Okay so let's do the birds of a feather. I was kind of hoping there's a few more birds here but maybe I'll turn up in a few minutes. Okay so this is what I put on the abstract when I was submitting this talk. So ASP developers are many but widely dispersed so we don't get a lot of opportunities to get together and share ideas but here we are. So the mic is open for anybody who wants to contribute. This isn't about me but I do have a couple of ideas. So this is my kind of outline agenda. Happy to add things in as we go. So these are the topics that I really wanted to or thought would be great to talk about. So top of my list is community. How do we get some kind of community behind ASP? So I've got a couple of slides of that and we'll come on to that moment. Then other topics I thought of is where do you go to get information about ASP? Is it source.android.com or is it some people you happen to know or is it some magic link that nobody else knows about that we all should know? And any conferences which cover ASP topics would be great as well. Any experiences on porting ASP? So issues to do with board support packages? Which build tag do you use? Actually that's the next topic but how do you find a good version of ASP? And then there's the final thing. What are your main grumbles about ASP? Don't this to be particularly negative but there are pain points. So what are the pain points that you experience and do you know ways around them? Do you know where the near-refen is? So just to get things rolling then I just want to do this slide and the next slide and then we'll kind of open it up a little bit. So open source really in my opinion is at least 50% but it's 90% community. The whole point of open source is that there is a community. We can come together. We can share code. We can communicate about things. We can share bugs. People can post patches and so on and so on. And the way that ASP is structured none of that happens or at least none of it happens easily. And I'm going to call out Google here. Google a little bit absence here. So there is this community page which hopefully this is going to work. So Android community and contacts. Somewhere there's some ASP stuff. Android.com. Yeah. So what I was going to say, yeah, groups you go. So there are a whole bunch of groups like Android platform, Android building and whatever. But if you go to these groups there's basically nothing happening. And that kind of bugs me. Oops, wrong way. Yeah. It would be nice if there's a little bit more interaction on this or if we could set up some alternative mechanism. I really would like that. So there we go. So questions. Why don't we talk to each other and how can we make it better? So does anybody want to contribute on this? I have a mic. So thoughts. How can we build a community? I don't really got any magic ideas on this. Anybody? Burn it. So from where I stand, I think there's a big problem for ASP and that problem is called Google. And what is really needed is more open project that follows ASP closely, that copies every line of code from ASP, but that is more useful as a standalone project. So if you try to put ASP on your phone, you will find that you cannot really use it because it's missing even basic features like an email client. And there are open source tools that can fill in all the gaps. I'm using an un-Googled phone right now and not really missing anything. But what is really needed is putting ASP and all those projects that turn it into something that is actually useful together and then try to build a community around that while also trying to be somewhat less ignorant about community issues than the upstream ASP maintainers. And of course the idea there would be to not really fork ASP, will keep all the code that is there as it is in ASP, just pull it in and build a couple of extensions around it that are pulled in through a different manifest. Maybe having the completely usable system will already help more attract more community members. Isn't that more or less what Lydia, Joes, do already? In a way it is. My criticism of lineage is that they try to fork it too much. There's quite a bit of divergence from the code base. There's no way whatsoever that all the changes that go in there will ever be much back into ASP. So what I am suggesting is kind of similar but trying to stay closer to the ASP code base, trying to upstream patches that make sense. Yeah sure. The issue with forking, we for sure could do that. ASP is open source, we can fork it any time we like. But then once you've made the fork then what do you do? That's always the point where it falls to pieces. Because you have to follow the ASP because everybody wants the capability, compatibility with the later versions of Android. You can't just stick with Android 4.4 KitKat, which is actually my favourite version of Android. But no, you've got to keep on going forward. So it's a great idea. I fully support it but it needs quite a lot of effort behind it to maintain it. Right. That's why I think it needs to be brought up at a session like this to see. Absolutely, yes. So if anybody wants to do that, I'm totally with you. Yeah, in fact to some extent I have done it, the code for it is flying around on a Git server in my cellar so it just needs more people to look at it and maybe a better place to host it. Okay, well if you can post a link to that or tell me and I'll write it on the slides. That'd be great. Yeah, sure, we'll do that. Yeah, yeah, if you scroll it down, I'll put it on the screen. Okay, super. Yes, so I come from also like the Google free Android community and from my point of view like contributing to AOSP, it is not really clear how to do that or if you can even do that and when you maybe find the right Garrett whatever project and you submit a patch and then it just sits there for seven years and the bug is still unfixed. So that is I think a huge problem and then you have the various like Linear.js is one fork that maintains their own tree. They're also quite closed. I don't know anyone from that community. That's a good point as well. So it'd be great if Linear.js, if anybody happens to be watching this, were to join this community or at least be a little bit more open. And there's various other projects that build on top of Linear.js or AOSP, other custom ROMs, other companies that sell phones with less Google integrated into Android and they all maintain their own like framework trees tracking AOSP or whatever upstream they have and then they have a bunch of patches and a bunch of bug fix patches and you kind of move them around Garrett instances like they picked that from this one and we also need this bug fix and it's all a mess and it sometimes or mostly never makes it up to AOSP because it's too complicated and so I don't have any solutions. I just have problems, I guess. Yeah, I hear you and I'm gonna have a complete solution either but maybe a quick suggestion. Most of the Git projects in AOSP have a file called owners which has a list of usernames who are allowed to merge into that particular Git project. So typically when you upload a change to Garrett, it doesn't get assigned to anybody which is horrible and there should be an auto assign but you can figure out from that file who has the permission to make that decision. So you know assign it to them, maybe send them an email if they don't respond but at least there is a list of maintainers somewhere. It's not much but at least something. Okay, that'd be cool. And maybe just to add to that like I guess even if you would do that like with some projects maybe you would want one get your patches merged in because like the product timelines there are other things that are happening behind the scenes is not just because we're assholes but sorry I shouldn't have said that but like maybe in like instances like this having a prioritized community list of like here are the biggest pain points with the CLs or like bugs or like some sort of description and then using this as the venue to get like the top two or three or five fixed might be interesting. Okay, other thoughts I guess. So adding on top of what David just said and nowadays get it automatically assign the owners. I've tried it a few times so the owners get assigned automatically with the new version of get it maybe. I don't think it does it for all the projects but yeah it does for some that's true. So I'm just making a note here I'll be with you in just a moment. I have a question and the question is sort of like what are the projects that people feel like they need to modify the most or have most changes against and then the follow-up would be why is that? Is it because the projects are not designed in a way in which you could interface quite easily or is it because functionality is missing? So I guess from my point of view the things would be so basically the low level stuff so bug fixes to house bug fixes maybe to the Bluetooth stack which is somewhat buggy in places. Basically it'd be really really great to at least to start with if we were just able to fix bugs and have a workflow and a strategy for doing that. That helps everyone and it should be pretty much no-brainer. The problem is of course that the internal team developing Android are probably working on a different code base to the one we're working on so there's always going to be some mismatch. But there is a there is a kind of solution to that which I think John Stoltz recommended is that there is a period which he called the merge window directly after the release of the next Android release and before they start the next version. So at that time sort of September Octoberish time is probably the best window to get stuff merged upstream because the Android developers are kind of merging their stuff into main at that point and they're much more it's much easier for them to to merge in external changes. So another idea then go for the merge window do stuff September October. Does anybody else have experience in that? Have you tried different periods? Does it work better at some times of the year than others? So our changes are very small in nature so we don't try to push too many changes to its internal projects it's like 10, 15 at max 50 lines of code just the bug fixes. So our experience with ASP is rather good maybe it's because we have been involved with ASP for last 10 plus years so I don't know if that helps the contributions and other things but this merge window thing is I have heard that too that but sometimes if you do it just at the time the release is dropped then it takes about a week for the things to settle down but if you try to sync or download or sorry sync or build it doesn't even build at times. So even they are still free because merging Android release tag in ASP gets very complicated for certain projects because as you mentioned that for the release they are working on a totally different code base and it may not align with ASP as such and there could be merge issues and we have run into issues where it takes about two or three weeks for things to settle down and okay now the ASP is bootable. Okay but there's still a period I think once that settling has happened before they basically take a snapshot of main and then start the next round of development which I guess happens towards the end of the year so there must be a period when the code bases are kind of a little bit more in sync. Maybe somebody at Google should kind of publish this maybe this should be made to kind of common knowledge seems like a reason maybe they get too many patches that way though so we should keep it quiet. Okay okay anyone else otherwise I want to move on to another topic