Addiction Medicine Made Easy | Fighting back against addiction

Saving Two Lives: How I Manage Opioid Addiction During Pregnancy

• Casey Grover, MD, FACEP, FASAM

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Join me, Dr. Casey Grover, as I provide a comprehensive guide to treating opioid use disorder during pregnancy, examining evidence-based approaches that protect both mother and baby through critical periods of care. The statistics are sobering - opioid use disorder in pregnancy has more than doubled in recent years, with overdoses now a leading cause of pregnancy-associated death.

• Two major medical societies (ACOG and ASAM) recommend treating with methadone or buprenorphine rather than attempting medication-free withdrawal
• Buprenorphine shows slight advantages over methadone for pregnancy outcomes, but the best choice is whichever medication keeps the mother sober
• Neonatal abstinence syndrome occurs when babies experience withdrawal after birth, but can often be managed with supportive care rather than medication
• Medication dosages often need adjustment during pregnancy as increased blood volume dilutes medication concentration
• Breastfeeding is compatible with both methadone and buprenorphine treatment
• The postpartum period brings unique challenges that increase relapse risk, requiring enhanced support for new mothers
• Two patient cases illustrate both successful treatment and the challenges of maintaining recovery while parenting a newborn

Visit centralcoastoverdoseprevention.org to learn more about preventing overdose deaths in your community.

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department, seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

This episode is going to be on the topic of treating opioid use disorder in pregnancy. I gave this lecture a few weeks back as a part of my monthly training for the drug and alcohol treatment program that I work for, and I recorded this lecture to post on the podcast. We've covered this topic opioid use disorder in pregnancy once before, with an episode that came out last summer. This episode today is a much more holistic overview of opioid use disorder and addiction in pregnancy, rather than a more specific discussion of pharmacology and the nuances of medical decision making. I hope you find it helpful. My colleagues and I had a great discussion after I gave this lecture. It's such an important topic. Here we go. Okay, so today we are going to be talking about opioid use disorder in pregnancy, and I actually had a lot of fun putting this lecture together, because there's a lot of funny stuff on the internet about just how awesome or not awesome being pregnant is. So many of you know my wife, dr Close. She's on the board for Sun Street and she's one of the other addiction doctors and this was a meme I found about being pregnant. And the woman on the right is, I think, my wife's experience with pregnancy. So you can see the woman on the left Pregnancy is amazing, she's glowing, she's having a great time, and the woman on the right, the clothing is stained, she's been eating ice cream in bed. She's having trouble getting up. My wife was done with pregnancy about month seven. She was like you know what? I'm ready to have this thing over with. So I just want to acknowledge that pregnancy is a very unique time and for many women it is very challenging. Anecdotally, some people really seem to enjoy it and have a positive experience from it, and other people have a lot of issues, whether it's nausea and vomiting, early pregnancy pains. It can be a very difficult time and a lot of stress on the mother. But in honor of my wife, I thought this was funny.

Speaker 1:

Okay, so I think we all know that America has a major problem with opioids and this is a chart and I really just looked online for the waves of the opioid epidemic and we all see the trend where we see an increasing number of deaths from opioid use disorder over time and, as you can imagine, pregnant women aren't spared from this. In other words, as addiction to opioids increases across America, it's also going to increase in pregnant women because they are part of our population and arguably, one can say there's probably a similar trend globally. But this is American data and we know that the opioid epidemic has risen very steadily until about last year, when it may have gone down a little bit. So here are some numbers. So, as I said, opioid use disorder affects pregnant women too, and you can see some data here on the screen. In 2010, the prevalence of opioid use disorder was 3.5 people per 1,000 deliveries and by 2017, that had risen to 8.2 per 1,000 deliveries. And just to give you some context, at our hospital in Monterey we do about 1,100 deliveries a year. So that's something that we're getting. Probably a pregnant woman with opioid addiction once a month, twice a month, something like that. So not particularly common at our hospital, but certainly in large hospitals with larger labor and delivery units it's going to be a bigger problem or in areas where opioid use disorder is more common in the general population. That's going to be higher. That's going to be higher.

