for the symptoms, and
making sure that there was still communication between their units of the NICU when needed
and the regular maternity area of the hospital where babies may be rooming in with their
parent. Over that time period, they were able to decrease
the NICU stays. You see the outcomes dramatically, that they
also decreased it with almost a standard practice, that maybe would receive morphine during that
withdrawal syndrome to just about 14 percent. Obviously, dramatic implications for their
NICU cost and finding that there were not any infants that were readmitted for treatment
of NAS, and no adverse events were reported. I have this citation there. I would encourage you to take a look at that
and to share that with your state. We take very interesting research as well
as implications for public policy that we need to be paying attention to. I mentioned the MOTHER study which was conducted
a few years ago. We do know that there are many factors that
affect the infant’s manifestation of full withdrawal syndrome as well as the longer-term
outcomes for the infants. Receiving prenatal care is critically important. Maternal and child health plays such a huge
role in making sure that these moms are engaged in prenatal care. Exposure to the multiple substances. Again, from the MOTHER study, some of evidence
from that research that also, smoking and using opioids tended to increase the severity
of the NAS symptoms. What that means in terms of the childhood
experience, particularly for the infant, if they’re afforded those opportunities to bond
with their birth mother, when that can happen safely. How important that is as well as some of the
other health and psychosocial factors that may be imminent with the family that need
to be sometimes remedied and sometimes be aware of in terms of the child long-term impact. There’s also a consensus statement that was
recently issued a couple of years ago form the American Academy of Pediatrics. It’s not actually a meta-analysis. It is a consensus among the researchers that
have been looking at the short and long-term effects of substance exposure on infants. A lot of these research began, again, in a
cocaine epidemic. There are several studies from the ’70s on
opioid-exposed infants. Certainly more studies that have been done
on alcohol and tobacco than the illegal substances. You see the kinds of outcomes that the researchers
were looking for to see, as they look at this whole body of a 30 plus years of research
on the effects on children, the kinds of outcomes that they were looking for. On the next slide, I apologize for the blurriness
of this. We reproduced this directly from the article
that was published in the technical report for AAP. You see those areas of the substance in which
there is not enough information, those that have a star, those in which they did not have
a consensus on the effect. Then you see those that have been studied
and shown to have no long-term effect, or a strong effect, and across each of the different
types of substances that infants have been exposed to and have been researched. While we see this immediate, strong effect
of withdrawal from opioid, if you look across that withdrawal line, opioid is the one that
has the strong effect, not enough information on methamphetamine. The other kinds of substances don’t have that
immediate withdrawal impact but may have longer-term kinds of consequences, particularly in behavior
and neurodevelopment, cognition, language. I think this is a very helpful way for us
to be looking at both the short-term in birth outcomes as well as the longer-term effects. We’re happy to be able to share this information
with you. I think it’s a lot of what policymakers are
trying to understand, what happens when infants are exposed to these various substances. Again, you have the citation. Please let us know if you have any difficulty
with locating that. We can make sure that you get access to that. Windows of opportunity. What do we do with all of these data? What do we do with all of these information
about the impacts on family? We mentioned a little bit of time, for our
SAMHSA colleagues, this is information that you are very familiar with. I wanted to make sure that our friends in
ACF and maternal child health, HRSA, other areas of helping human services also has some
of these information. Then we’ll turn our attention specifically
to what the changes have been in the Child Abuse Prevention and Treatment Act and then
what we have been learning from the states that we’ve been working with. First, let me turn things over to our IT staff. We’re going to launch this poll, just a few
ways to engage you a bit. The first polling question, medication-assisted
treatment is used to treat a variety of substance use disorders. I’ll give you a few seconds to respond to
that and click your response. Yes. In fact, there are medications for a variety
of substance use disorder. Very knowledgeable audience that we have already. Interesting fact, again, this is information
that’s very well-known to our SAMHSA colleagues. The advances that have happened and understanding
their neurological advances in the brain disease of substance use disorders is quite remarkable
over the last decade to decade and a half. When we say it’s a chronic brain disease that
affects judgment impulse control and memory, we know that from the studies of the brain,
and the reward pathway, and the connections to the frontal lobe and decision-making. If you’re in the child welfare system, and
