August 15, 2024 • 40 mins
Episode 6: Putting Harm Reduction to the Test: Drug use, Pregnancy, and Parenting
Featuring:
Leah Warner, NP, MPH
Street Medicine San Francisco Department of Public Health
Simone Vais, MD
UCSF Department of Family and Community Medicine
Host:
Jamie Lang
New Beginnings Case Manager, Homeless Prenatal Program
Pregnancy and the postpartum period challenge our notions of harm reduction and force us to address fundamental questions: who is our patient, and who is the primary focus of our harm reduction efforts? Is it the birthing parent, the fetus, the baby, or the entire family unit? Join host Jamie Lang and presenters Simone Vais, MD, and Leah Warner, NP, MPH, as they navigate through two intertwined journeys—one of substance use and recovery and another of pregnancy, birth, and parenting. On this journey, we inevitably encounter values that might be in conflict with one another, such as the family unity, recovery, and safety. Episode six delves into these dilemmas, exploring the tensions that arise and examining various harm reduction strategies applicable at different points along the continuum.
Find us online at amersa.org, and see our tweets at x.com/AMERSA_tweets.
Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kinna Thakarar (00:13):
I'm Kinna Thakarar and welcome to the
podcast series, Harm Reduction,Compassionate Care for People
Who Use Drugs.
Harm Reduction is a socialjustice movement started by and
for people who use drugs, andit's a philosophy of care and
practical set of strategies tooptimize people's health,
safety, and rights.
We want to acknowledge and honorthe long history of street
(00:33):
medicine and healthcaredeveloped by people with lived
and living experience to keepone another alive and safe
through community care.
Whether you're a seasoned harmto the concept, we're glad
you're here and hope you'lllearn something new and are
curious to explore seeingpatient care through a harm
reduction lens.
This podcast series is broughtto you by the Providers Clinical
Support System, Medications forOpioid Use Disorder Project, and
(00:56):
AMERSA.
This week, we welcome JamieLange in conversation with Dr.
Simone Bays and Leah Warner todiscuss putting harm reduction
to the test, drug use,pregnancy, and parenting.
Our host, Jamie Lange, iscurrently employed by Homeless
Prenatal Program as a casemanager supporting people in
pregnancy and postpartum who areexperiencing homelessness,
substance use, and mental healthchallenges.
(01:16):
She is also a passionateadvocate with Homeless Emergency
Service Providers Association,Treatment on Demand Coalition,
and Housing Justice.
She is formerly chronicallyhomeless, used substances and
found recovery in pregnancy.
Most importantly, she is thededicated mother of a six year
old.
Simone Bays is a family medicinephysician and current addiction
medicine fellow in the UCSFPrimary Care Addiction Medicine
(01:39):
Fellowship.
Her clinical focus is perinatalsubstance use with a particular
interest in the postpartumperiod and the gaps in care
between pregnancy and primarycare based services.
She works as a primary carephysician at the Family Health
Center and in the Team LillyPostpartum Clinic, a family
based clinic for postpartumpeople and their infants
impacted by substance usedisorders.
(02:00):
Leah Warner is a nursepractitioner in whole person
integrated care on the streetmedicine team.
Since 2014, she has worked onthe street medicine team
providing primary care servicesfor San Francisco's patients
experiencing homelessness.
Other interests includeunderstanding and improving
homeless services through a lensof gender, pregnancy and
substance use, intimatepartnerships in the setting of
substance use, and trans care atthe intersection of substance
(02:23):
use and homelessness.
Prior to becoming a clinician,Leah worked in public health in
the field of reproductivejustice.
The presenters reported nothingto disclose.
Thanks for joining us, Jamie,Simone, and Leah.
Jamie Lang (02:34):
Greetings and welcome to this podcast.
I'm very excited to be here withmy esteemed colleagues to
discuss a topic that's very nearand dear to our hearts.
The intersection of harmreduction, substance use, and
the pregnancy postpartum period.
So much of what we believe aboutharm reduction really gets put
to the test when it comes topregnancy and parenting because
(02:54):
we're faced with the existentialquestion of who are we reducing
harm for?
The birthing parent or theinfant?
Leah Warner (03:02):
Now, why does it sometimes feel like harm
reduction for one party canstand in direct conflict with
harm reduction for the other?
Are there cases where that'strue?
How do we practice harmreduction?
We want to dig into all thesequestions, but first, let us
introduce ourselves and lay outour learning objectives.
Jamie Lang (03:24):
I'm Jamie and I'll be your host.
I currently hold A client facingrole at a local non profit
supporting people in pregnancyand postpartum who are
experiencing homelessness,substance use, and other various
adversities.
I also advocate with variouscoalitions related to
homelessness and treatment ondemand.
I lived on the streets of 10years.
(03:45):
I'm a former drug user.
I used substances and foundrecovery during pregnancy, and
I'm a parent to a happy andhealthy six year old.
Now, I'll send it over to my cohost, Leah.
Leah Warner (03:57):
Thank you, Jamie.
I'm a big fan of yours.
I'm Leah.
I'm a nurse practitioner with abackground in public health and
I work on a street medicine teamin San Francisco.
So what that means is mypatients are adults who are
experiencing homelessness.
And what that means is that Isee a lot of extremes.
(04:18):
I see extreme poverty.
I see really extreme substanceuse.
Unmet mental health needs andsome very extreme wounds, but no
matter all the extremes that Isee, it still really challenges
me to see people in theirreproductive and pregnancy
stages of life while they'reexperiencing homelessness and
(04:40):
using substances.
So I am so excited to be hereand talk about this very topic
today.
Jamie Lang (04:49):
Thank you, Leah.
Welcome, Simone.
Simone (04:52):
I'm Simone.
I'm a family medicine doctor bytraining, and I'm currently
finishing up my addictionmedicine fellowship at UCSF.
My clinical work is at SanFrancisco General, where I
primarily work at a postpartumclinic for people with substance
use disorders and theirchildren, which means that my
patients are birthing parentsand their babies and can I just
say how grateful I am to haveJamie here to not only ask Leah
(05:14):
and I questions, but also tocheck our assumptions as
somebody with lived experiencein this realm.
Jamie Lang (05:19):
Thank you, Simone.
It's great to have you bothhere.
Could you tell our listenersabout the learning objectives of
this podcast?
Simone (05:26):
Our learning objectives for this episode are firstly to
identify the harms that we'rescared of when pregnant and
postpartum people use drugs.
Like, let's just name it.
What are we actually afraid of?
Two, talk about what are theharm reduction strategies that
we can use at each stage in thereproductive cycle?
So preconception, pregnancy, andthen postpartum and parenting.
(05:48):
And then three, to analyze thebarriers to healthcare during
pregnancy and postpartum forfolks who are using drugs.
and a brief disclaimer onlanguage.
Throughout this episode, we'regoing to use different pronouns
to refer to people who givebirth.
Sometimes we'll use genderneutral pronouns, sometimes we
may use male or female pronouns.
We just want to acknowledge herethat there are a diversity of
people who can and do givebirth.
Jamie Lang (06:08):
Thank you, Simone.
Simone and Leah, as medicalproviders, what scares you the
most about caring for pregnantor postpartum people using
drugs?
Can you describe a time when youfelt overwhelmed by a patient's
substance use?
simone--she-her-_1_04-26 (06:20):
Thanks for asking this, Jamie, because
I think, if we don't clearlyenumerate like what exactly are
we afraid of, it's difficult tocome up with solutions that are
right size for our fears.
So my clinical work, like Isaid, focuses primarily on
postpartum people.
And so I'm going to focus onthat time period for a moment,
also because I think likesocietally we focus so much on
pregnancy when we think aboutthis topic.
(06:42):
And so, so much of people'srecovery actually happens in the
postpartum period.
Just to name some of the thingsthat I'm afraid of in no
particular order at all.
And ask also to add the caveatthat when I do this clinically,
like I do try to outline whatI'm afraid of, but I also add
how likely are each of theseoutcomes, because I think it's
important when you're trying toright size your solution to not
only name your fears, but alsosay, okay, but how likely are
(07:04):
these to happen?
With no order at all.
I'm afraid of a postpartumparent using fentanyl while solo
parenting like a newborn andgetting so sedated that they
either inadvertently drop a babyor just aren't watching while a
baby crawls into somethingdangerous.
I'm afraid of babies ingestingfentanyl, which is something
(07:24):
I've had happen.
to several patients.
I'm afraid of having babiesremoved from their birth parents
and placed in foster care wherewe know the outcomes are not
good.
I'm afraid that if I, forexample, call CPS on a family
that I will break my trust withthem and with the healthcare
system.
I'm afraid that if a dyad isseparated, then what might have
(07:45):
been a brief slip in a parent'srecovery will become like a long
term return to use and will kindof end the chances of
reunification.
obviously, a lot of these fearsare in conflict with each other.
Leah Warner (07:58):
Yeah, the thing I'm most afraid of is my own bias
and agenda.
Think there's really goodnational meta analyses
describing the prejudice thatpeople who use drugs feel when
they access healthcare, and ifyou add reproductive health and
pregnancy, postpartum andparenting to that conversation,
(08:19):
that prejudice only increases.
And I think there is a lot ofprovider bias and prejudice out
there.
I think it's very real and itcomes from a lot of places.
But if I'm speaking for myselfpersonally, my bias really can
come from fear.
So I'm grateful for thisquestion.
I fear all of those bad outcomesthat Simone listed.