Speaker 1:

And this next slide is really sad, which is that as opioid use disorder becomes more common, unfortunately so do opioid overdoses, and I found some data looking at the number of fatal overdoses in pregnancy in the postpartum period. And, just for reference, the postpartum period refers to the time immediately after delivery, and so the rate of overdose deaths in pregnant women and women immediately after delivery, and so the rate of overdose deaths in pregnant women and women immediately after delivery, that rate doubled between 2007 and 2016. And then after that, between 2017 and 2020, that rate increased again by 81%. And one of the articles I looked at was from a reference for doctors called UpToDate, and it pointed out that opioid-related overdoses are now a leading cause of death associated with pregnancy in the postpartum period, and you can just think how sad that is right. Not only does the mother die, if it's during pregnancy, the fetus dies, and if it's in the postpartum period, we now have a neonate with no mother, and it's very, very devastating to families and in terms of the absolute size of this problem, the rate of opioid overdose death per pregnancy is anywhere as high as 16 per 100,000. So we might see that maybe once or twice a year here in Monterey for context. So not a big, big problem here in our area, but obviously very devastating and when you bring those numbers out to include all of America, it's a significant issue. So obviously treating opioid use disorder and preventing overdose in a pregnant woman or in the postpartum period is extremely important.

Speaker 1:

Now it turns out there are some other issues as well. As we enter the fentanyl era and this is a picture from a news story that talks about that there is now thought to be a birth defect syndrome when neonates are exposed to fentanyl in utero, and I don't think it's been fully worked out yet, but there appear to be some changes in the facial structure and in the hands, and this is still emerging data. But again, what we're seeing is that in mothers who use fentanyl during the pregnancy, their babies may be born with birth defects. This was a particular child that was highlighted whose mother used fentanyl throughout the pregnancy, and I'm just going to point out in this picture you can see there's a little white thing under his neck. That's a breathing tube, so there are some difficulties with the airway, the leg is in a cast, so there's likely some skeletal abnormalities, but you can see at least the baby seems very happy, and this was a story about a family that adopted this child with special needs. So as we shift from the previous eras to the fentanyl era, the reason to help treat women with opioid addiction during pregnancy becomes even greater, and I'll talk about withdrawal in newborns as we get further on.

Speaker 1:

Okay, so how do we treat opioid use disorder in pregnancy? In the world of medicine, every specialty usually has a professional association. So I used to work in the emergency department. We had the American College of Emergency Physicians. Thousands of emergency doctors across the country participate and as a professional society they make recommendations on best practices, in other words, what's the most evidence-based medicine. So for OBGYN, that's the American College of Obstetrics and Gynecology that's called ACOG, and then the American Society of Addiction Medicine, that's the American College of Obstetrics and Gynecology, that's called ACOG, and then the American Society of Addiction Medicine that's often referred to as ASAM. Both of these professional societies recommend treating opioid use disorder in pregnancy with methadone or buprenorphine, and we'll talk about the differences.

Speaker 1:

But just at the highest level, obgyns and addiction doctors across America all agree that the treatment for opioid use disorder in pregnancy should be either methadone or buprenorphine. Additionally, these same professional societies, again, that's the American College of Obstetrics and Gynecology and the American Society of Addiction Medicine, recommend against withdrawal management. And again, just to clarify, withdrawal management is the idea is that someone just wants to wean off of opioids, deal with the withdrawal and not be on any medications for addiction treatment like buprenorphine or methadone. And the reason for that is because once they are off of opioids and not on buprenorphine or methadone, their risk of relapse is very high. And that goes back to this idea that we're really trying to prevent fatal overdose in pregnant women. Now I mentioned two of the FDA-approved treatments for opioid use disorder buprenorphine and methadone.

Speaker 1:

What about naltrexone? Well, naltrexone is actually not used in pregnancy because we don't know the safety data and I don't know the history behind this, namely why we have data on bup and methadone and we don't have data on naltrexone. But that's just where we're at. And, for context, we don't use naltrexone for alcohol use disorder in pregnancy either. So, and again, to quote the up-to-date article up-to-date being a reference that doctors use across America quote information related to the use of naltrexone for the treatment of opioid use disorder during pregnancy is limited, end quote.

Speaker 1:

And you know, if it's a really bad situation and the only thing that can keep a woman sober while she's pregnant is naltrexone, it becomes a very individualized decision of weighing out the risks and benefits of a birth defect from fentanyl, an overdose, it's just. It's gotta be a really multidisciplinary, everyone's informed kind of decision. If we're going to use naltrexone in pregnancy, no-transcript Okay. Now we have to realize that while pregnancy is a very unique state, many of the things that contribute to addiction during a time when a person is not pregnant are the same as when a person is pregnant or not. If they're unhoused, it's the same If they have severe post-traumatic stress disorder, which we talked about before, if they're a victim of domestic violence or they're in an unsafe living circumstance, all of the same factors that we try to address when people are not pregnant are the same when a person is pregnant. So it's really again we've got to think about the whole person's circumstance and not just focus on the pregnancy. And I thought I was being really clever here when I made the point that mutual support meetings like AA and NA and therapy are safe in pregnancy, meaning that there's no medication, there's no side effects, there's no impact on the fetus. You can do all the therapy and meetings you want while you're pregnant.