you’re working with families that have a brain disease that’s affecting their judgment, their
impulse control, and memory, you can imagine that the approach to this set of families
may need to look a little different than families that are not impacted by this brain disease. We know that there are variety of factors
that contribute to its development. Importantly, that is, in fact, a treatable
disease. That there is hope, and that there are ways
in which individuals recover. If you’re not familiar with the principles
of effective drug addiction treatment, this comes from NYDA. We can make sure that you have copies of that
for your states, if you’re interested. We wanted to highlight this component about
medication as an important element of treatment for many patients. The importance that we want to always make
sure that we’re saying is medication-assisted treatment. Medications need to be combined with the counseling
and other behavioral therapies, in most cases, and making sure that families are getting
access to both. We have another poll coming up. We have already looked at this. There are medications for a variety of substance
use disorders. We have polling question number two. Is medication-assisted treatment to treat
opioid use disorders in pregnant women safe? Sometimes, certain medications, yes. It’s recommended by ACOG and the World Health
Organization and the American Society of Addiction Medicine. Yes, abrupt discontinuation of opioids rebuilds
awesome results and relapse. Yes, in conjunction with counseling and other
services. About half of you shared your views. We’ll go forward. Most indicated all of the above. We would agree with you that these are all
things that are specific to the use of medications with pregnant women that, again, ACOG, the
American Society of Addiction Medicine, and the World Health Organization recommends as
a clinical standard. Also, medications that are available to treat
opioid use disorders. These are the names that I’m sure that you
have seen, in even the mass media, or regular media of understanding Narcan, reversing overdoses. The extended release of naltrexone that is
a once a month injection. We recognize that some states are using that
in conjunction with the criminal justice system because after released from incarceration,
or after a period of time of abstinence is a very risky period of overdose. As well as those that have been researched
to be used during pregnancy. Methadone and Buprenorphine in the Subutex
form are those that have been studied for use during pregnancy. The goal of providing medications during pregnancy,
when we certainly get media reports about how could you do this during pregnancy and
how could ACOG and ASAM and the World Health Organization say we should be giving medications
during pregnancy. If we think about the goal of stability for
the pregnant women and the fetus, the studies that have been done show the high relapse
rate for return to opioid use after periods of abstinence, and that the stability for
the pregnant women in using medication helps to provide that stability for the fetus. That’s really one of the goals of existing
treatment with medications during pregnancy. When we say it’s a standard of care, it was
in fact a public release justice week from ACOG, again, on reiterating the standard of
care with medication-assisted treatment with counseling during pregnancy. Again, some of that information that we just
talked about, the substance withdrawal that the fetus experiences is the pregnant women
experiences that, is part of the need for making sure that the prenatal care going on,
as well as decreases in other substance use, the reduction in acquiring HIV or HCV during
pregnancy. Again, the risk of overdose, and providing
that increased opportunity for stability for the pregnant women and the fetus. Each medication varies in its ability to prevent
or reduce the withdrawal symptoms and the craving symptoms. We think it’s important that we recognize
that medical doctors should be those that are making those determinations of which medications,
the dosage, and the duration. You have probably had phone calls from your
states about sometimes, policymakers or judges that insert their way of saying that this
is what they believe should happen for medications. We think it’s important that we’re relying
on our healthcare system and our physicians to make those determinations about dosaging
and medications during pregnancy. We’re going to turn our attention to cap the
specific kinds of information. For our next poll, what does CARA, the Comprehensive
Addiction and Recovery Act, have to do with prenatal substance exposure? I already told you this answer. We should have 100 percent voting. Let’s see what the result looks like. Yes, in fact, these are the very knowledgeable
audience we have because many times, I’ve been making presentations around the country. I mentioned CAPTA and CARA and what does it
have to do with prenatal exposure, and no one seems to know. We’re delighted that this is a very informed
audience that, in fact, that the Child Abuse Prevention and Treatment Act was changed,
and that it expands the plan of care that’s required when infant is identified beyond
the needs of the infant to also address the needs of the affected caregiver. This is a true opportunity, to be able to
look at the way we construct family-centered practice and interventions for the set of