(08:44):
And I fear that in trying toprevent them, trying to prevent
these bad outcomes from everhappening to my patient, that I
will turn into a biased providerand that bias will really guide
how I talk to my patient.
So that's.
Pretty abstract, so I'm going togive a real example.
(09:04):
I had a patient once who reallyhad me scared.
She was in a really abusiverelationship, she was very deep
into her substance use, and shehad a lot of medical, kind of
dangerous health problems goingon that were unstable.
And when she shared with me thatshe wanted to get pregnant, I
spent the visit trying toconvince her not to do that.
(09:27):
And I'm someone who has seen theresearch that describes the
prejudice that patients can feeldiscussing reproductive health
with providers like me, likepressure to use long acting
contraception.
But in that moment, I was onlythinking about what I was afraid
of for her.
And I was also thinking aboutthis abstract pregnancy that
(09:49):
didn't even exist yet.
And the fears I had for herturned me into this provider
that I don't want to be.
The one who gives her patientsthe message that their substance
use defines their reproductivegoals and that a bad outcome is
already written in stone.
Simone (10:05):
I think like my biggest takeaway from my experiences, in
this realm so far has been, youknow, pregnancy can be so
incredibly motivating for peopleand we never know what's going
to happen.
And so all we can do is offerpeople and surround people with
the support they need and kindof let them write the rest of
the story.
Jamie Lang (10:22):
I definitely identify with that.
Becoming pregnant wascomplicated for me and the first
interaction I had with ahealthcare setting was a male
doctor and his recommendedtreatment for my situation was
an abortion.
He told me that since I was adrug user and I was living in a
tent, it was probably the bestdecision for me.
I wish he would have helped meget into treatment.
(10:44):
I tried getting into treatmenton my own, but they sent me away
and said I had to come back inthree days.
Treatment is ultimately what Iwanted.
This was the first time Irealized that the systems in San
Francisco were not going tosupport my needs with this
pregnancy.
became highly motivated to startdetoxing on my own without any
support in the streets.
I came in contact with thehealthcare system three times in
(11:05):
my early pregnancy wantingtreatment and was discharged to
the streets with nothing eachtime.
leah-warner--she-her-_1_04 (11:11):
See, hearing that story, Jamie, it
really makes me of course, judgethis provider, right?
Who recommends that you go andget an abortion when he hears
that you're pregnant.
I think it's important for mepersonally to remember that I
can be on that side of healthcare where I can let my own bias
(11:36):
start to guide how I'm talkingto the patient in front of me.
So I appreciate that story.
jamie-lang--she-_1_ (11:43):
Absolutely, Leah.
Simone and Leah, can you giveexamples of harm reduction
approaches through the stages ofpreconception, pregnancy and
postpartum, and the stage ofparenting that work, and any
that were not as effective?
Simone (11:56):
Oh yes, I love this question! Here come four soap
boxes from me.
Strap in everybody.
First and foremost, as we allknow, the, the best thing that
we can offer any of our patientswith, let's just talk about
opioid use disorder, the bestthing that we can offer any of
our patients with opioid usedisorder is access to life
saving medications on demand.
(12:17):
So, methadone and buprenorphine.
And then, specifically, in thepregnancy and the postpartum
period, those medications dosedappropriately, right?
We know that the metabolism ofmethadone and buprenorphine are
increased tremendously inpregnancy and in the early
period, which means that peopleneed both higher doses and more
frequent doses.
(12:38):
And, and they need that forthose medications to be
therapeutic and to actuallywork.
Not only do people need theirdoses to increase when they're
pregnant, they also, will havetheir metabolism change again
when they become postpartum, anda dose that was previously
therapeutic for them mightbecome super therapeutic and now
causes them sedation.
And we need to tell people aboutthis, and we need to monitor for
(13:02):
it, and then when we see thisover sedation, which is an
expected outcome of metabolismchanges, we need to treat it not
like a failure, but like anatural history of medication
metabolism.
I think so often when we, whenwe in different spaces encounter
folks who are on methadone orbuprenorphine, particularly
methadone, and are over sedatedon their methadone, like, There
(13:24):
are so many questions that arisepatients are accused of using,
and it can be incrediblytriggering for patients when all
they've done is get pregnant,get postpartum and keep taking
their methadone as prescribed.
And then we're just accusingthem of doing things wrong.
So dose it appropriately, bothwhile you're up titrating and
down titrating.
Leah Warner (13:42):
Here here.
Get that dose right.
I love that.
I think it is also important toeducate not just providers who
are prescribing the methadoneBut also all the frontline
healthcare providers who willsee that patient, that sedation,
over sedation can be a thing inthe postpartum period.
Simone (14:02):
Okay.
So box number two, are youready?
So first, you're going to getpeople on life saving
medications, and you're going todose them correctly.
Second, we need to haveframeworks that guide our
conversations around ChildProtective Services, or whatever
it's called locally for you.
The decision to call ChildProtective Services, has a
profound impacts on patientslives.
(14:23):
Appropriately, it is therefore avery stressful and overwhelming
decision for providers, and wenever make our best decisions
when we're stressed,overwhelmed, and scared.
And so, in any way, a decisionthis big and with these profound
impacts should never be made byone person.
At San Francisco General, whereI work, we, we've instituted
this, it's called the Dyad CareCoordination Timeout.
(14:46):
Basically, on labor and deliveryand postpartum, if anybody
thinks that Child ProtectiveServices is going to need to be
called, we have amultidisciplinary meeting where
The inpatient team is present.
The continuity outpatient teamis present.
And we sit down together and gothrough like this set of
standardized questions,including what are the patient's
strengths?
What are the challenges they'refacing?
(15:07):
What are the biases that we haveabout this patient coming in?
Who is not in this room thatneeds to be in this room for us
to have this conversation?
And then after we go throughthis entire conversation, only
then do we actually make thedecision about whether or not to
call CPS.
even if we don't, If we decideto call, we also talk about,
like, how can we minimize theharm even having made this
(15:28):
decision?
Like, who's going to tell thepatient?
How are we going to tell thepatient?
What do they need to feelsupported?
we do this for every patientwith the hope that by
standardizing the process, Andincluding as many voices as
possible, it increases ourchances of making equitable
decisions.
Obviously, we're not perfect,and obviously it is, it's always
an incredibly painful decision,but hopefully by trying to be
(15:48):
more equitable and thoughtfulabout it, we're at least
minimizing the harm that we'recausing.
jamie-lang--she-_1_04-26-2 (15:53):
I've actually been in timeout
meetings before, and itdefinitely does feel like the
people supporting the birthingparent are up against the
pediatrics team from the NICU.
leah-warner--she-her-_1_04 (16:03):
What do you mean by that, Jamie?
What does, what does it mean tobe up against the pediatrics
team?
jamie-lang--she-_1_04-26- (16:09):
Well, the pediatrics team usually
supports a CPS referral andwelcomes the idea of a
separation.
It's like if the parent is notvisiting the NICU enough or not
doing everything exactly howthey want them to do, they start
to judge them.
Simone (16:24):
I think you can definitely, It can definitely
feel like that.
I think an important, like, Ithink this all comes back to the
point they were making earlierthat, when you focus exclusively
on the needs of one entitywithin the dyad and focus on
like what is best for baby in acomplete vacuum where they are
not part of any family unit, itcan really change what you think
might be best.
But when you kind of zoom outand think this is a family, this
(16:45):
is a dyad, what is best for thisdyad, right?
Is that they are together.
In a loving and supportiveenvironment that kind of meets
both of their needs.
And I think we can make betterdecisions.
And that's why it's so importantto have these meetings where
lots of people are in the roomcoming from lots of different
perspectives, so we can kind ofcompromise and come to a shared
decision.
(17:06):
Okay, that's the end of thatsoapbox.
Let me go on to my thirdsoapbox.
Three of four, everybody.
That Soapbox was about decisiontools about calling Child
Protective Services.
Soapbox number three is aboutdecision tools about urine
toxicology.
So, urine drug screens are aclinical tool and should be used
for clinical purposes.
shout out to my residencyfriend, Noelle Martinez, who has
(17:28):
a recent paper with a helpfulframework around this.
The TLDR is that, urine drugscreens should be used when you
have a clinical question.
So a clinical question in thepostpartum space might be this
person was using stimulants upuntil the time of delivery.
She delivered yesterday and shewants to breastfeed.
We know that stimulants are notsafe for babies and breast milk,
(17:50):
and so she consents to giving aurine so that we can
appropriately time when she'sgoing to start giving the baby
the breast milk rather thanpumping and discarding it.
That's a clinical question.
But at the end of the day justto say, these are tests that
need to be obtained withconsent.
And should not be randomlygotten as a screening tool.
If you want to know if somebodyuses drugs, you should ask them.
And if you want to use a urinedrug screen, you should have a
(18:12):
clinical reason to do so.
Leah Warner (18:14):
Pause on urine, pause.
That's wild.
I honestly, since I don't workin a hospital, have it in my
mind that.
If you're in a hospital, you canget a urine on anyone at any
time, no matter what, withouttheir consent.
And it was not long ago, I thinkthe late 1980s, that there was a
(18:35):
federal law that passed out ofSouth Carolina that did enable
hospitals to obtain nonconsensual urine drug tests on
any pregnant person and thenreport a positive drug test to
law enforcement.
Now, this law has since beenrepealed, but I think this
sentiment of like, you have tocatch people who are using, is
(18:56):
still a very strong belief heldin our society and, and in our
healthcare system.
And I think it's important toask, is a punitive approach the
way to support someone's health?