Speaker 1:

Okay, so the next question becomes how do you actually start methadone and or buprenorphine in pregnancy? How is it different? And the answer is it's not. Starting methadone and buprenorphine in pregnancy is the same as starting methadone and buprenorphine in people who are not pregnant. Who are not pregnant. So, just how we start methadone, we start at a dose. We titrate up until we manage their cravings and withdrawal. That's the dose, exactly as we do it for someone who's not pregnant, and the same for buprenorphine. If they need 8 milligrams, great. If they need 16 milligrams, great. Now, granted, we want to treat with the lowest effective dose possible, but that's, again, not any different for a person who's not pregnant. No one needs extra methadone or buprenorphine just because we're going to want to treat with the lowest effective dose. And again, how I dose it is you basically go up on the dose of methadone or buprenorphine until you find a dose where they're not having cravings and they're not having withdrawal.

Speaker 1:

Now there is some data comparing methadone and buprenorphine head-to-head in pregnancy, and the effect size isn't huge. But when people are on buprenorphine there is a lower risk of preterm birth as compared to those on methadone. There is less neonatal withdrawal also known as neonatal abstinence syndrome, which I'll talk about and that's lower in people who are on buprenorphine as compared to methadone. And there's actually a higher birth weight in mothers who are on buprenorphine for their babies as compared to methadone. So you might be thinking, okay, well, there appears to be a slight edge to buprenorphine over methadone. Be a slight edge to buprenorphine over methadone, but when we think about what the ultimate goal is, which is sobriety, the real answer to which is better, methadone or buprenorphine in pregnancy is whichever keeps the person sober, meaning that if somebody's doing great on methadone, we don't switch. If somebody really wants to start methadone, go with that. In other words, again, the main focus of what we're trying to do is to keep them sober during their pregnancy because of the reduced risk of overdose and then the reduced risk of fetal harm.

Speaker 1:

Now, one thing that comes up that a lot of mothers talk to me about, that I've treated and we probably think about when we're treating someone with opioid use disorder in pregnancy, is is the baby going to withdraw and the medical term for that is neonatal abstinence syndrome or NAS. And essentially what happens is when a mother is on buprenorphine or methadone or fentanyl or heroin or morphine or any opioid, that opioid goes into their bloodstream and it passes through the placenta and the baby is exposed to it. The baby develops a tolerance to the opioid and dependence on the opioid, just like the mother. So when the baby is born and they stop getting placental blood, they don't get any opioid and they get withdrawal the way an adult would. And symptoms are a little bit different in a newborn. They usually don't sleep well, but that's not that different from adults. They often are shaky or jittery that's actually not that different from adults. They get sweating, a runny nose and yawning again very similar to adults. The main issues are that they have frequent crying and their cry sounds different. Some neonatal ICU nurses will actually say that they can detect a neonatal abstinence syndrome cry, it's just different. And then they have trouble feeding and that's probably similar to the GI symptoms that we get in opiate withdrawal in adults, like nausea, diarrhea, stomach cramping, that sort of stuff. So yes, this is a real concern for moms that are using illicit opioids and moms that are on methadone or buprenorphine. And just to go back a couple of slides, the risk of neonatal abstinence syndrome is actually lower in moms on bup as compared to methadone.

Speaker 1:

Now how do we treat neonatal abstinence syndrome? Most often we do not use medication, and there was a campaign that came out a few years ago called Eat Sleep Console, which is we try to help the babies feed, we try to help the babies get to sleep by swaddling, and then we console them. We try to shush them, rock them, whatever it's going to be, to help them be soothed, and then eventually they just deal with their withdrawal. They go through the withdrawal, they begin to feel better, their tolerance and dependence go away and then they start feeding more normally. In more severe circumstances, babies may actually be given morphine or methadone to treat their withdrawal and then they're weaned off of that. Now, if you did not know, you can actually, depending on the hospital, sign up as a volunteer to help cuddle babies with neonatal abstinence syndrome. In one particular area of Florida, where there was a very high rate of opioid use disorder, there was actually such a rush of support from the community that there was a waiting list to be a baby cuddler to be actually to be able to cuddle babies in the hospital and this is an article published by the hospital computer system Epic that there was a hospital in Denver that actually did a study that showed that babies who were swaddled and consoled, who were in neonatal abstinence syndrome, actually did better and went home sooner. So again, we really focus on behavioral interventions with babies whenever we can. So I mentioned that for babies who are born to moms on buprenorphine the risk of neonatal abstinence syndrome is lower compared to moms on methadone. But this is not a reason at all to switch off of methadone. Again, the whole goal is to keep the mom sober and keep her in recovery throughout the pregnancy. So if the mom's doing great on methadone, keep it. If the mom's doing great on buprenorphine, keep it. We can manage the neonatal abstinence syndrome after delivery.