well actually not quite but yeah maybe I'll just add to that a little bit. I think two things was one of the most I think Christy mentioned that Google might be working on a different source base at given times that might be true for kind of the more product oriented grid repositories kind of UI and application level but it's definitely not true for the layers of the stack right the kernel, a Selenax, all the kind of base in its scripts all of that is developed directly in OSP and actually merges into the internal tree from there. But are they working on the master branch or are they working on the master branch? That's on master okay so those lower layers we're seeing the exact same thing as you do okay and on the timelines yes September is usually the drop of the the latest release but that is after some period of stabilization yeah so especially if we're talking about these lower layers they're usually developed in OSP around you know maybe one to two quarters earlier so winter is usually the busiest time and then things start to stabilize so gradually. Okay right so that would argue for maybe targeting late spring, early summer as they as a good time to emerge okay interesting okay okay great thanks for that. Ideas for making it better so I want to kind of move on a little bit away from the interaction with Google and think more about the interaction between us developers. And so I've got a blatant plug here which I guess you guys are aware of this but let's do it anyhow the the meetup so this is something I put together just over a year ago with the aim of creating some kind of community and it was it was a bit of a shot in the dark but it's something I've been thinking about doing for years and years and I keep thinking to myself somebody's going to do this if I wait long enough somebody will do it and then I finally realized that actually it's going to have to be me so I actually put this together it's a little bit amateurish I'm not the most organized person in the world for doing this kind of stuff to be honest so I put this stuff together and it is a meetup so it's an online meetup because you can never get enough people together in one place to make it work as an in-person meetup but it seems to be quite successful we typically I mean that the group has 350 members right now the meetups would typically have 30 35 people turn up online and many of the faces here have been present there and I very much appreciate that so this I think is I'm quite pleased with the way it's gone it's been more more successful than than I might I feared it might be and it's turning into quite a good resource here I'd like to somehow publicize this so at the moment I just have a list of past talks this needs kind of organizing and kind of categorizing a bit and also when I look at the the stats of the videos on on YouTube um yeah we don't get a lot of hits to be honest the most popular talk it only has about 300 views so I'd like some ideas of how do we get this information out people ought to be there's some good stuff there there ought to be more people watching this stuff so I'll open that up in a moment um but the other the other thing I'd like to look at is that this is great it happens every every two months and a bunch of people get together and we chat for a couple of hours about this and that and it all goes really nicely um but at the end of that you know it it kind of shuts down and then nothing happens until the next meetup now okay that's the nature of meetups but what I was looking for is is some kind of thing where we could keep the ball rolling in between the the the meetups some kind of community so if anybody has any ideas about that again that would be very very useful and I'm very happy to kind of work on that so first point then how do we make this stuff more more more more known um it's so I am part of another community which does pretty much the same thing so the first thing would be to merge maybe similar initiatives to begin with yep sure so I think you are also part of that IRC channel right asp-developers I am I was looking for the link to it yeah so it is not this page which is a mistake yeah carry on I'll find the link so what that project does is so right now it is mostly phone-specific so a bunch of people trying to run asp and write open source project not the release tag it's the the asp version on form factor devices on phones so I know that they are running it on SDM 845 SoC which is called count couple of them uses it for SDM 600 series phones as well and the reason they are doing it is because free dinner right the graphics is open you can run AOSP you can run upstream kernel post market OS is something which is different than AOSP but we I mean not me but there are a bunch of developers who are you know twin timing between AOSP and post market OS development so we get to share the features which are being supported on both side of the ecosystem so maybe there's a good opportunity here to collaborate on your project and asp mainline project or any other project if there are any and this is just phone specific right I'm hoping that should because you have if you have seen my talk this morning the dev board requirements in asp is getting very strict nowadays so should we expand this project to include the dev boards as well this project yes so this plus your one and throw in development boards in the mix so this one only talks about this is john this is john's uh page which looks very similar to my page I know I apologize that I did steal a lot of his ideas so I'm saying that yeah these two projects when you both are talking about the same thing right building a community around AOSP people using AOSP on their devices be it development board be it phones tablets whatever device they could find I I mean it would be really great if we could have more dev boards more embedded conversations on on this so I mean essentially this is mostly about the the IRC channel I think so if we scroll down a little bit come chat with us does this work I think it works so I think okay it's not a work yeah so we should definitely so one one thing I never one thing I have not set up is any kind of IRC or chat or whatever and that's a big mistake on my part um so maybe we should come together yeah I'm more than happy to do that I did kind of I spoke briefly with John Stoltz at Plummer's last last October whenever it was and we kind of said we'd do something and we both said yeah that's a really good idea and then neither of us me in particular didn't follow through on that so I will take that I will send an email to John tonight and say maybe we can kind of do more than just cross-link and actually do you know do something together um but yes and also as a follow-up to that I really would like to do more kind of embedded Android so I define embedded Android as being Android not on a phone so as we all know Android ends up in all kinds of weird places um in pizza ovens I happen to know run run Android and um Garmin use it and there and there are navigation systems for all their yachts that's that's all running Android and security cameras and all kinds of stuff so there are thousands and thousands of products out there running Android embedded Android uh that kind of nobody really knows about um and I speak to people doing these things and they all have the same problems they all kind of you know how do we build a thing how to get the platform to work how do I access the GPIOs how do I how do I add in a SPI or an I2C device and talk to that from my app you know all kind of basic stuff that should all come together I think because you know like it or not this is how Android is used and it's it's kind of in a lot of people's minds it's kind of a replacement for Windows CE so Windows CE is kind of you know it's dead what are you going to use instead Android that's the way the world goes um okay so okay so we've got something positive there so I'll get in contact we'll see if we can do a bit more together on these two uh two projects um oh yeah yeah so this is this is me being lazy so I set up a slack workspace turns out slack is a really bad tool for this kind of thing I need to get rid of that sorry slack but it just doesn't work mostly because unless you pay them big dollars they they they're the it you know the messages are deleted after 90 days which is a bit silly well okay from my point of view um oh yeah and a quick plug as you probably all know the next meetup is 12 which is only a few weeks away and I sure I don't have any talks arranged so come to me afterwards if you've got any ideas for for really interesting talks otherwise I'll have to chase you up individually what is a os a a os actually ah okay that's a secret um so that is android automotive os so it's a usp on android and it's one of the cases where the the acronym a os is harder to say than android automotive or android automotive or android automotive os um but yes the thing that that you know poll star put into there their poll star two cars and such and the meeting is virtual or in a physical location it's it's virtual yeah i mean it wouldn't work um any other way because there are people from all over europe and from india and from usa and all kinds of all kinds of places yeah i'm also part of the community of open source android developers but mostly on the like system framework ui to app level so but there's some overlap i guess yeah so i mean the the reason i called it the a osp and a os meetup is i did not want android to be in the name because as soon as i put android out there on meetup.com i'll get tons of application developers piling in and i this is not about the applications this is about the os so that's why it's named slightly obscurely in that way so this is very much the operating system okay um moving on from that okay next topic so how do you find out about a usp what are good resources for a usp so the obvious one is sourced android.com but as we know that well i mean sourced android.com is kind of great but it's also a little bit random and a lot of the stuff is out of date so where else do you go can you can you uh microphone so i would say cuttlefish get logs okay that's i mean i would find very good information there why they are doing the change and then you can realize whether you want that change in your device or not so this is once you already have a device set up and if you want to do some modifications or keep track of what is happening in a usp framework level which you may want to change or incorporate in your device config so i have always find a cuttlefish uh get logs very useful in that case okay that's great because i mean um a related thing to that which i think i come to in a moment or two is if you're if you're porting android to to new hardware what do you use as a reference platform um so i i've got you know some something pie board which somebody's just given me and i want android to work on that where do i start where where where what's the configuration i should i should kick off with cuttlefish would it be or i would start with cuttlefish i would start with cuttlefish i mean we don't do that ourselves because we have a device config so we just keep piling things on the same we reuse the same device configs but if i have to start on a new board today then i would start with cuttlefish yeah cool because there are a lot of build configurations which are some of them are very legacy uh for 10 years 15 years old uh board config file board config variables and which i still see them getting used in certain board config files but those configs are no longer valid but people are using it because someone has used it once and