Now shout out to jail health,because at least in San
Francisco, that can be apositive health touch for
people.
And there are people withstories of recovery through.
(19:18):
Jail and the penal system.
But I think in general we movetowards this punitive approach
because we think we need toprotect the fetus.
What you were talking about,Simone, kind of evaluating whose
needs are most important in thisvacuum.
Instead of thinking about thisis a dyad.
(19:40):
If we care for the patient infront of us, which is our job,
that is our job.
That that will then support thefetus or the baby that is inside
of it.
So just like to bring it allback to urine.
I think there is good reason forwhy patients are scared to go
into a hospital or to give usurine because it can feel like a
(20:02):
way people get in trouble ratherthan support it.
Simone (20:07):
Oh, 100%! And I still have patients, I had a patient
like last month, Go into adifferent hospital for a viral
gastroenteritis and without herconsent, got urine drug tested
and she is somebody who's veryengaged in recovery, goes to the
methadone clinic, gets urinedrug tested all the time between
methadone clinic CPS.
She has not used in months andshe had a false positive at this
(20:27):
outside hospital, which acutecause, like, tremendous upheaval
until.
Until we got confirmatorytesting that was negative and
like that can be incrediblytriggering for somebody in early
in recovery.
So yes.
We're up to my last soapboxpeople.
I can't believe we got to justlike talk and give my soapboxes
out loud.
My fourth soapbox is aboutsafety planning before a crisis.
Early in my postpartum visits, Itried to have a frank
(20:48):
conversation with patients abouthow in recovery, and we know
this for all people, it's notdifferent because people are
postpartum.
In recovery, return to usehappens, and we need to plan for
minimizing harms.
And so what that looks like inthis time period is to talk
about like, if you are ever onthe precipice of a of returning
to use, who are you going tocall, right?
(21:08):
Who can you give the baby to?
Because it is not safe.
You cannot use while with yourbaby.
So who can you give your babyto?
So that if you have to use, youcan use.
And if ever there is a CPSremoval, do you have a family
member who could take the babyfor a couple of weeks at a time
so that, you know, it can remainwithin the family?
These are questions that can bereally painful to ask, but also
(21:31):
can in the future prevents somuch harm.
Also, like, naming for peoplethat when your baby starts to
crawl and become a toddler,toddlers put things in their
mouth.
So if you have drugs in thehouse when they're a baby, you
really need to rethink that whenthey become a toddler.
Like, put things in a lockbox sothe babies can't get to them.
Anyway, that's what I say,Jamie.
What do you say when you safetyplan?
Jamie Lang (21:53):
I safety plan in a very similar way.
I try to be very real with themin a non judgmental way and just
say, hey, return to use is anormal thing.
It's not your fault, it's just apart of recovery.
The thing to consider is whereare your kids when you're doing
it.
Make sure they're with a safeand sober grown up.
And do what you gotta do.
Sharing that information with aparent gives them so much power
(22:15):
over how they navigate parentingand recovery.
While also ensuring the safetyof the children.
Leah Warner (22:22):
Do either of you have an example of actually
doing safety planning?
I'd love to hear it.
simone--she-her-_1_04-26-202 (22:29):
Oh yes.
And I would love to tell you.
Okay, I'm gonna tell you about apatient of mine who, this is a
story from about a year ago whenshe was five months postpartum.
She was 26 p one five monthspostpartum.
She has a history of opioid usedisorder and stimulant use
disorder, and I get a call fromher incredible patient navigator
who shares with me that thepatient has disclosed that she
(22:51):
had this one time return tofentanyl use.
And part of what's triggeringher is her knee pain.
And so the navigator iswondering if I can see the
patient in clinic.
So patient comes into clinicwith her five months old.
And in the course of her visitwhen I ask about her recent use,
she shares that actually she'sbeen using fentanyl several
times a day, including whileparenting her baby.
She stays with her mom, so withgrandma, and that can be hard
(23:15):
because grandma doesn't knowthat she's returned to use.
Actually this patient never hada CPS case open because she was
in recovery significantly priorto delivery.
Putting myself back where I wasin that moment, right, like, I'm
in clinic, it's a busy primarycare clinic, and now this
patient is disclosing to me thatshe's using fentanyl multiple
times a day while solo parentingher baby.
Basically all the fears that Ilisted at the top of this
(23:36):
episode were in conflict here.
I'm afraid that, while she'sintoxicated, is she providing
adequate supervision of thisbaby?
Is this baby at risk of, like,getting into her supply and
ingesting something?
But what am I going to do if Icall CPS?
I've never met her before.
This is our first time meeting.
If I call CPS and theyimmediately remove this baby,
like, this return to use canspiral and that might be the end
(23:57):
of her recovery.
And certainly it will break hertrust with me and with our
clinic.
And so in the long term, howdoes that serve us?
I felt overwhelmed.
I stepped out of the room, Andcalled my colleague Dana, and we
try to have this like rulewithin our little cohort that
does this work of like neverdeal with the return to use
alone, because sometimes youneed somebody who can see the
forest and somebody who can seethe trees.
So I called Dana, who is apublic health nurse who is
(24:20):
honestly at the core of allperinatal substance use in San
Francisco, and Dana helped megame plan and so when I returned
to the room, this is how theconversation unfolded.
I asked the patient if she'd bewilling to share her return to
use with her mom, because hermom is a sober grown up that
lives in the same house as thisbaby, and maybe could help us.
The patient said she was notready to tell her mom that she's
(24:41):
returned to use, but she waswilling for us to share it with
her mom.
And so, that night, our patientnavigator called the patient's
mom, called grandma, anddisclosed this return to use to
grandma.
And grandma agreed to step inand take care of baby while we
found mom a higher level of carefor her substance use.
Ultimately, we were able to getmom into a withdrawal management
(25:03):
facility for a little bit, andthen after withdrawal
management, she moved into aresidential treatment program
with her baby and now her andbaby are living together in
residential treatment.
And I love this case becauseone, it is just like really
highlights how indispensable themultidisciplinary team is in
taking care of, of our patients.
I didn't have these difficultconversations with the patient's
(25:25):
mom, with grandma, like that wasa hundred percent our patient
navigator.
There's so much of like the realwork of taking care of these
patients does not happen byproviders and does not happen in
the clinic room.
Also because it reallyhighlighted for me like there
are options between the binaryof CPS is evil.
Never call CPS.
I'm never gonna call them andI'm just gonna have to live with
(25:45):
the anxiety that this baby'sgonna ingest fentanyl on one
hand and call CPS and have thebaby removed every time on the
other hand, neither of thoseextremes really serve our
patients, but there are optionsin-between but those options
they require a lot of work a lotof frank and difficult
conversations and a robust teamto do the work, I am so
(26:07):
eternally,.of work this patientand for teaching me about this
work.
Leah Warner (26:15):
I love that case.
Simone.
I do feel like you're right.
It highlights how non binaryactually harm reduction is
because on, I think oftentimeswhen we are really worried or
fearful for our patients, wethink, okay, there's only two
options here, call CPS or donothing and never sleep again.
(26:35):
But actually harm reductionshows us that there's so much in
the middle between those twochoices.
And it does sound like it takesnot only a really good team
multidisciplinary approach, butalso a lot of creativity and
time, which isn't something thehealthcare system always gives
us, but is probably the betteroutcome in the long run for our
(26:58):
patients.
And we really do need to takethat time to see all the choices
in between the binary.
Jamie Lang (27:05):
Okay, Simone and Leah, question three.
One thing I encountered duringmy pregnancy was barriers.
Health insurance, prenatal care,treatment, housing, clothing,
shower, food, you name it.
How would you change the currenthealth care system to reduce
barriers and improve health careaccess for pregnant or
postpartum and parenting peopleusing drugs?
Leah Warner (27:28):
Okay.
Thank you.
I am so excited to step on mysoapbox now, because first let
me say our public health system.
And healthcare system can bevery complicated to navigate.
You need tenacity and a lot ofinterpersonal skills to talk to
the various offices and servicesthat don't always talk to each
(27:50):
other.
And this is important becausethe clients this system is
designed to serve are peoplelike my patients, people
experiencing homelessness orliving in poverty, who have a
lot of substance use, unmetmental health needs, but also a
lot of physical disability, likebodies that are in pain.
(28:10):
And have to walk back and forthbetween these various places to
get the services they need.
And a surprising incidence ofcognitive dysfunction from brain
injury, either acquired ortraumatic.
So already there's a hugebarrier here between the system
design and the clientcomplexity.
So, to bring it back topregnancy and parenting, let's
(28:33):
take my pregnant patient, forexample, and let's say she needs
to come into health care becauseshe needs to get a form signed.
I cannot tell you how manyhealth care visits I have for
people who bring me a form thatthey just need signed to get
through the system of care.
To get to me.
She has to leave her stuff,right?
(28:55):
She, she may be sleeping on thestreet.
She may have like the tent sheneeds, the equipment she needs.
It took her a while to get thatstuff, all her precious
belongings.
She has to find someone she cantrust to either watch it or
leave it during a time where shethinks it's not going to get
swept away.
She also has to find a goodroute to get to my clinic.
One that won't be superdistracting or that feels safe
(29:18):
to her.
Then once she gets there, shehas to take her pregnant body
through the gates of healthcare, maybe presenting as a
person experiencinghomelessness, maybe getting
dirty looks, or even just moreattention than she's used to
being pregnant, and get throughRegistration, show her ID.
(29:39):
I don't have an ID.
Okay, what else do you have?
Give me your social securitynumber.