Speaker 1:

Now, as the pregnancy grows, the mother experiences some changes in her body. So you can imagine a woman has a fixed amount of blood in her body as the pregnancy grows, the placenta grows, the uterus grows and the baby grows and the whole blood volume that is required to nourish all of those organs and the fetus increases. So you can imagine a woman has a large pregnant belly. That's more organ tissue and the fetus that is requiring blood and the term for this is the volume of distribution. In other words, there's just more blood in the mother circulating. So you can imagine if you're on eight milligrams of buprenorphine a day and the whole blood volume in the mother is five liters.

Speaker 1:

As the pregnancy grows and let's say it grows to six liters, it's going to dilute out the dose of buprenorphine or methadone. So what tends to happen over the pregnancy is that some moms will start to feel some withdrawal in the second trimester and we actually have to increase the dose of methadone or buprenorphine as the pregnancy progresses. And I'll actually share a case of one of my patients where this happens and that's totally normal. Again, if a mom says I just feel like I'm craving a little bit, can we go up on the dose? The answer is yes. We have to keep the mother in treatment with methadone or buprenorphine to keep her in sobriety throughout the pregnancy. Okay, so we get to the pregnancy.

Speaker 1:

The mom delivers, mom delivers. Vaginal delivery can be uncomfortable. It can be painful. Sometimes women will tear vaginal tissue and require stitches afterwards. Or there's a cesarean section, which is a surgery, so there can be pain after delivery. The best way to manage the pain is to continue buprenorphine or methadone and then add in, as possible, non-addictive medications on top of it, like acetaminophen, if tolerated, anti-inflammatories. We might even add in a few days of a full agonist opioid like oxycodone or hydrocodone, and then, once the pain is better, within like maybe three to five days of delivery, we really just switch them back to methadone and buprenorphine again and we're looking for the dose that manages cravings and withdrawal so they can stay sober. So pretty simple there.

Speaker 1:

My daughter and I had a lot of fun coming up with funny pregnancy and breastfeeding memes for this talk. I love this. A happy baby. It might be the milk talking, but I love you man. So, yes, let's talk about the postpartum period and breastfeeding. You're going to see a theme which is in breastfeeding. We just continue medication for addiction treatment.

Speaker 1:

It is absolutely okay to breastfeed while taking methadone. Again, we want to prevent relapse. And it is okay to breastfeed while taking buprenorphine. We want to keep them on the dose that prevents relapse. You can imagine if a mother dies from opioid overdose, that neonate just lost a parent. Now one little nuance here is buprenorphine may be a little better for breastfeeding women because, if you think about it, how do we take buprenorphine? We take it sublingually. If we take buprenorphine orally, it doesn't really get absorbed. So for the neonate that's nursing from a mother taking buprenorphine, it actually doesn't get very well absorbed. So it might be a little safer in the postpartum period to breastfeed while on buprenorphine, as compared to methadone. But once again, the whole focus is to keep the woman sober and focusing on getting adjusted to being a new parent. So really again, if they're doing well on methadone, stay on methadone. If they're doing well on bupe, stay on bupe.

Speaker 1:

Okay, parenting a newborn I don't know how many of you have kids, but parenting a newborn is particularly hard. Here are a couple of funny things that I found about parenting. This is a card I found at a grocery store. Parenthood it's like a hangover, with less tequila and more vomit in your hair, and then I love this picture of this little baby with a kind of a conniving grin. How do I put this? You will never sleep in again. Yes, parenting, particularly the neonatal period, is hard for every human on planet Earth, and if they say it's easy, they're probably lying. I'm obviously being facetious there, but yes, transitioning to parenthood is very challenging. As I said here, parenting a newborn it's hard, like really hard. I mean really hard. Maybe my wife and I just had a very difficult newborn, but that was probably the hardest thing I've ever done is just adjusting to the lack of sleep, having to change your whole routine.