people keep following the same set of configurations and we were talking to some of the cuttlefish developers once and they told us that they do keep track of what build variable is currently being used and what is being deprecated so if something which they're using in their board config file or device mk file so any kind of common configuration which you can make use of then you can rely on that okay that's good to know because i must admit when i'm looking through uh board configuration files quite often you look at stuff and you think that doesn't do anything anymore why why is that still there and that's because they just copied and pasted from somewhere else um exactly yeah so i didn't work on it for a while but i usually looked at the latest um google phone that um for for android 10 i think it was the pixel or pixel two or something and i started from there and copied the stuff from there because i figured it would be the most up-to-date and current way to to work with it okay cool um yeah so what again information coming back to this anybody know of any good kind of blogs or anybody who is writing stuff about a usp apart from things we've already spoken about so you can go to stack overflow and that there's there's some random stuff there some of it's good some of it not so so i find the google groups helpful too at times you do i've never got an answer on a google group maybe i asked them the wrong questions this is a strange one but there's a there's a guy named michael who keeps probably scouring through the garret all the time and i actually learned i actually learned a lot about new features from his tweets you write actually yes um michael raman yeah am i right yeah uh yes i i i do follow him and uh he does come up some really good stuff i i've never met him in person which would be an interesting thing to do okay okay that didn't work um okay another bug bearer mine then is when i do my repo sink and whatever how do i know that what i've got is a good version of a usp because quite often you download bsp and it doesn't build or it builds but doesn't boot or whatever and this is especially an issue with the android automotive stuff a usp a usp obviously is working on a different release cadence to everyone else and so trying to get an a usp build to work sorry i'm trying to get an android automotive build uh to build and boot is a little bit hit and miss in my opinion does anybody so how do i know so i i guess to to simplify the question a little bit when i look at the build tags uh for the android manifests how do i know what they all do they all say uh this this is updates for pixel seven this is pixel six whatever what does that all mean how do i know how do i decode uh those build tags and know which ones i should navigate to anybody have any magic here so you're talking about the builds from ci dot android dot com right or i was talking about the builds from um from yes from from google source dot com just the just the canonical um i'm talking about the pre builds or you're doing a local build i'm talking about the a usp source code with the local builds right yeah so when i do a repo thing repo when i do a repo in it and repo saying when i do the repo in it you know what what what should i what what branch should i give that so i'm mostly on master branch and what we end up doing is at some point we were maintaining a list of known good manifests right that's what we need so we were doing it but then we realized so uh after that we pivoted to having daily builds so now what we do is that if something breaks today i'll go to my daily build page download the two days older build and see if the issue is still there or not if it is not then i know that this a usp bug is being introduced in last two days and with our daily builds we published the manifest files so i have a manifest file of two days earlier two days which was there two days ago and today's manifest file then it's like a manual thing right okay which projects got changed then okay so i'm gonna solve your problem but maybe a tool that you might not be aware of there's the ci.android.com where we do continuous builds with some basic testing on cuttlefish i think so at least we will tell you whether this is a build that boots and when you open the artifacts for the for that particular build it has a manifest.xml which is a copy of the of the manifest but it has inserted the comet hashes of the individual good projects that were used for that particular build so you can sync to that and you should have the exact same checkout as was used for that particular known good build okay that's cool um it's in the artifacts so i uh we only got another couple of minutes left but um so following off from that i i've i've always kind of avoided the master branch because it's unstable and i'm not quite sure what it's going to build or whatever but also it's not so as i'm teaching android people don't really want to know about master they want to know about the currently released version which currently would be android 13 or maybe even earlier versions a lot of people are still working on 11 or even 10 so i tend to want to know uh i tend to work with with tagged releases because that's that's that has version numbers that people recognize if i start teaching people about master well for one thing i'd have to update my slides every day which i don't want to do um but it's it's not stable enough for most uh most of my customers okay and we have a couple of things okay we probably don't have time to do this the grumpy developer so i i plan to do this but i think we're running out of time uh i was going to ask you to give a give me your your favorite moans about uh about android so we have time for maybe two so anybody want to yeah what was what was what's the worst thing about a a osp nobody wants to commit okay so this is not really about a osp as a whole but for for example bionic is a very interesting project it would be useful outside of android as well but it's pretty much impossible to rip it out of the android tree to build it in the context of some other learning system that happens to use bionic as well oh i've never tried doing that yeah i've tried doing it as part of researching different libsi implementations but uh but it's no it's certainly doable if you invest a lot of time but then five days later they modified the build system again and then it's broken again yep yeah now that so it would be really nice if some of those projects that are part of android could be modified to make them more usable outside of android as well i think that's true and i i i think we kind of come into the end here but i my final plea would be to make android more modular android is this huge enormous monster which kind of gobbles you up um so if if there's one thing a google could do to improve android they could split it into smaller pieces and make it more modular and more more more rebuild rebuildable and so on okay um so i think we're out of time there so thank you all very much for contributing that's been really great and um yeah don't forget we've got one more talk on the asp track um chris haze from mem fault is given his talk on debugging android uh just before the closing game so whatever that is i still haven't looked at the time 1640 i think meanwhile thank you very much enjoy the conference and see you around


9 UC Berkeley faculty members have been awarded this year's Alfred P. Sloan Research Fellowships, making UC Berkeley the university to receive the highest number of fellowships. The awards are granted to help young scientists and scholars fulfill their endeavors early in their respective academic fields. We sat down with Dr. Thomas Mamoni, one of the recipients to find out more about his research experience in the synthesis of natural compounds. So our lab is involved in synthetic organic chem. That involves usually two main areas, methods development where one creates new reactions and target oriented synthesis where you develop a route to a complex predefined structure. So my Sloan award was for the latter case. So most of our group is currently working on developing synthesis of complex natural products. Having done his undergraduate studies at UC Berkeley and his doctoral studies at the Secrets Research Institute, Dr. Mamoni had the opportunity to work in many chemistry labs. Before returning to UC Berkeley to continue his research and teaching, he pursued postdoctoral studies at MIT where he works in the area of palladium catalyzed carbon oxygen and carbon fluoride bond formation. So synthetic chemistry I think is one of kind of a unique area of science in that you are a classic scientist making observations, formulating hypotheses. But you're also there's creative or artistic side to it much like architecture, art or music. So you can basically synthesize whatever you can think of. So I think natural products are certainly powerful inspirations but synthetic chemistry has the unique ability to tune the structure in any way conceivable. That's pretty unique right now to synthesis. Dr. Mamoni hopes that his research will be used in medicine, particularly in the field of cancer research in antibiotics. I think our goals, our future goals are two-fold. So one we're interested in advancing the field of synthesis in general, more in academic pursuit to be able to synthesize something using less chemicals, less steps, generating less waste. The other kind of benefit is that you can make something therapeutically relevant. An antibiotic, for example, an anti-cancer agent. Currently Dr. Mamoni can be found doing extraction synthesis on the 8th floor of Vladimir Hall. My favorite molecule is probably the molecule four-ball. It's found in the plant family euphorobiasae. It's a potent activator of protein kinase and also has an incredibly beautiful structure. Reporting for CalTV News, my name is Carlo David.


Welcome to Dr. Garmash-Murthy, and this is starting the conversation. This is a forum on women and infants affected by opioids, right? So, it's a beautiful day. Maybe if you look outside and think it's like 30 degrees and it's snowing. Our planning committee includes Elizabeth Abler. She's part of the Sheboyin County Division of Public Health. Dan Conway, as I did, okay? Eva Bromo. Debra Schmitt. Debra Schmitt. Okay. All right. So, we've got a couple slides. Okay. All right. So, this is put on by the WAPC. This presentation is very possible. This is a partnership between Sheboyin County and Wisconsin Social Security Care. Please know their contact information right here. The WAPC has been working on this issue since 2009, when they started reporting that the NICs in which they were filling up and the babies were out of methadone. They were unsure how to care for these babies and also wanted to better communicate with local methadone clinics. The result was a creation of a toolkit for patients and providers, which you have a copy of today, and educational sessions held across Wisconsin. The toolkit was created by members who wanted to make sure that, excuse me, that pregnant women on methadone understood the road ahead of them, who wanted to expect them to withdraw for their babies and help us to handle it. And equally important, that providers understood as much as possible about caring for women and infants affected by opioids. The Health and Human Services. Sheboyin County has been seeing an increase in referrals to our public health and social workers relating to opioid use and drug-addicted babies, which illustrates in our community for education at this time. I belong to the Healthy Sheboyin County AOEA Committee. As a member, our committee is made up