families. This is a summary. In case you’re interested in the various changes
based on the 1974, CAPTA’s origination of the first change in 2010, that included conditions
for the state grant. We’ll talk about these a little bit more in
detail. This is pretty small on the screen, but we
wanted you to get the sense of 2003, 2010, and 2016 are the changes that were made in
CAPTA. We also want to point out that in each of
the changes in CAPTA, it was established in 2003 and has continued that while there is
a requirement of a notification from the health provider to PCS, that’s the notification. I shall not be construed to establish a definition
under federal law of what constitutes child abuse or neglect or require prosecution for
any illegal action. States vary. You know that probably even within your own
region, about their state statutes regarding this population. We always say that that’s the place to start
is understanding what the state statute says right now about how they address this population
in terms of substantiated child abuse or neglect based on their state statute. The primary changes that were related to infants
with prenatal exposure in 2016 was first to clarify this population. Born with and affected by substance abuse,
remember that left-hand component of the prevalent slide that we looked at, or withdrawal symptoms
resulting from prenatal drug exposure or fetal alcohol spectrum disorder. What’s unique is that it specifically removed
illegal. Born with and affected by, used to say, illegal
substance abuse. Now, it says affected by substance abuse. You can imagine that these are some of the
challenges I’m sure that you’re hearing about from your states about how to implement this
with families that may have an infant who’s affected by illegal substance, particularly
in the area of marijuana. The changes that we have across the states
in both legal marijuana use, as well as medical marijuana, and some states in which it has
not been made available for medical or for legal use. What we think is important in that is to make
sure that we’re talking about those substances as it relates to risk and safety for the individual
child. When we talk about the legal substances is
that place that child at immediate safety concern or risk of chronic neglect, are there
other things that are being reported besides just the substance use? The second component is this requirement that
the medical provider is to notify CPS of the infant that are identified in these three
categories, and a plan of safe care is to be developed that addresses the needs of both
the infant the family or caregiver. The family caregiver is to add in 2016. It specifies data to be reported by states. It increases the monitoring and oversight
per state to ensure that plans and safe care are implemented and that families have access
to those appropriate services. Many changes that, as you all know, have created
an increased awareness and mistakes about what they have been doing are related to plans
of safe care in the past as well as trying to understand the implications for their implementation
in their state. Children’s Bureau has released three program
instructions and an information memo. We wanted to highlight those in case you haven’t
had the opportunity to read those or to have those in your toolkit as you’re working with
your state. First in April 2016 that ask states to describe
what they were doing. I’m sure all of you, those that are on the
Children’s Bureau side of the house in the audience have been reading those and understand
that. Then in August, an information memo that was
information about these changes that went into effect in July 2016. As well as highlighting some of the promising
practices, particularly related to collaborative practice and how states and communities put
these services together. Again, program instructions in January 2017
that provide clarifications, and the program instruction in April related to the reports
that were just turned in for the state plans. In that era of these increased changes, the
National Center on Substance and Child Welfare, under the leadership of our SAMHSA and Children’s
Bureau, have had a variety of initiatives to look at the local and state implementation. First, last summer, hard to believe it’s a
year ago now, with the release of a monograph that was done in conjunction with a team of
about 40 professionals from across disciplines and across the country to provide guidance
to states on implementing a collaborative approach to treatment of pregnant women with
opioid use disorders. The tendencies of this monograph include ways
for states to come together to assess their practice now, as well as for local community
to understand a way in which families are identified and what their system looks like
at present in order to identify the priorities about their practice and state changes that
they may need to better serve this population. We also want to make sure that you are aware
of the information that’s available on the National Center on Substance Abuse and Child
Welfare’s website. We’ve conducted a series of webinars on the
full scope of medication-assisted treatment to treatment of pregnant women, treatment
of NAS, and the information that’s available in the monograph that was released last summer. We know that some communities that are coming
together, watching these webinars that are in the library and then having their policy
in practice discussions about what their implications are in their own community. We also adapted a program that the National