She has to shout why she'sthere.
I'm here to get a form signedfor my housing.
You know, all of these thingsthat she has to get through in
order to see me.
So, while I can't really talkabout what we could do to reduce
(30:00):
barriers en masse, for ourhealthcare system.
That's probably like a differentpodcast, but just on an
individual level as a provider,I really try to keep all of
these various barriers in mindso that by the time I'm sitting
face to face with my patient,I'm giving a very wide margin,
(30:23):
not just for error, but forfrustration, for irritability,
for just discontentment.
I really do try to honor thatpeople have had to go through a
lot.
To Just get to a provider visitand lo and behold what if it's
the wrong form that case managerPrinted out the wrong form, you
(30:47):
know It takes me probably tenextra minutes to figure out what
form I actually need to printout for this patient So she can
connect these dots, but I I'mholding all of this in my head
I'm going to help reduce thosebarriers.
And I think other ways we canreally reduce barriers is to
have options where appointmentsaren't a thing.
(31:09):
You know, not just a drop inclinic, but really a
comprehensive set of serviceslike primary care that don't
have appointments.
So we call our clinic openaccess.
People never have appointments.
They can just show up.
In the times that we are thereand get pretty good
comprehensive care.
And that takes away a lot of theshaming around.
(31:32):
You missed your appointment.
Sorry, I can't schedule you anappointment.
You've missed too manyappointments.
And then finally, I think we canalso think about putting
healthcare in very creativespaces.
There's healthcare on thestreet, like street medicine,
but there's also healthcare thatcould be found in syringe access
or drop in centers.
Mostly I think about puttinghealth care in spaces where
(31:56):
people experiencing homelessnessare welcome is there aren't a
lot of those spaces and wherethey are welcomed is where the
healthcare should be.
Simone, your thoughts?
simone--she-her-_1_04-26-2 (32:09):
Just to add like very briefly on
something you already said,which is that, I like cosine
1000 percent that would need tomove away from a traditional
appointment based system.
And that is a system that wasnever created with the needs of
the marginalized in mind.
Just imagine you're a brand newparent, with a brand new baby,
you're learning to parent, whilealso kind of still on an
unstable methadone dose andfeeling like you're in
(32:29):
withdrawal all the time, and CPSmandates that you go to like,
this therapy, and then this NAgroup, and then this court
appointment, and like, it has athousand hoops for you to jump
through, and you also have tomake it to your Doctor's
appointments, but also your babyvomits everywhere every time you
leave the house and also youhave to walk there with your
stroller.
And so, with all those things inmind, like, of course it was
(32:50):
never going to work for you tohave a 15 minute window to show
up at this clinic.
We need to get away from that ifwe're going to try to take care
of our patients.
Jamie.
Leah and I have rambled for 34minutes now.
I'm going to flip the table onyou.
As someone with livedexperience, what do you think
that pregnant and postpartum andnewly parenting people who are
using drugs perceive tothemselves as the most harmful
(33:13):
to their health during thistime?
I'd love to hear both like yourthoughts from your lived
experience and also from yourjust immense experience working
as a case manager for thesefolks.
Jamie Lang (33:22):
Thank you, Simone.
The first thing that comes tomind is a child separation.
They're going to take my baby,that adds a whole extra layer of
accessing care and being honestabout my situation.
for me living in the streets atthe time, there was also the
constant fear or threat ofintimate partner violence and
(33:42):
community violence.
when I say community violence,not just the community of my
peers, but community providerslike the police department or
department of public works, whowere also very harmful and
dangerous.
I also think the constant stressof being in survival mode was a
concern towards the pregnancy,specifically around housing and
(34:02):
shelter and the mistreatment Iexperienced due to stigma and
judgments when I tried accessingthe systems.
Leah Warner (34:11):
Wow, talk about barriers.
Those are some prettyinsurmountable barriers.
I want to pause on intimatepartner violence, which is
something we see very often inour clinic and is not easy for
us to talk about with ourclients.
How do you talk to your clientsabout intimate partner violence?
Jamie Lang (34:31):
They usually come in wanting support around it.
I don't have to pry it out ofthem.
They're usually forthcoming, andI think there's an urgency
around intimate partner violencewhen there are children involved
versus maybe someone who is inthe preconception or pregnancy
stage.
Leah Warner (34:48):
I think that's a fair point.
If you had to think back to thetime when you were accessing
care, what do you think the roleof a provider is when bringing
up intimate partner violence, orsupporting somebody who's in an
intimate partner violencesituation?
Jamie Lang (35:05):
The role of provider should be whatever the patient
wants.
I was not looking for supportaround that.
I was still very much living instreet culture, where you don't
talk about that type of thingunless you're ready to
completely leave the situationor suffer the consequences of
speaking out.
What I really needed supportaround was the community
violence, the police telling usto constantly move our tent or
(35:27):
calling to have it taken away.
Department of Public Workssprayed me with a pressure
washer when I was sleeping onetime.
This was actually a barrier togetting care because I would
have to leave my tent and all mythings behind and if they come
while I'm not there to move mytent.
They'll take the whole tent andeverything inside.
Leah Warner (35:46):
Jamie, Were there any signals from providers that
made you feel like you could besafe with them?
I mean you really mentioned likewhat's on your mind is child
separation, the communityviolence you're experiencing,
coming in with all of thesethings.
Were there signals from healthcare providers that made you
feel like yes, this person ishere for me.
Jamie Lang (36:09):
I first met my midwife, Mary Mays, and she was
just like, cool, how can I helpyou?
What do you want to talk abouttoday?
Like, it was so normal for her,and learning to trust her opened
the door for me to trust otherproviders, like nurse Dana, who
would come and see me at my tentsometimes.
Her support really changed myattitude and the trajectory of
(36:30):
my life.
Leah Warner (36:31):
I think that's It's sort of the definition of harm
reduction right there.
It's hearing a patient's story,maybe feeling inside very
overwhelmed by all that yourpatient is going through, all of
the factors pressing down onthem and remembering that you're
(36:53):
there to support their healthand moving forward and saying,
okay, what can we do today?
How can I meet your needs today?
It takes a wizard like Mary Maysto pull that off.
Simone (37:07):
I really could not agree more that we should all just end
with acknowledging that MaryMays is a wizard.
But I also want to just Bring usbriefly back to our learning
objectives to kind of recenterus where we started.
We started off talking about,like, what are the harms?
What are the harms that we areafraid of in pregnancy and the
postpartum period?
And to list them out, we'reafraid of not doing enough about
(37:30):
our return to use, that thatwill lead to parenting while
intoxicated, inadequatesupervision of babies, and
potential ingestions.
But we're also afraid of doingsomething and our intervention
being harmful.
So, calling CPS, that leading toremoval, and that leading to a
to sustained return to use.
And then we talked about like,so what are some harm reduction
(37:50):
things that we can try?
And in that, we mentionedappropriately dosing people's
MOUD.
Noting that metabolism changesin pregnancy in the postpartum
period.
Having frameworks for morethoughtful and more equitable
decisions around calling CPS andusing urine toxicologies.
And having honest conversationsabout safety planning that
(38:11):
acknowledge that relapse is apart of recovery even when
you're postpartum And as jamiebrilliantly said what you have
agency over is where your childis during those times And then
finally we talked about thebarriers to health care access
for pregnant people and honestlyall marginalized people.
Which is that providers are notin the places where patients who
are Living outside, feel safeand comfortable.
(38:32):
And we need to get ourselves tothose places.
And we need to do away with thisappointment based model that
completely is based on the needsof the clinic and has not at all
centered the needs of ourpatients.
Leah Warner (38:43):
What a beautiful summary.
I want to add to that and saythat when we are thinking about
our greatest fears, we also haveto acknowledge that sometimes
that fear can easily turn into abias.
And that bias can really guidehow we're talking to our
patients and that it's okay.
It's okay to feel that fear.
It's okay to feel overwhelmed bywhat you're seeing, but remember
(39:07):
our patients can pick up on biasand discomfort.
And so it, It is important touse your multidisciplinary team,
your resources in the community,and to make sure that, just like
Jamie said, you're like, cool,well what can we do for you
today?
And make sure that you arereally seeing what your patient,
who overcame a lot of barriersto get to you, is there to talk
(39:29):
about that day.
And actually, it's a lot easiersaid than done.
Like it does take wizardry.
Jamie Lang (39:37):
I think that's great.
Thank you, Simone and Leah.
I think this was a really greatconversation.
Kinna Thakarar (39:43):
That was Dr.
Simone Vays, Leah Warner, andJamie Lange in conversation on
harm reduction compassionatecare for people who use drugs.
Thank you for listening.
Be sure to tune in next timewhen we welcome Dr.
Joshua Lynch, Shelby Arena, andDr.
Shoshana Aronowitz to the seriesto discuss innovative access to
harm reduction support andlinkage to treatment.
Please take a moment to completeSAMHSA's post event evaluation
(40:05):
survey on the AMERSA podcastpage at www.
dot AMERSA dot.
Org forward slash harm reductionpodcast.
We welcome any comments,questions, or other feedback for
presenters.
You can send those directly toAMERSA through the contact us
form at AMERSA.
org.
To learn more about theprovider's clinical support
system, Medication for OpioidUse Disorder Project, and AMERSA
please visit our websites atPCSSMOUD.
org and AMERSA org.
(40:26):
Funding for this initiative wasmade possible by Cooperative
Agreement No.
