Los Angeles County Maternal Mental Health Access (LAMMHA) is a five-year program funded by The California Health Care Foundation (CHCF) to support Los Angeles County community health centers in the identification and treatment of common perinatal mental disorders in primary care. At least one in five childbearing persons in the U.S. will experience a mental health or substance use disorder (SUD) during pregnancy or in the first year postpartum¹. To reflect on the experience of perinatal SUD treatment, we spoke with Dr. Nadejda Bespalova, a perinatal and addiction psychiatrist and Acting Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington. During our conversation, Dr. Bespalova shared her reflections on a case of a pregnant patient who had a history of substance use. “Some things went well, and some things didn’t go well – for a lot of reasons. Things are complicated,” Dr. Bespalova reflected.

Dr. Bespalova initially saw the patient in clinic. The patient was referred to her for concerns of depression and anxiety. During the intake process, the patient disclosed that she had a history of opioid use disorder, but she had not used recently and she had not used since she became aware of her pregnancy. She also shared that she was very motivated to stay substance free during the pregnancy. She had older children whom she wasn’t parenting.

Dr. Bespalova discussed treatment options for depression and anxiety and opioid use. The patient agreed to begin taking Sertraline (a medication to treat mental/mood disorders such as depression, obsessive compulsive disorder, post-traumatic stress disorder, and social anxiety disorder) for the depression and anxiety, but she felt strongly that she did not want to take Buprenorphine (a medication to treat addiction to opioids) for the opioid use. She had taken it before and was concerned about neonatal opioid withdrawal. She felt that she could avoid opioid use during pregnancy if her depression and anxiety were managed. Dr. Bespalova honored her preferences.

The patient managed her substance use disorder well during pregnancy. She made a joint decision with Dr. Bespalova to undergo regular urine drug screenings because she wanted evidence that she was engaged in treatment and doing well if Child Protective Services (CPS) were to get involved. All screenings were negative.

The patient delivered a little early via emergency c-section. As part of standard c-section recovery, the patient was prescribed opioids. When she ran out of the prescription after discharge, she purchased Fentanyl on the street. This was difficult for her and her family. Her partner was very upset and asked her to leave the house. At this point, the patient reached out to her care team at the health center and they were able to get her started on Buprenorphine again to manage the opioid use. CPS was contacted and opened a case. Ultimately, the patient did well on the medication, engaged in treatment, met CPS requirements and was able to parent the baby.

The good news is that the relapse only lasted a couple of days. However, Dr. Bespalova reports that if she could do it again, she would have planned for all delivery scenarios better.

We asked Dr. Bespalova for her advice for making a report to CPS.  She shared the following:

• Be familiar with your state laws around what constitutes a requirement for CPS contact. For example, it is required to report substance use during pregnancy in some states, but not in others. Know as much as you can and ask questions when you don’t know.
• Focus on concerns about the wellbeing of the child(ren) and whether they are in harm’s way, more than the parents’ substance use. If you have concerns about a child’s well-being or safety, it doesn’t matter why. You should contact CPS regardless.
• Always be honest with your patients. If you’re going to call CPS, tell your patient. Offer to call together. Sometimes the person might say “no way”, and that’s okay. At least you offered. Still let them know that this is something you will be doing. You don’t want the CPS report to be a surprise.

We hope that by sharing this case study, we better prepare clinicians involved in the LAMMHA project to identify and respond to substance use disorders during pregnancy. Two resources that may be helpful include the mcpapformoms.org/Toolkits/Toolkit.aspx and the Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants (samhsa.gov). The LAMMHA ECHO series will cover this topic on May 14, 2024 in the session titled “Perinatal Mood and Anxiety Disorders and Co-Occurring Substance Use Disorders.” Please see LAMMHA ECHO page to register.

For additional information on supporting and treating perinatal SUD, please see LAMMHA resources page. For more information and/or to apply for an upcoming LAMMHA cohort, please visit the CCALAC LAMMHA program page and our previous blog posts on the LAMMHA program and the LAMMHA ECHO series. For more information and resources around maternal mental health in California, please visit the California Department of Public Health – Maternal Mental Health page.

Dr. Nadejda Bespalova, a perinatal and addiction psychiatrist and Acting Assistant Professor in the Department of Psychiatry and Behavioral Sciences at the University of Washington.