Center have been conducting. We refer to it as in-depth technical assistance. We’ve been in just over half of the states
in providing assistance to states in strategic planning on this broader population of substance
abuse child welfare in the court. In 2014, we adapted that, to be specific,
to substance-exposed infants to provide assistance to states to advance their capacity. You know that this is what’s created even
before the changes in the CAPTA statute. We’ve been focusing on this for some time,
about what it takes for a state to actually implement the changes that are needed to have
this collaborative approach. You see the states that have been part of
the in-depth technical assistance that was tailored to implement practice and policy
changes specific to these set of infants. At present, Delaware and New York are active
in-depth technical assistance sites. The other states are in varying stages of
post-IBTA follow-up and implementation. I mentioned previously that Children’s Bureau
and SAMHSA supported a policy academy in February of this year. You see the states that participated as well
as the states that had been part of the in-depth TA came to share their experience in a bit
of a mentor role for the new states. From this experience with these various states
in these different programs, we’ve tried to categorize the challenges that they’ve told
us about, but also turning that around a bit to the opportunities that have been identified
by states and the area of practice and policy that they needed to address. First, in the area of prenatal screening. Really trying to understand, does prenatal
screen happen in private practice or public health clinic in the MCH programs? To understand some of the reasons that OB-GYNs
were giving us about why it doesn’t happen. Often, it was about these kinds of things
that are listed in the bullet points. Frequently, we heard, even if they scream,
they didn’t really have the expertise to know where to spend that individual pregnant women
for the next step. If someone breaks their arm, if pregnant women
breaks their arm, there is an orthopedic physician in their network, probably a colleague that
they know in their community that they would be referring that pregnant woman to. If it’s assessment disorder, they may not
know who the provider network is in their community. They didn’t really know, what do I do as a
next step if I scream? You see some of the other things that physicians,
in particular, and community providers told us about why they think or why they didn’t
conduct a screening as a practice that is supported by ACOG that all pregnant women
should be screened, why that really wasn’t happening. A second area was related to understanding
medication-assisted treatment. Then we heard not only are there OB-GYNs that
are reluctant to have patients with opioid use disorders in their case loads, but there
are also opioid treatment providers who are reluctant to have pregnant women in their
case loads. We have this gap on both sides of the delivery
system as well as the need to make sure that the treatment resources were culturally-appropriate,
evidence-informed, and gender-specific, that there are some real gaps in the treatment
network for this particular population. The third area was about having a protocol
at the hospital. At birth, how are these protocols implemented,
if there are protocols, about how they identify infants with prenatal substance exposure? We look at the protocol at Yale and how they
changed that. That’s very rare. We don’t hear that too often on having the
other kinds of non-pharmacological approaches always being implemented in the hospital. There is often reluctance to follow-up to
do the notifications. Who is supposed to do that in the hospital? Is that the hospital social worker’s responsibility? Is it the OB who’s delivered the baby? Is it the nursing staff? Inconsistent protocols about how that hospital
notification was to happen, and then also the awareness that the hospital discharge
plans often didn’t address the mother or the caregiver of substance use. Typically, at this point, there are not plants
to take care that are being developed that addressed the infants, the family, and the
caregiver. We’re currently looking at this as a standard
practice right now. We also know that there are challenges about
making sure that there’s ongoing support. How do we know that the infants that do become
part of the case load of child welfare services, that they’re getting the early intervention
services that are required as part of Part C. The home visiting providers who may not be
equipped to work with pregnant and parenting women that have substance use disorders, what
kinds of training do they receive? How do they engage families, particularly
the new mother or the pregnant women, in these voluntary services? We know that there’s a lot of variation and
lack of medical coverage for the continuing care and the follow-up for postpartum services,
particularly in states that were non-Medicaid extension states. While we know that Medicaid covers about half
of the prenatal care in birth for infants and their families in the country, there is
a great deal about what the postpartum coverage is under Medicaid. Again, they’re making sure that the services
are reflective of gender-specific services that are needed. We’ve talked about those four areas of information
