Webinar presenter Dr. Carolyn Sufrin answered a number of your questions after her presentation, “Managing Pregnant Women in Jail Based Settings.” Here are a few of her responses.
Audience Question: In our facility, which is a jail with up to 108 beds we’re faced with methamphetamine abuse in a majority of our male and female populations. At any time you have 2-3 women under 2nd or 3rd trimester who come in meth positive. We work closely with her the local OB-GYN providers and they initiate prenatal cares soonest we’re aware of the pregnancy. Would Dr. Sufrin be able to say something about meth and pregnancy?
Dr. Carolin Sufrin: Well thank you so much for sharing your environment and the prevalence of meth use in your setting. It sounds like it remains a really transient issue. So in terms of methamphetamine use in pregnancy, ongoing meth use or any stimulant use, including cocaine poses severe risk to the pregnancy. One of the most prominent ones is the risk of causing that scenario while your health care providers probably are aware of placental abruption being a risk that’s where a placenta separate early. Hypertension, high blood pressure, that can lead to stroke, cardiac, myocardial infarction or heart attack. The stimulant using including methamphetamine use in pregnancy put the pregnant women at use for those direct effects. So, when a woman comes to jail and is not using, has a history of meth use but has stopped using it. She may have some symptoms, it’s not classified as a withdrawal syndrome necessarily in that there is no pharmacologic treatment for the symptoms that someone experiences when stopping methamphetamine use. So, opioid use disorder. And I did not talk about alcohol use disorder that’s also another topic but opioid use disorder is the only substance use disorder where there’s a pharmacologic treatment for the condition. Wherein methamphetamine use, the treatment is predominantly behavioral and getting really good mental health care and addiction treatment and linking them to community resources. So that they can stand treatment when they get released. So, I would say that the prominent issues are, especially when they first come in jail they might still be intoxicated from methamphetamine, so they’re going to be at risk for those conditions like abruption, high blood pressure, chronic stimulant use in pregnancy also put them at risk for growth restriction for having a small poorly grown fetus. So, those are some the issues I would highlight and it’s wonderful that you’re working with the community partner to get these women the treatment that they need.
Audience Question: Should the facilities train correctional staff to identify signs of problematic pregnancies?
Dr. Carolin Sufrin: That’s a great question. I think that there is an absolutely should be some training for custody officers but I don’t think the expectation at all should be to give them, to make them act like health care providers. They have so many things to worry about but I think some training to know, what are concerning signs to look out for? And basically, that with pregnant women who are in jail, you really need to have a low threshold to involve medical. And when I worked at the San Francisco Jail, I remember one of the lieutenants said to me, “You know, a pregnant woman could hiccup and it could be something bad.” It may harm may not be, he would use that as an exaggerated example but he was saying, you just don’t know. I just always have my officers call co-medical. And I think that’s the right approach and I know It might some like, “Is that going to result in overburdening of the healthcare system?” I don’t think that should be the question that should be. We need to make sure that we’re providing us a safe environment to women and there are so many things about pregnancy and symptoms that you just don’t know. Like, headache and pregnancy can actually be a very concerning sign. It could be a sign of preeclampsia which can lead to seizure and kidney failure and other things. But headache in a non-pregnant individual, maybe they would get some Tylenol but it’s not something that should race the alarm bell. Where is in pregnancy it should. So, I think there absolutely should be some degree of training for correctional officers but I don’t want them to feel burdened that they need to triage the symptom because basically, the training should be there all kinds of concerning sign and symptoms and things that can arise and so if the pregnant woman has pains, bleeding, leakage of fluid, a headache, chest pain you should call medical right away.
Audience Question: Can you name a leading facility that has a great pregnancy inmate training that we might be able to model? A facility that really does a great job in working with their pregnant inmates in every stage of the pregnancy?