of healthcare providers, social work, law enforcement, counselors, and concerned parents. Our committee has been instrumental in decreasing the amount of scripts and drugs on the street by implementing drug drop boxes around the county. We have done alcohol and tobacco checks at various businesses to make sure that youth are not able to buy. One group here wanted to educate more those who are playing getting pregnant or who are already pregnant. I mean, here's the problem. According to a 2010 National Survey on Drug Use and Health, 4.4% of others used illicit drugs while pregnant. Alcohol is used by 10% to 28% with almost 4% of those being stringent. The consequence on bomb and immune aid can have effects for the rest of their lives. We are here today to bring light and address this issue and to distinguish faculty to be able to educate us on this. Our faculty include Dr. Fahriwe. She's an associate professor at the University of Wisconsin School of Medicine and Public Health. She's also the director of psychiatry services at the Rural Behavioral Health Services in Milwaukee. Mary Rola. She's an assistant professor of nursing at Bell and College in Green Bay, in Tommy Heizer. She is the state opioid treatment authority at the Department of Health Services. And when we do our prevention treatment recovery in Madison. So now we'll have Mary Rola talk a little bit more about that. All right, just to do the official things. Notice of disclosures, none of us have anything to report. No conflicts of interest regarding the topic. In terms of successful completion, as you were already told, if you please complete your evaluations, you'll be able to them receive the continuing education credits. In terms of the objectives for today, at the conclusion of the program, we would like you to be able to identify interventions for pregnant women affected by opioids, identify interventions for the newborns affected by opioids, and then to describe the role of the state opioid treatment authority in the care of women. So with that, we would like to introduce a video that was made a couple years ago to sort of set the stage for the discussion. Selena is a 32-year-old mother of two children, Miranda, who is six, and Thomas, who is 18 months. She battled with opioid addiction for many years and currently is in recovery. We came to know Selena through the WAPC members in the north-central region of the state who were working with the local methadone clinic where Selena was receiving treatment. WAPC staff conducted an interview with Selena, and this is her story. So we want to show this. I think it's helpful in laying the groundwork for what we're going to be talking about. Anyone who is an addict on opioids or anything else, it's no fun at all.  It really is.   And I've met some people throughout the year, pharmacists and not doctors, but like medical staff, and you'd never suspect to be an opioid addict.  They don't act like it. They have nice jobs and nice things. I think I started about 12 or 13 with alcohol. And then they used to sell some kind of speed over the counter. I couldn't buy it, but I'd steal it. And really like those. And then it was pot, and then it was acid, and then it was whatever I could get. I eventually ended up on cocaine bad. And that's around the time when I was engaged and loved my life, and he overdosed and passed away. After we broke up two weeks prior to that, or three weeks. So then it's, I thought for a while, okay, now I got a reason to get sober. But that really made me spiral down, down, as far as I could go until I hit the bottom. Opi, it's always we're there. I think the first time I got him was for dental or some type of injury. And I really liked them. They made everything that hurt physically go away, plus emotionally. And I really enjoyed that. Because I think I had depression a long time, but didn't realize it. And I self-medicated. That's just my theory. I don't know. Because I have never been treated for depression while I was sober, until now. So we really don't know that. It's kind of like the chicken movie. There were coworkers that would supply me with pills. And I had to deal with medication at work. And that's the only rule. One of the only rules I never broke was toying with that, because I needed my job. But more than that, my patients needed their meds. Because there are a lot more pain in my bones. And I had a couple coworkers that would supply me. My boyfriend's mother was like my main supplier. It was terrible. What were you mainly on? You're talking about pills. I'm talking about Vicodin, Oxycontin, L-percocet. Any of you about that. I got very good prenatal care during that pregnancy. And it was very good at hiding the fact that I was addicted to opiates. How did you do that? Well, it was tricky. I had a rule. I had several, but I broke most of them. The one rule I had was, because you have to take a urine for the protein test, I wouldn't use any opiates for three days before my doctor's appointment. I wouldn't take any during, because I didn't want to look high. Once in a while, I would go to an dentist or get an injury and be prescribed opiates. And in those cases, then I was covered in my head. But that's how I avoided it. I was healthy. The baby was very healthy. There were no signs, I guess, of opiate addiction or any other addiction, because opiates aren't the only thing it used during the pregnancy. There was some cocaine use. There was not much alcohol. No marijuana. Mostly just opiates and cocaine. Do you think they ever suspected it at all? Or didn't see it at all? I really don't. Because with the second one, I had two of the same nurses, and they remembered me. And they said, how could we have known? And I said, I don't know, I didn't want it to stop on my own. I tried and tried since the beginning. I tried. And the longest I made it was four days. And by that fourth day, I could deal with the mood swings. And I could deal with nausea, diarrhea. I could deal with that. What I couldn't deal with was the feeling of my skin trying to crawl out of myself or the crawly feeling. It's almost like restless leg syndrome throughout your body and your hair. It's the most awful. And then the brain too is appealed enough to know what to do and know how to deal with those things. You don't want to eat. You don't sleep. But you do sleep. I would sleep all day and be up all night. And I was working full time. So it was a challenge. That one was a challenge. I did not know at that time the baby was in withdrawal with me. Had I known that, I think I may have gone for help. But I was so afraid to because I wasn't enjoying it. I was not enjoying having to take pills to function every day. But I didn't like the feeling of withdrawal and maybe if I had known that the baby was suffering as much if not more than me, maybe that would have encouraged me. And maybe if I had known that they weren't just going to take her away from me when she was born, if I sought help, I'd never knew any of that. So I learned all that with the second pregnancy. But I had no idea. I thought they would just take her and I would never see her again. In my mind I was a wreck. Her withdrawal started after we got home because we were only in the hospital maybe three days. And I'd say she was a little over a week old when it really hit her. And she cried seemed like a week straight. And there was nothing I could do to calm her. In the back of my mind I thought maybe that's what it was. But I'm not telling anybody that. And we just called the colic. She's colicky. She would cry for hours. I felt so bad for her. She had tremors or that, I forgot what they call it, but it's that moro reflex. They check. That's one of the scorers things. She had that kind of where she'd just be real rigid-y. So did any provider ever check ever do any scoring? I don't know. I don't know. I don't think so. She didn't show any symptoms at the hospital. Oh, right. And her first checkup went well. The only thing that happened with her was she had to be put on a different formula because they thought she was lactose intolerant, which she's not. So I'm thinking that diarrhea spell was some of the job. Had I been honest with the hospital staff they would have been able to treat her. The first person I ever told was a PA that I was addicted to opiates. And I was scared out of my mind. And I just cried to her. She was so great and treated me with respect and dignity. And she listened to me. I've never been in a doctor's appointment that long in my life, or they're usually five or ten minutes, you're too scripted to go home. It was great just to talk to her and have her listen. Sometimes I think they get overwhelmed with so many patients. And when you're in treatment it's really important to talk about things and have somebody listen. In treatment for like three years I think before I became pregnant. It was an accidental pregnancy but it was a hard pregnancy for me because I had all the knowledge now. Now I knew what could have happened with my daughter and I'm pregnant at the time and I'm emotional and I had a lot of fear that I was going to be punished. With this pregnancy because of what I did with my first. And thank goodness for some of the medical staff that came in and spoke in one of my pregnancy groups for I went to in treatment. That lady was awesome and she taught me a lot and helped alleviate some of that fear that I had about specifically well she gave me a lot of information that I didn't have about because I was on methadone with my second about what was going to happen, what could happen, what to expect. They showed the scoring sheets they used for the infant withdrawal and how helpful. I mean they gave me one so that I could take it home and know if my baby was in withdrawal and not to be afraid if he wasn't withdrawal to call. Because yes he might have to be hospitalized a little bit longer if he had it but it's for his benefit and well-being. And I did try to breastfeed and I was unsuccessful so we pumped for maybe three or four weeks and he didn't have withdrawal. He had a few minor symptoms in the hospital but nothing where he had to be medicated or treated for it. He stayed with me every night. We were there five nights because I had to have an emergency C-section and he was in my room every night. Things get better after you do seek help. It is hard but it gets better and I have met some of the coolest people and they treated me with so much respect.  They treated me with more respect when they found out that I think they did before and they were all very appreciative of my honesty and that is one big one I think and also the knowledge of your baby is suffering if you're suffering. A lot of them don't know that. I didn't know. I don't know if a lot of medical providers or anyone works. I call it a buzz blocker because you take it and it does help for pain but it also helps. It blocks your opiate receptors in the brain.  