Women and Perinatal Addiction Psychiatry

Slide 01: Title Slide

2 min

Speaker Notes

Welcome with appropriate gravitas—this is high-stakes content
Emphasize ABPN/board relevance
Preview the "telescoping" concept and fourth trimester mortality spike
Set expectation: active cases with discussion

💡 Tip: Acknowledge that perinatal addiction is emotionally charged. Your calm, evidence-based authority will set the tone.

→ Transition: "Today we move from resident-level knowledge to fellowship-level mastery in one of the most complex areas of our field."

Anticipated Questions

Q: How does this apply to VA settings given predominantly male population? Easy

A: Female Veterans are the fastest-growing cohort. Additionally, as dual-boarded psychiatrists, you'll likely consult in community OB settings where this is daily reality.

Slide 03: The Telescoping Effect

5 min

Speaker Notes

Define telescoping: faster progression to dependence
Explain neurobiology: estrogen + dopamine in nucleus accumbens
Clinical implication: 2 years ≠ mild disease in women
Emphasize trauma nexus: 80-90% have trauma history
Connect to MST in VA population

⚠️ Watch for: Fellows dismissing severity because "only used for 2 years." This is the telescoping trap.

→ Transition: "Given these vulnerabilities, how do we identify these patients?"

Anticipated Questions

Q: Is telescoping seen with stimulants too? Medium

A: Best replicated in alcohol and opioids; stimulant data emerging but follows similar pattern. The estrogen-dopamine mechanism is substance-class specific.

Q: How do you assess for IPV/trauma without re-traumatizing? Hard

A: Normalize: "I ask all my patients about safety at home." Use validated tools (HARK questions). Create safety for disclosure—private space, no interruptions, validation. Don't require disclosure to provide trauma-informed care.

Slide 05: The Standard of Care

4 min

Speaker Notes

This is THE slide—most important in the deck
State clearly: "Detox is contraindicated"—not optional, not preference
Explain 80% relapse rate = death risk
Address naloxone safety explicitly

⚠️ Critical Teaching: Patients, families, and even OBs will push for "clean baby." You must hold the line. Document recommendation against withdrawal.

→ Transition: "If MOUD is the standard, which MOUD do we choose?"

Anticipated Questions

Q: What if patient insists on detox despite counseling? Hard

A: Document extensively. Engage shared decision-making while emphasizing risks. Consider ethics consult if patient truly "informed and refusing." Note: 59-90% relapse is population-level data—individuals may differ, but risk remains substantial.

Q: Is naloxone really safe? Doesn't it cause fetal withdrawal? Medium

A: Yes, it's safe. Precipitated withdrawal is uncomfortable but not dangerous to fetus. Maternal hypoxia from untreated overdose IS dangerous. "Save the mother to save the baby" is the guiding principle.

Quick Reference>/h2>

Key Statistic

80-90% of women with SUD have trauma history

Critical Safety Point

Split methadone dosing in 3rd trimester (CYP3A4 induction)

Board Trap

Topiramate + OCPs = failure + cleft palate

New Standard

ESC (Eat, Sleep, Console) replaces Finnegan

Danger Zone

6-12 months postpartum = peak overdose mortality

Legal Distinction

CAPTA (Plan of Safe Care) ≠ CPS (investigation)

Session Timing

0:00–0:05 Introduction, Learning Objectives

0:05–0:10 Epidemiology & Telescoping

0:10–0:15 Screening & Consent

0:15–0:25 MOUD Standard of Care

0:25–0:32 Dosing & NOWS Management

0:32–0:40 Other Substances (AUD, Stimulants)

0:40–0:45 Fourth Trimester & Legal

0:45–0:50 Summary, Pearls, Q&A