Dr. Carolin Sufrin: I know some places, I’ll mention in just a moment where aspects of their care that I know are really good. But I’m sure there are more, but the problem is all of you know there is no single clearinghouse if you will for knowing what everyone is doing. So, If I don’t mention you, you may still be doing a great job. I know that there are protocols and the Cook County Jail and Rikers Island Jail where they have very thorough policies. I personally review the policies of the Merlin Juvenile Justice System and although it is with adolescents, everything that is regarding their pregnancy and postpartum care applies for adults. I know that’s an outstanding set of protocols. And there are resources also through the National Commission on Correctional Healthcare and the American College of OBGYNs that have, not just position statements but there is a white paper in NCCHP website that outline, it’s not policies but it outlines best practices about each of the specific things that I talked about. I’m having trouble remembering all the other jails I’ve seen, the San Francisco Jail where I used to work, I had some I think an excellent system in place. But, it’s not a matter of highlighting one particular system because as all of you know, jails are in different environments. What works in a big county, urban jail in Chicago or New York City is not necessarily going to work in this small rural community where maybe only see a few pregnant people a year. And so, having model policies has to be a plural thing. And people really need to share their expertise in what works and what’s challenging. I’m sorry, I don’t have one singular answer for you but I know there are places out there that are going a good job that can help. And, I would encourage you to look at some of those resources for examples and to attend conferences where these issues are discussed. So that people can network and share their policies, but I wish there were more of the central clearinghouse where people could share their expertise. And I would also have that as a plug for participating in the survey about MAT in pregnant women. That’s only one slice of the care, but if you participate on that survey, you’ll be able to share your protocol and other things so that we can all do the best and adapt our systems.
Audience Question: The sleeping mats in our facility are very thin and outdated, from medical staff policy is that pregnant females will not receive an additional mat for added support. This is policy potentially place our agency at risk of litigation?
Dr. Carolin Sufrin: No, I am a physician I don’t think it would be good for me to answer any legal question, but what I can say for a health care perspective is that pregnant women have a lot of routine, discomforts, and as their body physiology changes. There a lot of things that can get worst and having a very thin mattress as you know can impair our sleep. Healthy sleep is really important for a developing fetus. Also, pain and the neurochemicals release are not good for a developing fetus. In addition, some women will develop sciatica which is an extremely painful condition and can be exacerbated by sleeping position and the thin mattress that can result in the women having difficulty walking which can put her at increase rate for blood clots. So, it just can cascade. So, I don’t think I can comment on the legal aspect and the risk of litigation but I would say best practice for the health of the women and the health of the fetus is to have a more comfortable environment. And of course, I know that Tempur-pedic mattresses for a pregnant woman is not realistic at all but I think that there are things that can be better about a safe and comfortable environment for the pregnant women.
Audience Question: I know you address when a pregnant woman is admitted on illicit opioids, what about when they are currently taking prescribed opioids for something such as chronic pain, should the treatment be basically the same?
Dr. Carolin Sufrin: What a great question. You have put your finger on an issue that the Broader OBGYN community is grappling with. There are several different camps on this and some say that women who’s done chronic opioids for a chronic pain syndrome should be managed with long term treatment with methadone and buprenorphine, there are others who say that it’s okay for long term maintenance for her to be on oxycodone or oxycontin. Both in an out of pregnancy. So, that is a decision I wouldn’t want the jail providers to have to make that decision on their own. Because it is a really a nuanced conversation. We’re having a partnership with opioid treatment providers and people who are expert on perinatal addiction treatment are optimal and I know that may sound aspirational in some of you in small jail in rural settings may be saying, “We don’t have anyone.” I know that’s one of the challenges that we need to work on. I think there’s a lot of potential for telemedicine. But if you don’t have someone in your community who can be a resource , who can provide consultation right now, while the community is getting its act together, try to find the nearest maybe an academic medical center that’s nearby that might have someplace. Maybe they’re not even not nearby, but find someone you can partner with, who can be a resource, who can help you answer those questions. But short of having nothing, if a women know medication assistant treatment or not knowing what to do. If a woman comes in and you can verify that she has on medically prescribed opioid, you should continue them for now until you can get expert consultation.
Audience Question: Going back into your report, does it include information from jails in every state, specifically Missouri.
Dr. Carolin Sufrin: I wish we could have, we have a small research staff so the project is actually called the Pregnancy in Prisons Statistics project or PIPS. We focus largely on prisons. So, we had 22 state prisons system and the Federal Bureau Prisons. Missouri was one of the state prisons system we asked to participate them and they declined. But, in terms of jails because there were just so many jails and we were a small staff, we only included the five very large jail and none of them where in Missouri. But if you’re interested in these results, they will be published very soon in the American Journal of Public Health, at least the prison results. And if you’re interested you can find their website by searching -ARRWIP or the website at PIPSdata.org, if anyone is interested.
Audience Question: Generally speaking, can a pregnant female be switched from buprenorphine to methadone or vice-versa?
Dr. Carolin Sufrin: So, someone who’s on buprenorphine. When you start someone on buprenorphine they actually have to go through like a little bit of withdrawal before you start them for their receptors to be able to respond to buprenorphine. So, you can’t switch someone from methadone to buprenorphine. Unless you fully get them off the methadone. Buprenorphine is partial agonist-antagonist for the opioid receptor so you can’t go from methadone to buprenorphine but you can go the other way.
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