You're not going to get high. Everybody in this place has tried it at least once and we've been very disappointed because you do not get high. People have had babies and been denied pain medication at hospitals after birth because we're on methadone. I wasn't denied and I took the medication and I didn't get a buzz. I was waiting for it though. That's just my addiction. It's the way it works. I was waiting and it never came. So I did not abuse my meths and the treatment staff here didn't count to make sure and that was great but that's one thing I wanted to add. If I could tell a doctor who may be thinking well what the heck do they need pain meds for? They're on methadone. That's pain med. After you take methadone for a few years or even a few months you get a little immune to that and you still have breakthrough pain I guess and having a C-section which I've never had until my second I'm really grateful. Then they gave me pain meds. They gave me morphine and it didn't really help a whole lot so I told them I didn't want any more of that but just give me ibuprofen alternating with Vicodin and worked well and I didn't need a whole lot but that was a fear too. I thought gosh what are they going to do when I'm in pain? Am I going to feel funny asking for a pain med? And they were great about it. We're people. We don't choose to be addicts but we are for whatever reason and we get pregnant and we do what we have to do for the best of the baby and just treat us like humans and not like we did this on purpose or why don't you just stop? It's a great question that I hear a lot and it's really a kick in the face to hear that because if it was that easy we wouldn't stop but it's not. I don't think I have the nerve to top off what Salina said. I think we can wrap up and go home because she taught so well what this is the problem and what not to expect. And I'm one of the psychiatrists in this autora system but I kind of came to Milwaukee in a circuitous fashion. I'm from India and I was an OBGYN trained, working with a lot of mothers and people like Salina is what got me interested to sit and listen and I was always late because I never could wrap up quick enough because I like to listen to the people and that's what got me directed from OBGYN to psychiatry and then I've seen people like Salina which got me interested so I went in and got myself a subspeciality in women's health related consultation is in psychiatry and then addiction medicine. So I see a lot of people like Salina and I learn every single day and there's nothing you can read from or learn from the books which people like Salina would not teach you. So I just want to kind of tell the boring PowerPoint presentation but I'll be happy to answer any questions later at the end of the presentation. So the heroin use has been increasing and then every year there are people adding on to the statistics but more than heroin use the prescription opiates have increased significantly and then as you see from the National Institute of Drug Abuse statistics. So when the question comes who are the people who got addicted to? Our thought is older people when you look at the prevalence of illicit substance use and pregnancy the youngest mothers are the ones highly addicted to. The 15 to 17 years show the highest prevalence of illicit substance use and as the age increases the prevalence goes down. So when we looked at the National statistics about accidental and unintentional drug overdose and these are the statistics when we looked at from 1999 all the way to 2008 and this is the heroin so although the belief system is the heroin that's all the commonly seen and this is the cocaine and what tops is your prescription pain medications and the availability of it and that's alarming. When you look at it there is a snip which Sanjay Dutta from CNN did with Bill Clinton which showed the United States uses 80% of world's prescription pain medications which is sad then makes us think about every time when you have a pain before you put somebody on the pain medication do they really need it if so what are we doing we're causing for the problems then we need to. So if you look at the US rates of sale of prescription pain killers that's an admissions of substance use again this shows about it there's increase in sales of prescription pain medications starting from 1990 to 2010 so in 10 years we almost quadrupled our use of it and the deaths and admissions shows but the disparity persists and their sales are soaring. So in Selena's story Selena was talking about untreated depression so I do want to kind of focus not just on the opiate addiction or dependence there's a lot of times my patients tell me there is this emotional pain they're trying to treat initially it starts with simple injury dental extraction many times I see people who are started after the C-section on the opiates and gradually they continue, never taken off and just they continue to get it from the streets whatever ways they can get hold of like the boyfriend's mother like Selena did but what was found is the comorbid mental illnesses make these people susceptible to continue the substance use the commonest ones are the menial and the panic disorder seems to have a very high prevalence compared to other mental illness but if you can look at it across the board everything increases the chance of these people getting addicted to different type of medications and drugs so this is of course Aurora stats which kind of made us a lot more aware of the problem because just in the neonatal withdrawal that is observed in the NAS so there is an increase that is so significant across the deliveries in Aurora made us a lot more aware of the problem not that it was not existing but there seems to be an opening for everyone in the system so who are the people and why some people get addicted I'm sure the dentists are prescribing opiates to everybody who comes down following a dental extraction but some do get dependent and some don't and who are the people what makes them more susceptible to develop it amygdala is your seat of emotions there are a lot of times there is a memory if you ever talk to someone who is dependent or addicted to medications or the drugs ask them what do they remember they remember the first time they took that drug and they remember the place the site and there are a lot of things it comes with it not just the bill alone that gives them the hype but the whole situation the ambience so there is an emotional memory that gets stored next to the amygdala and anytime you want to think about the medicine you go back to that memory of feeling great using that drug not so much what is happening now after you took it for 10 years 20 years, 30 years but you still chase that first experience so there is emotional memories that gets stored the amygdala plays a huge role in the use of that initial substance and so many times when people struggle with getting off of it we look at the emotion trigger the relapses Q trigger so if you drive in the places where they got their first drug or they see the people whom they use the first drug or they have the situations which provoke them either way they all trigger that emotional memory and people go back to that because it's not just the drug alone but there is a whole the neurochemistry that happens that make them continue the drug use so when you think a little more about why some people get dependent on the substances there is a genetic variability there is a documented hyperdopamine-ergic state in the mesolimbic pathways that's where the addiction reward pathways in the brain where the dopamine is a neurotransmitter that keeps people wanting it but people who get addicted seems to have less of the dopamine in these areas and if you expose yourself so you destroy the connections in the brain in the neural circuitry so you keep relying on this drug to fulfill the feeling good type of states and people who do not have this destruction of the cortical connections rely on say good music meeting up with friends going to a restaurant or listening to music as an association of feeling good but the people who do have the hyperdopamine-ergic state you have early on destruction the cortical connection need to have external factors to feel good so they don't rely on the other things which typically people do they have to need substance from outside and many times these are the biochemical variability some people get more addicted some people don't and I see this when I do the transplant evaluation some people drink alcohol like a fish from all the way until 60 their livers do fine but I do do the transplant evaluation people in their 20s and 30s and they didn't have that long a thing but the biochemical variability the enzyme system the metabolism varies from person to person so there is certainly a biochemical variability about it and bigger than that this is the biggest part of the social defeat stress that makes people much more vulnerable to get addicted to in the situations which are beyond their control and they don't have any ways of solving that situation one thing they can do they have control is to obtain the drug and use it and which is the sad part unfortunately so who do we kind of look at it and seldom like Selena she doesn't go out and explain yeah I got a problem it took us a little took her a lot of courage before she get in but providers are the ones have to be good detectives when you think about what are the findings which make us to be kind of suspicious of the potential of substance use so you want to think about looking at the back history thank God for electronic medical records it's a pain but it's a blessing too so you can go back and look at their drug screens and if you look at it there's already on substances like Selena said you do check the urine drug screens because the methadone is asymptotic so it doesn't show up in typical urine drug screens but if they use some other drugs in the street and they're diverting it so you would be able to check it out so you want to look at the compliance and then you want to look at the complications of the pregnancy if there's an abortion placenta the fetal growth restriction preterm labors these are all the ones you think about it and typically any type of opiates if someone takes it more than three months they're already dependent on it but there's a difference between dependence and addiction so not every dependent person is an addict and there is a way although it's a pejorative term but there's a difference of it what you want to look at are these the people who are visiting the emergency rooms like say five times a month and they're going in for every possible reason they're dogged their prescription something else has happened so you want to think about there's a frequent request for the scripts is a big red flag and you want to think about going into different systems in Milwaukee we see a lot of times patients come to the other ERs then go to the Wheaton-Francisco ERs go to somewhere remote small areas and then they come back and you rotate and keep getting the prescriptions which they shouldn't be getting it otherwise and they are not compliant so you want to think about it and then you're distinguishing these patients so you want to know how to assess these people well we're going to come back and look at it there is no one size fits all you have to be culturally appropriate when you're asking these people respectful and willing to listen to what they got to say and just have to not go by just the subjective information you got to look at the objective data too and then you want to look at the complete evaluation not just the antenatal checkup or not whatever is being told to you but you look at the bigger picture and that's what helps you not look at the trees but look at the forest and that gives us a great outcome in the end so as Selena said what are the barriers for these women they know they have a problem more than anybody else no mother wants to put the baby for the most part to the turmoil what the babies go through so what are the barriers for them why are they not seeking out and getting the help and the biggest problem is the guilt and shame so if you make a mistake it's not somebody else yelling at you you yell at yourself and it's hard for you and you have to face yourself every day when you're doing this so there's a lot of shame a