1 H 79 TI 086 770 from SAMHSA.
The views expressed in writtenconference materials or
publications and by speakers andmoderators do not necessarily
reflect the official policies ofthe Department of Health and
Human Services, nor does mentionof trade names, commercial
practices, or organizationsimply endorsement by the U.
S.
government.
Thank you for listening.
I'm Kinna Thakarar and welcome to the
podcast series, Harm Reduction,Compassionate Care for People
Who Use Drugs.
Harm Reduction is a socialjustice movement started by and
for people who use drugs, andit's a philosophy of care and
practical set of strategies tooptimize people's health,
safety, and rights.
We want to acknowledge and honorthe long history of street
(00:33):
medicine and healthcaredeveloped by people with lived
and living experience to keepone another alive and safe
through community care.
Whether you're a seasoned harmto the concept, we're glad
you're here and hope you'lllearn something new and are
curious to explore seeingpatient care through a harm
reduction lens.
This podcast series is broughtto you by the Providers Clinical
Support System, Medications forOpioid Use Disorder Project, and
(00:56):
AMERSA.
This week, we welcome JamieLange in conversation with Dr.
Simone Bays and Leah Warner todiscuss putting harm reduction
to the test, drug use,pregnancy, and parenting.
Our host, Jamie Lange, iscurrently employed by Homeless
Prenatal Program as a casemanager supporting people in
pregnancy and postpartum who areexperiencing homelessness,
substance use, and mental healthchallenges.
(01:16):
She is also a passionateadvocate with Homeless Emergency
Service Providers Association,Treatment on Demand Coalition,
and Housing Justice.
She is formerly chronicallyhomeless, used substances and
found recovery in pregnancy.
Most importantly, she is thededicated mother of a six year
old.
Simone Bays is a family medicinephysician and current addiction
medicine fellow in the UCSFPrimary Care Addiction Medicine
(01:39):
Fellowship.
Her clinical focus is perinatalsubstance use with a particular
interest in the postpartumperiod and the gaps in care
between pregnancy and primarycare based services.
She works as a primary carephysician at the Family Health
Center and in the Team LillyPostpartum Clinic, a family
based clinic for postpartumpeople and their infants
impacted by substance usedisorders.
(02:00):
Leah Warner is a nursepractitioner in whole person
integrated care on the streetmedicine team.
Since 2014, she has worked onthe street medicine team
providing primary care servicesfor San Francisco's patients
experiencing homelessness.
Other interests includeunderstanding and improving
homeless services through a lensof gender, pregnancy and
substance use, intimatepartnerships in the setting of
substance use, and trans care atthe intersection of substance
(02:23):
use and homelessness.
Prior to becoming a clinician,Leah worked in public health in
the field of reproductivejustice.
The presenters reported nothingto disclose.
Thanks for joining us, Jamie,Simone, and Leah.
Jamie Lang (02:34):
Greetings and welcome to this podcast.
I'm very excited to be here withmy esteemed colleagues to
discuss a topic that's very nearand dear to our hearts.
The intersection of harmreduction, substance use, and
the pregnancy postpartum period.
So much of what we believe aboutharm reduction really gets put
to the test when it comes topregnancy and parenting because
(02:54):
we're faced with the existentialquestion of who are we reducing
harm for?
The birthing parent or theinfant?
Leah Warner (03:02):
Now, why does it sometimes feel like harm
reduction for one party canstand in direct conflict with
harm reduction for the other?
Are there cases where that'strue?
How do we practice harmreduction?
We want to dig into all thesequestions, but first, let us
introduce ourselves and lay outour learning objectives.
Jamie Lang (03:24):
I'm Jamie and I'll be your host.
I currently hold A client facingrole at a local non profit
supporting people in pregnancyand postpartum who are
experiencing homelessness,substance use, and other various
adversities.
I also advocate with variouscoalitions related to
homelessness and treatment ondemand.
I lived on the streets of 10years.
(03:45):
I'm a former drug user.
I used substances and foundrecovery during pregnancy, and
I'm a parent to a happy andhealthy six year old.
Now, I'll send it over to my cohost, Leah.
Leah Warner (03:57):
Thank you, Jamie.
I'm a big fan of yours.
I'm Leah.
I'm a nurse practitioner with abackground in public health and
I work on a street medicine teamin San Francisco.
So what that means is mypatients are adults who are
experiencing homelessness.
And what that means is that Isee a lot of extremes.
(04:18):
I see extreme poverty.
I see really extreme substanceuse.
Unmet mental health needs andsome very extreme wounds, but no
matter all the extremes that Isee, it still really challenges
me to see people in theirreproductive and pregnancy
stages of life while they'reexperiencing homelessness and
(04:40):
using substances.
So I am so excited to be hereand talk about this very topic
today.
Jamie Lang (04:49):
Thank you, Leah.
Welcome, Simone.
Simone (04:52):
I'm Simone.
I'm a family medicine doctor bytraining, and I'm currently
finishing up my addictionmedicine fellowship at UCSF.
My clinical work is at SanFrancisco General, where I
primarily work at a postpartumclinic for people with substance
use disorders and theirchildren, which means that my
patients are birthing parentsand their babies and can I just
say how grateful I am to haveJamie here to not only ask Leah
(05:14):
and I questions, but also tocheck our assumptions as
somebody with lived experiencein this realm.
Jamie Lang (05:19):
Thank you, Simone.
It's great to have you bothhere.
Could you tell our listenersabout the learning objectives of
this podcast?
Simone (05:26):
Our learning objectives for this episode are firstly to
identify the harms that we'rescared of when pregnant and
postpartum people use drugs.
Like, let's just name it.
What are we actually afraid of?
Two, talk about what are theharm reduction strategies that
we can use at each stage in thereproductive cycle?
So preconception, pregnancy, andthen postpartum and parenting.
(05:48):
And then three, to analyze thebarriers to healthcare during
pregnancy and postpartum forfolks who are using drugs.
and a brief disclaimer onlanguage.
Throughout this episode, we'regoing to use different pronouns
to refer to people who givebirth.
Sometimes we'll use genderneutral pronouns, sometimes we
may use male or female pronouns.
We just want to acknowledge herethat there are a diversity of
people who can and do givebirth.
Jamie Lang (06:08):
Thank you, Simone.
Simone and Leah, as medicalproviders, what scares you the
most about caring for pregnantor postpartum people using
drugs?
Can you describe a time when youfelt overwhelmed by a patient's
substance use?
simone--she-her-_1_04-26 (06:20):
Thanks for asking this, Jamie, because
I think, if we don't clearlyenumerate like what exactly are
we afraid of, it's difficult tocome up with solutions that are
right size for our fears.
So my clinical work, like Isaid, focuses primarily on
postpartum people.
And so I'm going to focus onthat time period for a moment,
also because I think likesocietally we focus so much on
pregnancy when we think aboutthis topic.
(06:42):
And so, so much of people'srecovery actually happens in the
postpartum period.
Just to name some of the thingsthat I'm afraid of in no
particular order at all.
And ask also to add the caveatthat when I do this clinically,
like I do try to outline whatI'm afraid of, but I also add
how likely are each of theseoutcomes, because I think it's
important when you're trying toright size your solution to not
only name your fears, but alsosay, okay, but how likely are
(07:04):
these to happen?
With no order at all.
I'm afraid of a postpartumparent using fentanyl while solo
parenting like a newborn andgetting so sedated that they
either inadvertently drop a babyor just aren't watching while a
baby crawls into somethingdangerous.
I'm afraid of babies ingestingfentanyl, which is something
(07:24):
I've had happen.
to several patients.
I'm afraid of having babiesremoved from their birth parents
and placed in foster care wherewe know the outcomes are not
good.
I'm afraid that if I, forexample, call CPS on a family
that I will break my trust withthem and with the healthcare
system.
I'm afraid that if a dyad isseparated, then what might have
(07:45):
been a brief slip in a parent'srecovery will become like a long
term return to use and will kindof end the chances of
reunification.
obviously, a lot of these fearsare in conflict with each other.
Leah Warner (07:58):
Yeah, the thing I'm most afraid of is my own bias
and agenda.
Think there's really goodnational meta analyses
describing the prejudice thatpeople who use drugs feel when
they access healthcare, and ifyou add reproductive health and
pregnancy, postpartum andparenting to that conversation,
(08:19):
that prejudice only increases.
And I think there is a lot ofprovider bias and prejudice out
there.
I think it's very real and itcomes from a lot of places.
But if I'm speaking for myselfpersonally, my bias really can
come from fear.
So I'm grateful for thisquestion.
I fear all of those bad outcomesthat Simone listed.
(08:44):
And I fear that in trying toprevent them, trying to prevent
these bad outcomes from everhappening to my patient, that I
will turn into a biased providerand that bias will really guide
how I talk to my patient.
So that's.
Pretty abstract, so I'm going togive a real example.
(09:04):
I had a patient once who reallyhad me scared.
She was in a really abusiverelationship, she was very deep
into her substance use, and shehad a lot of medical, kind of
dangerous health problems goingon that were unstable.
And when she shared with me thatshe wanted to get pregnant, I
spent the visit trying toconvince her not to do that.
(09:27):
And I'm someone who has seen theresearch that describes the
prejudice that patients can feeldiscussing reproductive health
with providers like me, likepressure to use long acting
contraception.
But in that moment, I was onlythinking about what I was afraid
of for her.
And I was also thinking aboutthis abstract pregnancy that
(09:49):
didn't even exist yet.
And the fears I had for herturned me into this provider
that I don't want to be.
The one who gives her patientsthe message that their substance
use defines their reproductivegoals and that a bad outcome is
already written in stone.