related to practice in the policy. Then some lessons that we’ve learned about
collaborative practice that is needed in the state. First, some lessons about how to structure
the collaborative. We recognize that when we talked about these
kinds of health social service, other kinds of services that needs to be put in place
for families, there’s no one single agency who, if you will, has the ownership of this
population. It’s multifaceted, it requires multiple agencies. The foundation of collaboration about having
a purpose for this set of families often isn’t necessarily in place right now. We have to have the ability to look at the
differences in discipline and values and to reflect the local communities’ values and
the outcomes that they want to achieve. Much of our collaborative work, we try and
help communities and states really focus on the resources across these agencies. What are the rules that are preventing services
from being able to be delivered in a coherent way for families, and our real focus on what
does that community, what does that state want to achieve and the result so that they
have the glue, if you will, to hold these collaborative together? We also have been a little bit more prescriptive
in the last actually decade than we were in the first five years of the National Center
and trying to work with states in creating the major system changes than collaborative
practice. We have found over the years that if we don’t
structure the collaborative in a way that produces results so that each of these different
levels of the system has some specific rules and responsibility, that the collaborative
often becomes just a bunch of people talking and sharing the most recent things that they
have done in their own agency. We sometimes refer to that as a BOGSAT. That is a bunch of guys and gals sitting around
the table. We try and really help states and communities
move from sharing what’s the latest thing that’s happened in your agency. To be very focused on what are the results
that we want to see in that community, that they want to see in their community, and how
do they structure that collaborative work so that it become a way in which they’re really
working together in a productive way? We know that, that takes leadership. That is leadership at each of these different
levels of the system, from the oversight committee. It’s not just the state director. Leadership sometimes happens from the Family
Treatment Court Coordinator, or the public health nurse, or the person who is overseeing
the home visiting programs. That the leadership happens in various areas. Part of our task is to understand who those
leaders are and to help them create the change in their community. We also know that this is an era of increasing
complexity for child welfare agencies. They typically are not natural partners with
hospitals, other than perhaps getting referrals from them. They may not be as hide in with early intervention
providers, so the Department of Health or their home visiting program. Reaching out to Medicaid to understand what’s
going on for the families that are in the child welfare system or in substance use disorder
treatment. Those are new relationships for many of these
agencies. It’s challenging. Just as we know that over the 15 years of
trying to help substance use disorder, Child Welfare and Court build this collaborative
structures. When you add the new partners from the healthcare
arena, we often say it’s not additive. It’s exponential in the complexity because
they all have their own disciplines, and funding structures, and ways in which they are conducting
their own business. It become being increasingly more complex. We also are hopeful that we know some things
about how to engage, how to assess, again, the standard practice and how to bring them
together to create ways in which they’re working together and focus on those outcomes. We also have some lessons from the states
about the data collection recording and data integration that is needed in order to respond
to the increased reporting requirements in CAPTA. We know that there are some states that have
made changes in their information systems that are specifically addressing the items
that are in CAPTA. They are to be reported in the annual report. It also means that practice and the policy
protocols that I mentioned about, if you have a screening, are those results actually getting
into the information system? The practice protocol, the training on that,
as well as the policy for the particular state about how they are to enter that information. Importantly, how supervision happens to know
that that training and assessment has happened. Here’s a pop quiz. We have another polling question, if we can
launch that. We just talked about the current CAPTA provisions
requiring prenatal substance exposures. Read through those options. What does the new CAPTA requirements include? Clearly, a very attentive, smart audience
we have going. Thank you very much for indulging us with
that. Everyone recognized that these are the changes
that we’ve been talking about. I’m sure many of you were very aware of those
changes even before this presentation. When we think about what are the immediate
state considerations, it was interesting, I was at a three-branch institute. Many of you are probably aware of that when
they bring together the judicial, the legislative, and administrative branches in strategic planning
kinds of efforts. One of the gentlemen that talked about the