lot of guilt that wants you to hide it in there and not want to bring it and then make actually go use more drugs than what it is because they don't want to deal with it and there's a lot of fear what would happen and just keep using it that's the only control they have it and many times they think oh it's no big deal I'm going to be able to stop I only can take it just for this week and I'm going to stop it when I go see that and they sometimes show the control like Selena said like she was able to stop it for three days before she goes to her appointment because she knows exactly when the tests will show positive and a lot of times being judged by the caregivers and that happens all the time and the biggest fear I see in Sinai when we were looking at the newborn says the losing the child the child protective services get involved and then they do get taken out and the bigger problem am I going to go to the jail? a lot of times ignorance is a fear and they just don't know how to manage it because they don't have the whole knowledge base and they don't open up to get the knowledge so you talk about the barriers from the part of the patient what are the barriers from us like in the Aurora we have like 37 psychiatrists in the Aurora behavioral health services that's what I can speak for but I can tell you I can count who are the doctors who are comfortable treating pregnant women with addictions not even in a hand it's that few it's just the level of comfort so the availability is so little and many times the education and I trained residents medical students and this is one thing this is an area of like not a comfort zone for many people so you don't want to ask about it because if you ask about it you got to deal with it and many times I see this don't ask about depression don't ask about suicidal thoughts because then what what are we going to do about it same is the case with that so a lot of times education it's not so helpless situation once you learn the problem you bring it out we can find solutions and a lot of times people don't know what are the appropriate tools to screen for and that's what we want to think about it and what are the resources that are out there it's great we are able to have a better testing screen tools and we know how to diagnose these people and what are the resources out there and what are the availability of these resources as I said they're not the many psychiatrists and they're three months rate time for the most part for an elective appointment in the Milwaukee area to get an appointment with a psychiatrist and an addictionologist I'm not proud of it but that's the truth so then we go back to looking at we identify these people one of the things this opiate abuse and people took it for longer than three months were able to not do it you already cross from the abuse to the dependence is much simpler and what you look at is a bigger picture of it they're not able to come on time and they're not able to fulfill their obligations be it the work related be it the social roles and that's one of the biggest cues for you to think about it and a lot of legal problems and sometimes they don't have the control and they get tolerance once they develop physical withdrawal and that's one of the biggest difficult feelings I just don't want to feel feeling as she mentioned this crawling feeling and I just don't want to deal with it so I took maybe a little bit and before I realized you never can get off of it so the activities kind of go down because of that a lot of times they are aware of the consequences but the addiction is so deep rooted and the dependence kind of claims their lives it's so difficult for them to abstain mentally they know that the actions wise they just cannot adopt it so when you look at the subjectively what are the symptoms the patients do tell me oh I'm going through the draw and common as once you think about is they're irritable they're having rust less abdominal cramps a lot of sneezing rhinaria I don't know if people are familiar with this tool called cows it is like the alcohol the draw protocol thing it's a cow for the opiate the draw protocol it's a symptom driven and it goes by the checklist if people are acutely admitted in the hospitals the cows is the tool which we typically use and it takes into account all these symptoms so you know and you get a score for that if anybody gets about eight in the cow score may medicate them so you just don't want to go by like a lot of times people are addicted to them the drugs and many times you know exactly what to say oh I'm so restless I'm so nervous but they may not be you can't see the restlessness many times just by looking at it if somebody knows it but you also want to look at the objective data for that and what is the blood pressure like and you have a pulse rate of like say 60 and somebody says I'm so anxious it doesn't go and people do not have any type of autonomic hyperactivity as you expect when you withdrawing is not seen and you want to question it they're indeed going through the withdrawal and sometimes people do like the intoxicative states so they ask for it so you want to think about it so there are a lot of myths that come from that and that's a bigger problem for that people do justify their continued behaviors they said it's cocaine that's the worst problem the pain medications may not be that bad so the withdrawal cannot be that difficult so you come up with your own and many times and then they think it's somebody else's problem it doesn't apply to me and that's what the common myths you think about so when you look at the opiate dependence and what are the rest when you think about in pregnancy the biggest problem is malnourishment you don't have it's an apathy it's a symptom of some substance the opiates are it takes the motivation it takes the energy it takes the appetite you kind of have the apathy just sit around so a lot of times the malnourishment is what you see in these people and the fatal growth retardation is because of that and they don't have energy to go to their obstetrical appointments and sometimes they don't have the energy to fight the situation so they place themselves in a violent environment which they don't have ways of getting out of that and you have the common problems and I see all the time in my consultation service of infections because of the injecting the drugs which they shouldn't be doing it and of course the infectious diseases as we talked about so it's not just the person alone you want to look at the psychosocial support and the shame and the general sense of fear prevents them from reaching out and many times the family members are not aware of it so you want to think about what are the involved people down here and many times they may be in a relationships which are co-addicted partners it's difficult to continue to do that there always early interventions is the way to go then you get the better outcomes okay finally identify the people then what they usually did three principles what you think about the ideal scenario would be the abstinence from the totally from any type of opiate is your ideal scenario but how logical it is what we want to think about it and the detoxification is what we think about it and then you go down to the opiate maintenance after that so should we detox people while they're pregnant is one of the commonest questions I get asked when we do the consultations 96% of these people who get detox usually they lapse during the pregnancy so that's one thing you want to think about it and that's where you talk about maintenance of the drugs and we do not want to do it after 32 weeks because it could cause the pre-term labor and sometimes there is intoxication or the drug could cause the fetal distress and fetal death so you want to think about it it's always need to be followed very closely and temporary need to happen so methadone is one of the gold standards it's out there for 50 years or more and it's usually used for detox situations but also for the maintenance of the medication and there are a couple other ones the Biprenorphine and a lot of Suboxone we'll talk about it so the question is it's risk courses benefits about before you make the decision you want to think about maternal mortality fetal mortality and the goal for us is to decrease the illicit opiate use don't want people injecting you want them to be safer and completed so that's where the maintenance programs go to the frame so the bigger problems when you're giving people methadone is the risk of diversion risk of overdose and their difficult to vene and unfortunately they're not given by anybody it's only given by the license facilities and with the specific license with Tonya we'll talk more about it so typically the dosing is it's a range it's like everybody's different it goes from 20 to 200 milligrams although there's a lot higher doses are used but it's usually what is available and published highly absorbed they can keep it down for 10 minutes usually it's absorbed and it's given every day and if there are very high doses sometimes you need to do it and divided doses about it so the divided doses will improve the compliance and the one thing which I want to kind of emphasize is not to take not to ignore any withdrawal symptoms you cannot take them lightly and you want to make sure there's a lot of information out there about the methadone doses, the higher doses and how it impacts the neonatal abstinence syndrome and it's still evidence is emerging but what is available now it looks like you want to keep it the lowest possible dose if you can do it so this is one of the study which talks about it I got the timeline so I'm sorry if methadone is not an option what is the other option you want to think about it buprenorphine is one thing which is coming into because it does not have the same level of licensing restrictions as the methadone has the private psychophysicians can, it doesn't have to be psychiatrists but addiction medicine doctors can get certified by 8-hour training and then can prescribe but it needs to be combined with the psychosocial interventions not just the medication alone otherwise it's not, it works in the same lines it has a long half-life of 72 hours that helps the people not to feel the other drugs giving them the high the same way as the methadone does so it's an office-based management and it comes as a divided dose 1-24 milligrams per day but the problem is I've seen people at 64 milligrams too, it comes in all these things and the thing is sometimes you can dispense on weekly, it's much more easier for the pregnant mothers than the methadone they have to go every day, you can give it on a weekly basis and there's decreased evidence of physical dependence it doesn't give you the same level of high it's very well tolerated and so there is a combination of buprenorphine and naloxone that's what the suboxone is it's 4 to 1 ratio it's like 2 milligrams of buprenorphine you look at the half a milligram of naloxone naloxone is an antagonist why would you give the muroganous and the naloxone the combination is because the naloxone is not orally absorbed so they can take it without worrying about it although in pregnant mothers they try to give just the buprenorphine and not so much the buprenorphine and naloxone combination and this is what the naloxone does that to people, it causes the hormonal changes in the mothers and if they crush it and inject it sometimes it's precipitated withdrawal because it's the antagonist and risk of devotion is limited that's one of the things you think about in the combination versus not having a combination so the assessment