Simone (10:05):
I think like my biggest takeaway from my experiences, in
this realm so far has been, youknow, pregnancy can be so
incredibly motivating for peopleand we never know what's going
to happen.
And so all we can do is offerpeople and surround people with
the support they need and kindof let them write the rest of
the story.
Jamie Lang (10:22):
I definitely identify with that.
Becoming pregnant wascomplicated for me and the first
interaction I had with ahealthcare setting was a male
doctor and his recommendedtreatment for my situation was
an abortion.
He told me that since I was adrug user and I was living in a
tent, it was probably the bestdecision for me.
I wish he would have helped meget into treatment.
(10:44):
I tried getting into treatmenton my own, but they sent me away
and said I had to come back inthree days.
Treatment is ultimately what Iwanted.
This was the first time Irealized that the systems in San
Francisco were not going tosupport my needs with this
pregnancy.
became highly motivated to startdetoxing on my own without any
support in the streets.
I came in contact with thehealthcare system three times in
(11:05):
my early pregnancy wantingtreatment and was discharged to
the streets with nothing eachtime.
leah-warner--she-her-_1_04 (11:11):
See, hearing that story, Jamie, it
really makes me of course, judgethis provider, right?
Who recommends that you go andget an abortion when he hears
that you're pregnant.
I think it's important for mepersonally to remember that I
can be on that side of healthcare where I can let my own bias
(11:36):
start to guide how I'm talkingto the patient in front of me.
So I appreciate that story.
jamie-lang--she-_1_ (11:43):
Absolutely, Leah.
Simone and Leah, can you giveexamples of harm reduction
approaches through the stages ofpreconception, pregnancy and
postpartum, and the stage ofparenting that work, and any
that were not as effective?
Simone (11:56):
Oh yes, I love this question! Here come four soap
boxes from me.
Strap in everybody.
First and foremost, as we allknow, the, the best thing that
we can offer any of our patientswith, let's just talk about
opioid use disorder, the bestthing that we can offer any of
our patients with opioid usedisorder is access to life
saving medications on demand.
(12:17):
So, methadone and buprenorphine.
And then, specifically, in thepregnancy and the postpartum
period, those medications dosedappropriately, right?
We know that the metabolism ofmethadone and buprenorphine are
increased tremendously inpregnancy and in the early
period, which means that peopleneed both higher doses and more
frequent doses.
(12:38):
And, and they need that forthose medications to be
therapeutic and to actuallywork.
Not only do people need theirdoses to increase when they're
pregnant, they also, will havetheir metabolism change again
when they become postpartum, anda dose that was previously
therapeutic for them mightbecome super therapeutic and now
causes them sedation.
And we need to tell people aboutthis, and we need to monitor for
(13:02):
it, and then when we see thisover sedation, which is an
expected outcome of metabolismchanges, we need to treat it not
like a failure, but like anatural history of medication
metabolism.
I think so often when we, whenwe in different spaces encounter
folks who are on methadone orbuprenorphine, particularly
methadone, and are over sedatedon their methadone, like, There
(13:24):
are so many questions that arisepatients are accused of using,
and it can be incrediblytriggering for patients when all
they've done is get pregnant,get postpartum and keep taking
their methadone as prescribed.
And then we're just accusingthem of doing things wrong.
So dose it appropriately, bothwhile you're up titrating and
down titrating.
Leah Warner (13:42):
Here here.
Get that dose right.
I love that.
I think it is also important toeducate not just providers who
are prescribing the methadoneBut also all the frontline
healthcare providers who willsee that patient, that sedation,
over sedation can be a thing inthe postpartum period.
Simone (14:02):
Okay.
So box number two, are youready?
So first, you're going to getpeople on life saving
medications, and you're going todose them correctly.
Second, we need to haveframeworks that guide our
conversations around ChildProtective Services, or whatever
it's called locally for you.
The decision to call ChildProtective Services, has a
profound impacts on patientslives.
(14:23):
Appropriately, it is therefore avery stressful and overwhelming
decision for providers, and wenever make our best decisions
when we're stressed,overwhelmed, and scared.
And so, in any way, a decisionthis big and with these profound
impacts should never be made byone person.
At San Francisco General, whereI work, we, we've instituted
this, it's called the Dyad CareCoordination Timeout.
(14:46):
Basically, on labor and deliveryand postpartum, if anybody
thinks that Child ProtectiveServices is going to need to be
called, we have amultidisciplinary meeting where
The inpatient team is present.
The continuity outpatient teamis present.
And we sit down together and gothrough like this set of
standardized questions,including what are the patient's
strengths?
What are the challenges they'refacing?
(15:07):
What are the biases that we haveabout this patient coming in?
Who is not in this room thatneeds to be in this room for us
to have this conversation?
And then after we go throughthis entire conversation, only
then do we actually make thedecision about whether or not to
call CPS.
even if we don't, If we decideto call, we also talk about,
like, how can we minimize theharm even having made this
(15:28):
decision?
Like, who's going to tell thepatient?
How are we going to tell thepatient?
What do they need to feelsupported?
we do this for every patientwith the hope that by
standardizing the process, Andincluding as many voices as
possible, it increases ourchances of making equitable
decisions.
Obviously, we're not perfect,and obviously it is, it's always
an incredibly painful decision,but hopefully by trying to be
(15:48):
more equitable and thoughtfulabout it, we're at least
minimizing the harm that we'recausing.
jamie-lang--she-_1_04-26-2 (15:53):
I've actually been in timeout
meetings before, and itdefinitely does feel like the
people supporting the birthingparent are up against the
pediatrics team from the NICU.
leah-warner--she-her-_1_04 (16:03):
What do you mean by that, Jamie?
What does, what does it mean tobe up against the pediatrics
team?
jamie-lang--she-_1_04-26- (16:09):
Well, the pediatrics team usually
supports a CPS referral andwelcomes the idea of a
separation.
It's like if the parent is notvisiting the NICU enough or not
doing everything exactly howthey want them to do, they start
to judge them.
Simone (16:24):
I think you can definitely, It can definitely
feel like that.
I think an important, like, Ithink this all comes back to the
point they were making earlierthat, when you focus exclusively
on the needs of one entitywithin the dyad and focus on
like what is best for baby in acomplete vacuum where they are
not part of any family unit, itcan really change what you think
might be best.
But when you kind of zoom outand think this is a family, this
(16:45):
is a dyad, what is best for thisdyad, right?
Is that they are together.
In a loving and supportiveenvironment that kind of meets
both of their needs.
And I think we can make betterdecisions.
And that's why it's so importantto have these meetings where
lots of people are in the roomcoming from lots of different
perspectives, so we can kind ofcompromise and come to a shared
decision.
(17:06):
Okay, that's the end of thatsoapbox.
Let me go on to my thirdsoapbox.
Three of four, everybody.
That Soapbox was about decisiontools about calling Child
Protective Services.
Soapbox number three is aboutdecision tools about urine
toxicology.
So, urine drug screens are aclinical tool and should be used
for clinical purposes.
shout out to my residencyfriend, Noelle Martinez, who has
(17:28):
a recent paper with a helpfulframework around this.
The TLDR is that, urine drugscreens should be used when you
have a clinical question.
So a clinical question in thepostpartum space might be this
person was using stimulants upuntil the time of delivery.
She delivered yesterday and shewants to breastfeed.
We know that stimulants are notsafe for babies and breast milk,
(17:50):
and so she consents to giving aurine so that we can
appropriately time when she'sgoing to start giving the baby
the breast milk rather thanpumping and discarding it.
That's a clinical question.
But at the end of the day justto say, these are tests that
need to be obtained withconsent.
And should not be randomlygotten as a screening tool.
If you want to know if somebodyuses drugs, you should ask them.
And if you want to use a urinedrug screen, you should have a
(18:12):
clinical reason to do so.
Leah Warner (18:14):
Pause on urine, pause.
That's wild.
I honestly, since I don't workin a hospital, have it in my
mind that.
If you're in a hospital, you canget a urine on anyone at any
time, no matter what, withouttheir consent.
And it was not long ago, I thinkthe late 1980s, that there was a
(18:35):
federal law that passed out ofSouth Carolina that did enable
hospitals to obtain nonconsensual urine drug tests on
any pregnant person and thenreport a positive drug test to
law enforcement.
Now, this law has since beenrepealed, but I think this
sentiment of like, you have tocatch people who are using, is
(18:56):
still a very strong belief heldin our society and, and in our
healthcare system.
And I think it's important toask, is a punitive approach the
way to support someone's health?
Now shout out to jail health,because at least in San
Francisco, that can be apositive health touch for
people.
And there are people withstories of recovery through.
(19:18):
Jail and the penal system.
But I think in general we movetowards this punitive approach
because we think we need toprotect the fetus.
What you were talking about,Simone, kind of evaluating whose
needs are most important in thisvacuum.
Instead of thinking about thisis a dyad.
(19:40):
If we care for the patient infront of us, which is our job,
that is our job.
That that will then support thefetus or the baby that is inside
of it.
So just like to bring it allback to urine.
I think there is good reason forwhy patients are scared to go
into a hospital or to give usurine because it can feel like a
(20:02):
way people get in trouble ratherthan support it.
Simone (20:07):
Oh, 100%! And I still have patients, I had a patient
like last month, Go into adifferent hospital for a viral
gastroenteritis and without herconsent, got urine drug tested
and she is somebody who's veryengaged in recovery, goes to the
methadone clinic, gets urinedrug tested all the time between
methadone clinic CPS.