efforts that they had been making, specifically related to substance-exposed infants, they
had passed some state legislation. He said his most important advice to colleagues
was to make sure that they had a clear definition of what is an infant affected by substance
abuse before they passed state laws. That they passed their law, and then they
found that there were so many different opinions about, “How would you identify, and what does
this mean, ‘affected by substance abuse’,” that it was quite a path for them to try and
then fit these definitions into their statute. Clearly, understanding what the state’s definition
of these three populations, clarifying the notification procedures from hospitals, from
OB-GYNs, to know what that procedure is supposed to be. Then how it is made, the notification, as
well as what does the intake at CPS look like? Is there a procedure that is followed once
they have that notification from the hospital that needs to be standardized and needs to
be thought through about how the different populations of families, maybe the services
that are put in place for them? By those populations, the difference between
a pregnant woman who has a substance abuse disorder, a pregnant woman who is receiving
medication-assisted treatment, and a pregnant woman who may be receiving medications that,
in fact, the infant may have withdrawal symptoms. Benzodiazepines, for example, that may not
have a substance use disorder. How do we separate those populations and know
what the protocol is for CPS to put in place their services? In the CAPTA statute, there’s not a requirement
that CPS is the only agency who can develop and implement, oversee the plan of safe care. A critical role for SAMHSA agencies is for
those treatment providers who have pregnant women, to engage with their community partners
in advance of the birth, to make sure there’s a plan of safe care that is put in place before
the birth event. How helpful that would be to their colleagues
in child welfare, as well as how empowering for families to have their plan before the
birth if this is a population of pregnant women who may have an infant that could be
in these three categories of affected by withdrawal symptoms or FASD? How do we get engaged families in making those
plans in advance? Then responding to those changes in data collection
and reporting. I’m sure for the child welfare managers, the
Children’s Bureau managers, program managers that are reading the annual reports now, I’m
sure you’re beginning to see some of those data collection challenges in the states and
how states are beginning to respond to that. At the local level then, some of the challenges
are related to how to implement these coordinated assessments. Looking at the prenatal screening and the
different kinds of factors that we’ve been talking about today in assessment and the
components of the plan of safe care. We have some examples. There’s not a lot that is out there at this
point, particularly related to plan of safe care templates. The states that did have those in place, they
were before these most recent changes to CAPTA, we have states that are working on plans of
safe care protocols. We have examples from Ohio, in particular,
that made changes in their SACWIS system about identifying and reporting for this particular
population. We have some examples of both state statutes
that have passed and those that have been proposed and didn’t pass. If your states are struggling with some of
these different components, please do be in touch with us. If you don’t see it on our website, to let
us know how we can be helpful to make sure that you have those examples. Again, they’re not complete, but they’re the
beginning of an inventory of what states are actually putting in place that we’re trying
very hard to make sure that we’re staying on top of so that that information can be
shared across the states. With that, I think we have time to open up
for some discussion. Let me check first with our staff if there
are some questions that came in. While you are looking at the input that we
got from the survey that we asked, do you know of some initiatives that are going on
in your community? These are some of the things that you submitted
to us about some of the changes that have happened in your states. I don’t know if there’s anyone that submitted
this information that wants to share that in a chat box. Or Katy, if there are some other questions,
perhaps, that came in. Katy: We do have one question so far that
says, “Can you speak to any NAS prevention. For example, the importance of having clinicians
speaking referring women in treatment for SADs to use contraception, especially long-acting
reversible contraceptives in order to prevent pregnancies when taking these medications,
or the same question for clinicians who are giving prescriptions for opioids?” Dr. Young: The two places that I have heard
of in which this program is in place is Tennessee. They have an initiative underway to ensure
that physicians who are prescribing to women any of the medication-assisted treatment,
or that have pregnant women with opioid use disorders. No, sorry, scratch that part, because the
long-acting contraception is for those that are in treatment. We do have some information that came out
just this week related to that. They have a website that we can connect you
with in Tennessee. Then I just became aware this week that Ohio
is exploring some of those program strategies. I can speak to some of the things that we