of the substance abuse is very difficult there's no set pattern as we talked about it it's individual and many times you want to take a bigger picture you want to get the collateral from the parents whomever it is from the past history and how the other pregnancy so you want to have a healthy suspicion you want to look at the big picture to have a better understanding typically we use a modified cage we usually use it and that helps us to understand to do the screening tools so you want to kind of counsel them while they're pregnant and not to wait till they're already addicted and having that and faced with a nas of once a baby is born and many times the teratogenicity is one thing and then whether they have a lot of questions about whether they should be breastfeeding and how they have to present and what are the interventions pharmacological or non-pharmacological so it's ideal if you can get them to a program and there are a lot of programs which we can talk about and it's in the withdrawal kit it tells about how the pregnant woman can use the newborn withdrawal project it's very well documented as Selena said that knowledge is the power where you can give the tools for them they can understand how they can evaluate their own babies and how they can get to the point and to help the caregivers to care for their newborns and this is a very helpful tool so planning ahead is the key as I said the availability of the resources is there are very few so the collaboration and look at who are the methadone clinic providers, who are the psychologists, who are the addictionologists and work with them together and with the social work developing trust and crossing the barriers where the patients can trust you as caregivers and they can feel like you treat them with respect and the work is a collaborative always ill success so this is the flow sheet which we tend to use education of the providers is the heart of the problem you got to let the people know what to expect what not to expect and you screen them early refer them to the behavioral health team and ideally we have the consultation liaison model which I'll show you this is what we have in Aurora I just want to kind of for people to know about it the psychiatry consultation team has this many hospitals in the Aurora system has a psychiatrist on call for the consultation providing the consultation and these are the interventions but these are the your triage doctors who can give you as a resource and support it and you don't need to know the name of the doctors but more the hospitals you ask for consultation is in the doctors who are familiar with working with pregnant mothers and in the addictions and the dwell situations so that you can call the psychiatry consultation team and they can identify whether they need an inpatient admission they need a partial hospitalization program or they need an intensive outpatient program whether they need addictions are also addressing underlying the mental health problems so these are the kind of what I want you to think about a tree need some help but don't follow any one thing to seek out whoever is in the community it's your community you know who the providers are form alliances form the collaborations is the way to go thank you and I'll be back withdrawal that the newborn experiences as a result of intrauterine opioid exposure and the baby will go through withdrawal in utero and out of utero so if the mom is going through withdrawal while she's pregnant the baby is going through withdrawal in utero once the baby is delivered its source of opioids has been cut off the baby is going to go through withdrawal as it clears out of its system babies that have been exposed to methadone while the mom is in a controlled treatment program methadone still results in withdrawals so just having the mom in on methadone while it's great for her and it's controlled and it's good for the baby because we can know and manage doesn't negate the impact of the withdrawal so you can expect that if a baby is exposed to opioids the vast majority of them are going to experience neonatal abstinence syndrome how significant that is varies and as Dr. Ray talked about why some people get addicted you know there's all sorts of different factors the same is true with why a baby goes through withdrawal some of it may be dose related although as Dr. Ray mentioned that's still the literature is conflicted on that so it can be due to the drug that they're using the history the baby's metabolism the mom's metabolism other substances will touch on as well can have similar symptoms that present again these have been already mentioned so I'm just going to touch on this there are a number of things that lead to neonatal abstinence syndrome what I would draw your attention to is the red is the red when we look at the number of charts that had neonatal abstinence syndrome coded as a discharge diagnosis looking at 1995 and then 2008 you can see the number have significantly increased over the years now some of that is likely better identification so we know more we identify more so it's coded more but certainly there is an increase as well and that has been highlighted one of the complicating factors though is that poly drug use and babies that are exposed to nicotine to alcohol or SSRI's which is a drug that's used to treat depression may also show some of the same signs and symptoms of neonatal abstinence syndrome that a baby that's withdrawing from opiates shows so just because you see those signs and symptoms doesn't necessarily mean the mom was taking illicit drugs or is in a methadone program the baby may be exposed to something else as well and then when you put all of those in combination because in all likelihood as Selena said you know well she was taking a little cocaine a little harrowing you know whatever then you have a cumulative effect of that as well so some of the opiates that are associated with neonatal abstinence syndrome again there's a variety of them and you add to that some of the other drugs that can be used as well so what is this neonatal abstinence syndrome well there's a variety of symptoms that foster to form neonatal abstinence syndrome and not all babies will exhibit all signs and symptoms some will have some some will have more of them some will have fewer so it isn't cut and dry and those of you that work with newborns know that they are specifically if anything non-specific so they will have the same signs and symptoms for a multitude of different disorders so just because a baby is showing these signs doesn't necessarily mean it's withdrawal it may be sepsis it may be hypoglycemia it may be something else but just because a baby is showing that we can't assume it's an infection we also have to think that it may be withdrawal so to assess that then it's most helpful if we have a standardized assessment system to use to determine is this baby going through withdrawal and how significant is the withdrawal and the tool that we use most commonly is the finnigan scoring system and this is the one that Selina mentioned in the tool or in the video when she talked about that scoring tool that she referenced there are a couple other tools that you will see in the literature and that you may see used the ones that I have on the bottom in the smaller print have been used they have not been shown to have the same reliability and validity so I wouldn't recommend using those in your scoring system the ones that have been approved by the American Academy of Pediatrics are the finnigan and the lipsets quite honestly I've never seen the lipsets used at least in the nurseries that I've been in Wisconsin it is an approved tool but it just doesn't seem to be used in our region the one that is used most commonly and that you'll see referred to most commonly is the finnigan scoring system a modified finnigan tool is in your handout there are a variety of them available in the literature we chose this one honestly because it's not copyrighted so we could photocopy it and hand it out to all of you but there are a variety of different ones available what's important is they are is that we use them consistently and if you go back to the symptoms many of these are subjective so what defines increased tone what defines excessive crying or decreased sleep well having a standardized tool can help with that but it's also helpful that everyone be on the same page now one of the advantages with the finnigan tool is it has been shown to have about an 82% integrator reliability so two people looking at the same thing 82% of the time are going to come up with the same score so that's pretty good the higher that is the better it is but it is important that we all talk about okay how are we defining this and how are we using it to that end I will identify in your packet as well we to go through teaching how to use the finnigan would take more time than we have available today there is a webinar that's being offered in July that does go through specifically how to use the finnigan scoring system to try and get some of that standardization so if this is something that's of interest to you you may want to look at attending that webinar okay so how do we do the scoring well I'm going to talk about the timing of withdrawal in just a minute we want to start assessing the baby shortly after birth most babies are not going to show signs of withdrawal immediately they've been getting a pipeline of drugs so the minute they're born they haven't gone through withdrawal yet it's not cleared out of their system so starting the baby and scoring them at that time gives us a baseline where is this baby when they're not going through withdrawal then we can continue to assess them on regular intervals and look at what change is there and typically you will see a curve that they will start out not showing signs then they will gradually increase they peak and then they'll start to come back down again okay so it takes a period of time for the baby to show signs of withdrawal and it'll take a period of time for them to regress back from those signs of withdrawal hospitals that have used a scoring system find that it helps with the treatment of the babies there are some guidelines for treatment with the scoring system that when a baby reaches a certain threshold now maybe pharmacologic medication management is indicated versus non-pharmacologic it has reduced the length of hospital stays as well so I definitely recommend it as to who should be scored as Selena mentioned and Dr. Ray mentioned it is a myth to say that this is an issue of young uneducated individuals opiate abuse crosses economic lines socioeconomic, ethnic diversity it doesn't matter so we need to look at other factors associated with opioid dependence the maternal factors have been already identified neonatal factors certainly if there are babies that are showing signs and symptoms that suggest neonatal abstinence syndrome it could be something else but it also could be withdrawal so we need to pay attention to that if a baby has low apgar scores those scores we do at 1 minute and 5 minute after delivery looking at how well is that baby making transition to extra uterine life if there's no good reason for those apgar scores it could be that that baby's been prenatally exposed to substances microcephaly a small head could indicate exposure in utero that affected brain development and if the baby has a neonatal stroke or infarction that can be an indication as well that baby talks about the timing of withdrawal and what you'll see on the bottom is those SSRIs and nicotine those are the ones that are going to show up earliest so if you see signs