She has not used in months andshe had a false positive at this
(20:27):
outside hospital, which acutecause, like, tremendous upheaval
until.
Until we got confirmatorytesting that was negative and
like that can be incrediblytriggering for somebody in early
in recovery.
So yes.
We're up to my last soapboxpeople.
I can't believe we got to justlike talk and give my soapboxes
out loud.
My fourth soapbox is aboutsafety planning before a crisis.
Early in my postpartum visits, Itried to have a frank
(20:48):
conversation with patients abouthow in recovery, and we know
this for all people, it's notdifferent because people are
postpartum.
In recovery, return to usehappens, and we need to plan for
minimizing harms.
And so what that looks like inthis time period is to talk
about like, if you are ever onthe precipice of a of returning
to use, who are you going tocall, right?
(21:08):
Who can you give the baby to?
Because it is not safe.
You cannot use while with yourbaby.
So who can you give your babyto?
So that if you have to use, youcan use.
And if ever there is a CPSremoval, do you have a family
member who could take the babyfor a couple of weeks at a time
so that, you know, it can remainwithin the family?
These are questions that can bereally painful to ask, but also
(21:31):
can in the future prevents somuch harm.
Also, like, naming for peoplethat when your baby starts to
crawl and become a toddler,toddlers put things in their
mouth.
So if you have drugs in thehouse when they're a baby, you
really need to rethink that whenthey become a toddler.
Like, put things in a lockbox sothe babies can't get to them.
Anyway, that's what I say,Jamie.
What do you say when you safetyplan?
Jamie Lang (21:53):
I safety plan in a very similar way.
I try to be very real with themin a non judgmental way and just
say, hey, return to use is anormal thing.
It's not your fault, it's just apart of recovery.
The thing to consider is whereare your kids when you're doing
it.
Make sure they're with a safeand sober grown up.
And do what you gotta do.
Sharing that information with aparent gives them so much power
(22:15):
over how they navigate parentingand recovery.
While also ensuring the safetyof the children.
Leah Warner (22:22):
Do either of you have an example of actually
doing safety planning?
I'd love to hear it.
simone--she-her-_1_04-26-202 (22:29):
Oh yes.
And I would love to tell you.
Okay, I'm gonna tell you about apatient of mine who, this is a
story from about a year ago whenshe was five months postpartum.
She was 26 p one five monthspostpartum.
She has a history of opioid usedisorder and stimulant use
disorder, and I get a call fromher incredible patient navigator
who shares with me that thepatient has disclosed that she
(22:51):
had this one time return tofentanyl use.
And part of what's triggeringher is her knee pain.
And so the navigator iswondering if I can see the
patient in clinic.
So patient comes into clinicwith her five months old.
And in the course of her visitwhen I ask about her recent use,
she shares that actually she'sbeen using fentanyl several
times a day, including whileparenting her baby.
She stays with her mom, so withgrandma, and that can be hard
(23:15):
because grandma doesn't knowthat she's returned to use.
Actually this patient never hada CPS case open because she was
in recovery significantly priorto delivery.
Putting myself back where I wasin that moment, right, like, I'm
in clinic, it's a busy primarycare clinic, and now this
patient is disclosing to me thatshe's using fentanyl multiple
times a day while solo parentingher baby.
Basically all the fears that Ilisted at the top of this
(23:36):
episode were in conflict here.
I'm afraid that, while she'sintoxicated, is she providing
adequate supervision of thisbaby?
Is this baby at risk of, like,getting into her supply and
ingesting something?
But what am I going to do if Icall CPS?
I've never met her before.
This is our first time meeting.
If I call CPS and theyimmediately remove this baby,
like, this return to use canspiral and that might be the end
(23:57):
of her recovery.
And certainly it will break hertrust with me and with our
clinic.
And so in the long term, howdoes that serve us?
I felt overwhelmed.
I stepped out of the room, Andcalled my colleague Dana, and we
try to have this like rulewithin our little cohort that
does this work of like neverdeal with the return to use
alone, because sometimes youneed somebody who can see the
forest and somebody who can seethe trees.
So I called Dana, who is apublic health nurse who is
(24:20):
honestly at the core of allperinatal substance use in San
Francisco, and Dana helped megame plan and so when I returned
to the room, this is how theconversation unfolded.
I asked the patient if she'd bewilling to share her return to
use with her mom, because hermom is a sober grown up that
lives in the same house as thisbaby, and maybe could help us.
The patient said she was notready to tell her mom that she's
(24:41):
returned to use, but she waswilling for us to share it with
her mom.
And so, that night, our patientnavigator called the patient's
mom, called grandma, anddisclosed this return to use to
grandma.
And grandma agreed to step inand take care of baby while we
found mom a higher level of carefor her substance use.
Ultimately, we were able to getmom into a withdrawal management
(25:03):
facility for a little bit, andthen after withdrawal
management, she moved into aresidential treatment program
with her baby and now her andbaby are living together in
residential treatment.
And I love this case becauseone, it is just like really
highlights how indispensable themultidisciplinary team is in
taking care of, of our patients.
I didn't have these difficultconversations with the patient's
(25:25):
mom, with grandma, like that wasa hundred percent our patient
navigator.
There's so much of like the realwork of taking care of these
patients does not happen byproviders and does not happen in
the clinic room.
Also because it reallyhighlighted for me like there
are options between the binaryof CPS is evil.
Never call CPS.
I'm never gonna call them andI'm just gonna have to live with
(25:45):
the anxiety that this baby'sgonna ingest fentanyl on one
hand and call CPS and have thebaby removed every time on the
other hand, neither of thoseextremes really serve our
patients, but there are optionsin-between but those options
they require a lot of work a lotof frank and difficult
conversations and a robust teamto do the work, I am so
(26:07):
eternally,.of work this patientand for teaching me about this
work.
Leah Warner (26:15):
I love that case.
Simone.
I do feel like you're right.
It highlights how non binaryactually harm reduction is
because on, I think oftentimeswhen we are really worried or
fearful for our patients, wethink, okay, there's only two
options here, call CPS or donothing and never sleep again.
(26:35):
But actually harm reductionshows us that there's so much in
the middle between those twochoices.
And it does sound like it takesnot only a really good team
multidisciplinary approach, butalso a lot of creativity and
time, which isn't something thehealthcare system always gives
us, but is probably the betteroutcome in the long run for our
(26:58):
patients.
And we really do need to takethat time to see all the choices
in between the binary.
Jamie Lang (27:05):
Okay, Simone and Leah, question three.
One thing I encountered duringmy pregnancy was barriers.
Health insurance, prenatal care,treatment, housing, clothing,
shower, food, you name it.
How would you change the currenthealth care system to reduce
barriers and improve health careaccess for pregnant or
postpartum and parenting peopleusing drugs?
Leah Warner (27:28):
Okay.
Thank you.
I am so excited to step on mysoapbox now, because first let
me say our public health system.
And healthcare system can bevery complicated to navigate.
You need tenacity and a lot ofinterpersonal skills to talk to
the various offices and servicesthat don't always talk to each
(27:50):
other.
And this is important becausethe clients this system is
designed to serve are peoplelike my patients, people
experiencing homelessness orliving in poverty, who have a
lot of substance use, unmetmental health needs, but also a
lot of physical disability, likebodies that are in pain.
(28:10):
And have to walk back and forthbetween these various places to
get the services they need.
And a surprising incidence ofcognitive dysfunction from brain
injury, either acquired ortraumatic.
So already there's a hugebarrier here between the system
design and the clientcomplexity.
So, to bring it back topregnancy and parenting, let's
(28:33):
take my pregnant patient, forexample, and let's say she needs
to come into health care becauseshe needs to get a form signed.
I cannot tell you how manyhealth care visits I have for
people who bring me a form thatthey just need signed to get
through the system of care.
To get to me.
She has to leave her stuff,right?
(28:55):
She, she may be sleeping on thestreet.
She may have like the tent sheneeds, the equipment she needs.
It took her a while to get thatstuff, all her precious
belongings.
She has to find someone she cantrust to either watch it or
leave it during a time where shethinks it's not going to get
swept away.
She also has to find a goodroute to get to my clinic.
One that won't be superdistracting or that feels safe
(29:18):
to her.
Then once she gets there, shehas to take her pregnant body
through the gates of healthcare, maybe presenting as a
person experiencinghomelessness, maybe getting
dirty looks, or even just moreattention than she's used to
being pregnant, and get throughRegistration, show her ID.
(29:39):
I don't have an ID.
Okay, what else do you have?
Give me your social securitynumber.
She has to shout why she'sthere.
I'm here to get a form signedfor my housing.
You know, all of these thingsthat she has to get through in
order to see me.
So, while I can't really talkabout what we could do to reduce
(30:00):
barriers en masse, for ourhealthcare system.
That's probably like a differentpodcast, but just on an
individual level as a provider,I really try to keep all of
these various barriers in mindso that by the time I'm sitting
face to face with my patient,I'm giving a very wide margin,
(30:23):
not just for error, but forfrustration, for irritability,
for just discontentment.
I really do try to honor thatpeople have had to go through a
lot.
To Just get to a provider visitand lo and behold what if it's
the wrong form that case managerPrinted out the wrong form, you
(30:47):
know It takes me probably tenextra minutes to figure out what
form I actually need to printout for this patient So she can
connect these dots, but I I'mholding all of this in my head
I'm going to help reduce thosebarriers.
And I think other ways we canreally reduce barriers is to
have options where appointmentsaren't a thing.