know in the family treatment court arena, that this has been something in looking at
comprehensive treatment approaches. Reproductive health has been one of the areas
that family treatment courts have been aware of, making sure that participants have access
to reproductive health. This is pretty standard practice in gender-specific
treatment programs that women have access to reproductive health and that this is something
that is a focal point for gender-specific treatment to make sure that reproductive health,
as well as all of the health care needs of women, are tended to during the time that
she is in a treatment program. We don’t have other questions that have come
in at this point. Let’s take a minute to look at what was submitted. I think that there’s some information, particularly
from Louisiana, with the clinician toolkit, that we want to make sure that your colleagues
know about. We can follow up and make sure that that is
in our inventory of examples for you to be in touch with us about, and making sure that
the drug treatment programs for pregnant women are a part of the network that Child Welfare
Services and home visiting services are aware of. I often find, when I am working with a state,
that they may not be familiar in the Child Welfare System with the single state agencies
and the staff in the substance abuse treatment agency at the state level who oversee the
pregnant and parenting women program. They are referred to across the states as
the Women’s Services Network and often are the women’s services coordinator in the state
agencies. If your states are not working with the substance
abuse women’s services coordinator, we would encourage you to make sure that that connection
is happening. They have a lot of information. They have all the information about the treatment
programs that are in their state that are gender-specific programs and those that have
specialized services for pregnant women. There is a listing on the website for NASADAD,
the National Association of State Alcohol and Drug Abuse Directors. We can make sure that you are connected to
the Women’s Services coordinator for making sure that your treatment agencies are aware
of the components of CAPTA, that they could be helpful with, as well as vice versa, that
the child welfare agencies, home visiting agencies are engaged with the state agencies
related to treatment for pregnant and parenting women. Thank you for your participation. We have an evaluation that is going to pop
up after we close out the webinar. We would appreciate very much if you would
take a moment to complete the evaluation, a way to get in touch with us in the PowerPoint
that you received yesterday. We want to make sure that you have, from the
PowerPoint, the various information memos, the program instructions that we mentioned
today, as well as the way to get in touch with us, as I mentioned on that part of the
slide. We also want to make sure that you are aware
that the National Center on Substance Abuse and Child Welfare have three online tutorials
in which free CEUs are offered. We have about 70,000 or so, I think a bit
more than that now, individuals who have taken these courses. There are at least seven or eight states that
require the online course of all of their child welfare workers. First, the number one is geared to child welfare
workers and its understanding substance abuse and facilitating recovery. It just takes about four hours to complete,
and there are four free CEUs from the National Association of Social Workers at the end of
that. The courses were all updated last summer to
add new context related to opioid use disorders, and some other changes specifically related
to Family Treatment Courts, and making sure that the presentations of these courses were
updated. The second course is a guide for substance
abuse treatment professionals. It teaches about child welfare and the dependency
Court, particularly the timelines, the information that child welfare agencies need from treatment
professionals. Then you see the third course which is geared
to legal professionals. Judges and attorneys that are working in the
dependency court and have families that have substance use disorders. Then some of the other resources that are
available, again, on the National Center website. The guide for child welfare workers was intended
to be a basic primer that is available for child welfare agencies to download and make
part of their new worker training. Some tutorials that are available to you,
as well as the additional set of many different monographs that have been produced on various
topics, including drug testing and the substance abuse specialist. Meaning, the ways in which communities organize,
bringing in the expertise of someone from the substance use disorder treatment agencies,
or recovery coaches, peer mentors, various models in which that connection is happening
at the local level and pairing up with child welfare agencies and courts. A lot of resources, again, that are available
on our website. If you haven’t visited the website, you see
the link there on the bottom left. We would definitely encourage you do to that
because there are many resources that are available to your states. Again, thank you so much for making the time
for this webinar today. We look forward to hearing from you about
how the National Center could be helpful in your particular region. Thanks very much everyone.

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