of withdrawal in a baby within the first 24 hours that may be nicotine that may be SSRIs it may not be methadone or opiates the methadone actually has the latest leg in showing signs of withdrawal and as Selena talked about she was home from the hospital with her daughter before she started showing signs of withdrawal the length of stay in the hospital now post delivery is only 2 maybe 3 days so it's going to take a little time for these drugs to clear out of the baby's system so in all likelihood the babies may be fine in the hospital and start showing signs of withdrawal after they go home and certainly that complicates charge planning but increases the need for coordination of services between the hospital, the pediatrician community services social services public health etc so what do we do in terms of care of the newborn we'll start scoring the baby by 2 hours of age and then every 3 to 4 hours depending on how often that baby is eating so we have some regular data to look at that we want to continue assessing the baby at least for 7 days and that can be while they're in the hospital but it also should continue after discharge if the baby is going home at 2 or 3 days we want the parents to continue assessing that baby as well and that's where education becomes important and Selena talked about that she knew what that finnegan scoring tool was she knew that the hyperactivity the tremors was one of the signs of the scoring tool that was assessed for so the baby doesn't necessarily have to stay in the hospital that long but the baby needs to continue to be assessed we need to ensure adequate nutrition and hydration one of the problems that these babies can have is difficulty with feeding they don't tolerate the feedings well so they tend to spit up and they don't eat very well so they don't take very much in so the babies are at increased risk for dehydration and for failure to thrive or poor growth because they're getting inadequate nutrition if a baby needs to be medicated as a result of their withdrawal on average the length of the hospital stay then is going to be about 3 weeks subacute withdrawal can last 4 to 6 months so even though the baby may go home they are still going to show more subtle signs of withdrawal it's not completely resolved for months afterwards until parents again need to be aware of that that this baby is going to continue to show signs of withdrawal for continued and prolonged periods of time so given that how do we best take care of the baby as well as the family well there are some things that we can do within the hospital to facilitate this care one is to have the baby room in and I'll talk about the rationale for that in a minute but if the baby is in a quiet environment they will do better than if they are in a busy nursery with phones, a lot of activity other babies crying so the best place for the baby to be is in the mom's room now as we'll talk about that requires that the mom's room in it so that requires some education as well to make sure that they understand that it also helps to facilitate the parents learning the care of the baby what to look for what to assess so having the baby room in really becomes beneficial we do want to encourage the parents to avoid co-sleeping there is an increased risk of sudden infant dust syndrome in babies that have been exposed to opiates without saying that it's all due to co-sleeping a percent of it is due to co-sleeping so if we can eliminate that that will help that maternal smoking or smoking in the household also increases that risk so educating the parents on the need to avoid the newborn exposure to cigarette smoking is important we want to involve the family in the assessment and the management again going over the tools going over the scoring system what is that baby showing what's the baby doing and then explaining this could be a sign of withdrawal this is what we're looking for that hyperactivity that excessive sucking that they may identify we don't want these babies to be eligible for early discharge there are some hospitals, some patients some providers that will discharge within the first 24 hours these babies really should not be they need to be monitored to see how they're going to respond so if the mom really insists that she wants to go home within 24 hours that may be fine for her but the baby really does need to stay and be monitored and then as with any patient we need good documentation of the baby their assessments where they are as well as the family's ability to provide care for them the RN isn't going to be in the room continuously so the parents need to be able to provide that care and we need to assess their ability to do that Selena mentioned how her daughter cried for a week I don't think that's an exaggeration I believe that I've taken care of these babies in the NICU and after 8 hours I'm done, I'm ready to go home so these babies do have excessive crime and it's not just that they cry excessively, it is a high pitched squealing back in the day when we had chalk boards and you'd run your nail, yeah you all squint, that's exactly the feeling that you get so what can we do for these babies that are in such distress well there's both non-pharmacologic as well as pharmacologic measures that we can use first having that quiet minimal stimulation environment really is helpful to them so if they can be in the moms room great but then we need to educate the immediate family as well as the extended family that the room really does need to be quiet and the TV can't be you know turned up on loud volume and the baby can't be passed around to everyone in the room and when they go home this really isn't the time to have all of the extended visitors coming and passing the baby around because the baby just can't handle that if the baby is in the nursery then having a quiet space away from the phones ringing, the lights the activity is going to be best for this baby as well swaddling, very helpful the babies do have that exaggerated moral reflex and you will see these babies just tremor they just can't control their nervous system is hyper reflexive to the point that it can lead to seizures so swaddling the babies gives them a sense of containment and helps to control and set some boundaries for them so the babies do better when they are swaddled babies have an excessive urge to suck and it's not a nutritive sucking it's not that they're hungry they just have a need to suck and it is one of the signs of withdrawal that you'll see is this lip smacking where they're just and they just need something so giving them a pacifier on which to suck can help have a calming effect and support them and then gentle rocking and I do mean gentle just gently swaying with the baby or gently rocking but you can't try and do too much at once because you'll over stimulate them so if you're talking to the baby and you're rocking them and you're giving them a pacifier or you're trying to feed them that may be stimulus overload so it may be one thing that they can handle and then as they improve gradually introducing more and then as I mentioned these babies do have difficulty with feeding if you can't read the bottom it says it's still hungry and I've been stuffing worms into it all day the babies don't tolerate feedings very well and so small frequent feedings more often in smaller amounts hyperchloric they may need a higher calorie of formula or breast milk to provide the growth that they need I'm not going to go into detail on the pharmacologic management we do have some pharmacists and pediatricians who helped in preparing this series of discussions when we did it within the WAPC we're interested in that I can certainly get you in touch with those resources and we can support that the goal for pharmacologic management is to control the symptoms and provide sufficient growth so it's looking at the drugs that the baby was exposed to providing that and then tapering those down so that hopefully it mediates the baby's withdrawal until finally they grow and we taper down the drugs and we want to avoid using it will cause an immediate withdrawal and the baby may actually go into seizures as a result so we need to taper these babies down in terms of discharge planning the baby we can consider discharge after 48 to 72 hours if the baby isn't showing any signs of withdrawal and we have appropriate home follow up arrange so again the coordination there between the pediatrician's office public health social services if the baby is medicated there is some debate when we did these programs around the state we found some NICUs were not discharging babies until they were completely off medication others were discharging babies on low doses of methadone to be tapered off at home so again some discrepancy in practice there we do need to make sure family service and parental issues are identified in that we have appropriate follow up then arranged as well because again this is going to last for a period of time once they go home they're not done the parents are going to be dealing with at least subacute withdrawal for an extended period of time the question comes up as to whether or not the mom can breastfeed the answer is yes mostly if she is not, if the breast milk is safe that there's no other drugs that may be impacted there's no infectious disease concerns the advantage of breastfeeding is that there is some methadone that does get into the breast milk and so it provides almost a natural taper for the baby they continue to be exposed to much lower amounts now that said we can't count on that as sole treatment it may not be sufficient to really completely control those symptoms so the baby may show overt withdrawal but it does seem to moderate it and it does seem to reduce the need for medication with that if the mom abruptly stops breastfeeding well then the baby may show signs of withdrawal at that point because now they're no longer getting that medication so breastfeeding it's not an absolute yes or no it is recommended as with any baby but we just need to monitor as to how well these babies do again it's difficult to say because there's so many intervening factors it's the whole nature versus nurture component if you put a baby who's been exposed to drugs into a supportive nurturing environment where they have a wealth of resources they're cared for they're stimulated they're going to do better than putting that same baby in an environment that's chaotic and they don't have those supports so whether or not it's the opiates that make a difference or whether or not it's the environment that makes a difference it's a combination there do seem to be some notable differences with infants that have been exposed they do seem to have a lower IQ score on average there are some cognitive visual perceptual problems that have been identified and there may be some behavioral learning disabilities adaptations social issues as well but certainly this is an area that requires further investigation I'm just going to touch on very briefly the resources that are in that neonatal withdrawal toolkit there are facts for providers as Dr. Ray identified we need to educate ourselves we're not going to be able to help our patients if we don't know what's going on so the fact to see all of you here today is great because the more education we get the better we're going to be prepared to support our patients and this provides information for providers on what to expect we also have a guide for parents so as Selena said education is important it would help her to have known what to expect and then there are additional resources for further information both for families as well as for providers