(31:09):
You know, not just a drop inclinic, but really a
comprehensive set of serviceslike primary care that don't
have appointments.
So we call our clinic openaccess.
People never have appointments.
They can just show up.
In the times that we are thereand get pretty good
comprehensive care.
And that takes away a lot of theshaming around.
(31:32):
You missed your appointment.
Sorry, I can't schedule you anappointment.
You've missed too manyappointments.
And then finally, I think we canalso think about putting
healthcare in very creativespaces.
There's healthcare on thestreet, like street medicine,
but there's also healthcare thatcould be found in syringe access
or drop in centers.
Mostly I think about puttinghealth care in spaces where
(31:56):
people experiencing homelessnessare welcome is there aren't a
lot of those spaces and wherethey are welcomed is where the
healthcare should be.
Simone, your thoughts?
simone--she-her-_1_04-26-2 (32:09):
Just to add like very briefly on
something you already said,which is that, I like cosine
1000 percent that would need tomove away from a traditional
appointment based system.
And that is a system that wasnever created with the needs of
the marginalized in mind.
Just imagine you're a brand newparent, with a brand new baby,
you're learning to parent, whilealso kind of still on an
unstable methadone dose andfeeling like you're in
(32:29):
withdrawal all the time, and CPSmandates that you go to like,
this therapy, and then this NAgroup, and then this court
appointment, and like, it has athousand hoops for you to jump
through, and you also have tomake it to your Doctor's
appointments, but also your babyvomits everywhere every time you
leave the house and also youhave to walk there with your
stroller.
And so, with all those things inmind, like, of course it was
(32:50):
never going to work for you tohave a 15 minute window to show
up at this clinic.
We need to get away from that ifwe're going to try to take care
of our patients.
Jamie.
Leah and I have rambled for 34minutes now.
I'm going to flip the table onyou.
As someone with livedexperience, what do you think
that pregnant and postpartum andnewly parenting people who are
using drugs perceive tothemselves as the most harmful
(33:13):
to their health during thistime?
I'd love to hear both like yourthoughts from your lived
experience and also from yourjust immense experience working
as a case manager for thesefolks.
Jamie Lang (33:22):
Thank you, Simone.
The first thing that comes tomind is a child separation.
They're going to take my baby,that adds a whole extra layer of
accessing care and being honestabout my situation.
for me living in the streets atthe time, there was also the
constant fear or threat ofintimate partner violence and
(33:42):
community violence.
when I say community violence,not just the community of my
peers, but community providerslike the police department or
department of public works, whowere also very harmful and
dangerous.
I also think the constant stressof being in survival mode was a
concern towards the pregnancy,specifically around housing and
(34:02):
shelter and the mistreatment Iexperienced due to stigma and
judgments when I tried accessingthe systems.
Leah Warner (34:11):
Wow, talk about barriers.
Those are some prettyinsurmountable barriers.
I want to pause on intimatepartner violence, which is
something we see very often inour clinic and is not easy for
us to talk about with ourclients.
How do you talk to your clientsabout intimate partner violence?
Jamie Lang (34:31):
They usually come in wanting support around it.
I don't have to pry it out ofthem.
They're usually forthcoming, andI think there's an urgency
around intimate partner violencewhen there are children involved
versus maybe someone who is inthe preconception or pregnancy
stage.
Leah Warner (34:48):
I think that's a fair point.
If you had to think back to thetime when you were accessing
care, what do you think the roleof a provider is when bringing
up intimate partner violence, orsupporting somebody who's in an
intimate partner violencesituation?
Jamie Lang (35:05):
The role of provider should be whatever the patient
wants.
I was not looking for supportaround that.
I was still very much living instreet culture, where you don't
talk about that type of thingunless you're ready to
completely leave the situationor suffer the consequences of
speaking out.
What I really needed supportaround was the community
violence, the police telling usto constantly move our tent or
(35:27):
calling to have it taken away.
Department of Public Workssprayed me with a pressure
washer when I was sleeping onetime.
This was actually a barrier togetting care because I would
have to leave my tent and all mythings behind and if they come
while I'm not there to move mytent.
They'll take the whole tent andeverything inside.
Leah Warner (35:46):
Jamie, Were there any signals from providers that
made you feel like you could besafe with them?
I mean you really mentioned likewhat's on your mind is child
separation, the communityviolence you're experiencing,
coming in with all of thesethings.
Were there signals from healthcare providers that made you
feel like yes, this person ishere for me.
Jamie Lang (36:09):
I first met my midwife, Mary Mays, and she was
just like, cool, how can I helpyou?
What do you want to talk abouttoday?
Like, it was so normal for her,and learning to trust her opened
the door for me to trust otherproviders, like nurse Dana, who
would come and see me at my tentsometimes.
Her support really changed myattitude and the trajectory of
(36:30):
my life.
Leah Warner (36:31):
I think that's It's sort of the definition of harm
reduction right there.
It's hearing a patient's story,maybe feeling inside very
overwhelmed by all that yourpatient is going through, all of
the factors pressing down onthem and remembering that you're
(36:53):
there to support their healthand moving forward and saying,
okay, what can we do today?
How can I meet your needs today?
It takes a wizard like Mary Maysto pull that off.
Simone (37:07):
I really could not agree more that we should all just end
with acknowledging that MaryMays is a wizard.
But I also want to just Bring usbriefly back to our learning
objectives to kind of recenterus where we started.
We started off talking about,like, what are the harms?
What are the harms that we areafraid of in pregnancy and the
postpartum period?
And to list them out, we'reafraid of not doing enough about
(37:30):
our return to use, that thatwill lead to parenting while
intoxicated, inadequatesupervision of babies, and
potential ingestions.
But we're also afraid of doingsomething and our intervention
being harmful.
So, calling CPS, that leading toremoval, and that leading to a
to sustained return to use.
And then we talked about like,so what are some harm reduction
(37:50):
things that we can try?
And in that, we mentionedappropriately dosing people's
MOUD.
Noting that metabolism changesin pregnancy in the postpartum
period.
Having frameworks for morethoughtful and more equitable
decisions around calling CPS andusing urine toxicologies.
And having honest conversationsabout safety planning that
(38:11):
acknowledge that relapse is apart of recovery even when
you're postpartum And as jamiebrilliantly said what you have
agency over is where your childis during those times And then
finally we talked about thebarriers to health care access
for pregnant people and honestlyall marginalized people.
Which is that providers are notin the places where patients who
are Living outside, feel safeand comfortable.
(38:32):
And we need to get ourselves tothose places.
And we need to do away with thisappointment based model that
completely is based on the needsof the clinic and has not at all
centered the needs of ourpatients.
Leah Warner (38:43):
What a beautiful summary.
I want to add to that and saythat when we are thinking about
our greatest fears, we also haveto acknowledge that sometimes
that fear can easily turn into abias.
And that bias can really guidehow we're talking to our
patients and that it's okay.
It's okay to feel that fear.
It's okay to feel overwhelmed bywhat you're seeing, but remember
(39:07):
our patients can pick up on biasand discomfort.
And so it, It is important touse your multidisciplinary team,
your resources in the community,and to make sure that, just like
Jamie said, you're like, cool,well what can we do for you
today?
And make sure that you arereally seeing what your patient,
who overcame a lot of barriersto get to you, is there to talk
(39:29):
about that day.
And actually, it's a lot easiersaid than done.
Like it does take wizardry.
Jamie Lang (39:37):
I think that's great.
Thank you, Simone and Leah.
I think this was a really greatconversation.
Kinna Thakarar (39:43):
That was Dr.
Simone Vays, Leah Warner, andJamie Lange in conversation on
harm reduction compassionatecare for people who use drugs.
Thank you for listening.
Be sure to tune in next timewhen we welcome Dr.
Joshua Lynch, Shelby Arena, andDr.
Shoshana Aronowitz to the seriesto discuss innovative access to
harm reduction support andlinkage to treatment.
Please take a moment to completeSAMHSA's post event evaluation
(40:05):
survey on the AMERSA podcastpage at www.
dot AMERSA dot.
Org forward slash harm reductionpodcast.
We welcome any comments,questions, or other feedback for
presenters.
You can send those directly toAMERSA through the contact us
form at AMERSA.
org.
To learn more about theprovider's clinical support
system, Medication for OpioidUse Disorder Project, and AMERSA
please visit our websites atPCSSMOUD.
org and AMERSA org.
(40:26):
Funding for this initiative wasmade possible by Cooperative
Agreement No.
1 H 79 TI 086 770 from SAMHSA.
The views expressed in writtenconference materials or
publications and by speakers andmoderators do not necessarily
reflect the official policies ofthe Department of Health and
Human Services, nor does mentionof trade names, commercial
practices, or organizationsimply endorsement by the U.
S.
government.
Thank you for listening.
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In 1997, actress Kristin Davis’ life was forever changed when she took on the role of Charlotte York in Sex and the City. As we watched Carrie, Samantha, Miranda and Charlotte navigate relationships in NYC, the show helped push once unacceptable conversation topics out of the shadows and altered the narrative around women and sex. We all saw ourselves in them as they searched for fulfillment in life, sex and friendships. Now, Kristin Davis wants to connect with you, the fans, and share untold stories and all the behind the scenes. Together, with Kristin and special guests, what will begin with Sex and the City will evolve into talks about themes that are still so relevant today. "Are you a Charlotte?" is much more than just rewatching this beloved show, it brings the past and the present together as we talk with heart, humor and of course some optimism.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
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If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.