Speaker 1:

And many of you have heard this mnemonic H-A-L-T. Hungry, angry, lonely, tired. That's when a relapse is most likely to happen in a person who's trying to stay sober. I often joke that hungry, angry, lonely, tired, that's when I'm a bad parent, in other words, my willpower is down because I'm already in a stress state. So for pregnant women that are breastfeeding, they may be very hungry. When the baby's crying and won't stop, you can be angry. If you're a spouse at home with the baby while your spouse is at work, you might be lonely. And then the silly newborns never seem to sleep on a regular schedule. So every new parent I've met is tired. In other words, the stress of parenting a newborn in and of itself, in my mind, is a risk factor for relapse because it puts an enormous stress on our psyche as we try to accommodate the needs of these small little humans we have brought into the world.

Speaker 1:

A couple of personal stories from my wife and I trying to adjust to having a newborn. In the picture on the left that is me swaddling my daughter at about maybe five weeks it's probably about two in the morning. In that photo you can see I'm on a bouncy ball trying to gently bounce her to sleep. To my right is the dog for moral support and in front of me is the cat for moral support, and you can see to my left are several blankets that we've tried to wrap the baby in just to try to get her to stop crying and go to sleep. The picture on the right we heard from another parent that if you find a machine that makes a whirring noise, it will soothe the baby.

Speaker 1:

So we literally were so sleep deprived that we went through the house and grabbed every major appliance we could find to see if it would make the baby stop crying. So we've got the blow dryer, we've got a blender base, we've got a can opener, we've got the leaf blower, we've got the coffee grinder, we've got the Cuisinart, we've got the mixer, we've got the vacuum. We literally tried everything to get the baby to go to sleep. Ironically, it was the blender base, that little blender base you can see in the center of the screen. We traveled everywhere with that thing for like six months because it was the only thing that would make the baby stop crying.

Speaker 1:

And, mind you, this is parenting by two physicians. You'd think we'd know all the tricks. It was very, very hard for us too. So again, I just want to say the stress of a newborn is an independent risk factor in my mind for relapse, just because it's so hard. New parents all across the world need lots of support. New parents in recovery need extra, extra support.

Speaker 1:

Okay, let's do two cases and then we'll stop and we'll do some questions. Okay, so case number one. These are both my patients. I've changed the details of both of them to make sure that they're not recognizable. Okay, so case number one.

Speaker 1:

This is a 38-year-old female and she presented to me in recovery from opioid use disorder. Her original drug of choice was prescription opioids use disorder. Her original drug of choice was prescription opioids. She did have a fairly abusive childhood. She got an ankle injury and the opioids were very euphoric for her. She was using prescription opioids. Thank goodness someone put her on buprenorphine and her doctor retired. They needed her to see a new doctor to take over her buprenorphine, and so that was me. She was working, she was married, doing very well.

Speaker 1:

She's about three years sober when I first saw her and she was on eight milligrams of Subutex daily my next appointment with her. She was very happily surprised that she was pregnant and I actually. She was my very first pregnant patient and I told her I don't really know what to do with this. I'd only been done with my training and was a new addiction doctor. I'd only been done with my training for maybe like three or four months and I was debating weaning her off of her bupe because I was worried about neonatal abstinence. And so I checked in with her OB and I talked to some colleagues and everybody was just no, no, no, no, keep her on her bupe, keep her on her bupe. And no, no, no, no, keep her on her bupe, keep her on her bupe. And she had a lot of questions about neonatal abstinence. She was worried about wanting to wean down.

Speaker 1:

Significant opioid withdrawal is a risk factor for premature labor. So I said you know what? Let's just keep you on bupe, you're on a fairly low dose and let's see how it goes. So I saw her every month. For the first six months of her pregnancy and maybe about month five, month six, she started to get some cravings and she was getting further along in her pregnancy. I realized as her pregnancy was growing the buprenorphine was getting diluted. So I upped her dose to 12 milligrams in the second trimester and all of her cravings went away. I increased the frequency of her visits at 34 weeks to every other week. So she did very well. At 34 weeks I saw her every two weeks. She did very, very well. No change in her bup dosing. And then at 38 weeks I checked in with her every week and she delivered and did great. The only issue is she had a prolonged labor but she was able to deliver vaginally. She delivered a healthy girl and even though she was on 12 milligrams of bupe, she had absolutely no neonatal withdrawal. She was home with her daughter three days later and I just saw her in person maybe about two months ago.

Speaker 1:

Baby's doing great. She's still on 12 milligrams, she's back to work, she is a happy new mom. She has a lot of support from her family. She has a lot of support from her family. She has a lot of support from her husband and she works in healthcare and is very satisfied with her work. And the only issue that came up after I saw her last week is that she was having some cravings for alcohol. And we went through her history and I realized she had a lot of post-traumatic stress disorder. So we upped her bupe and added a little bit of praisesin at bedtime because she wasn't breastfeeding. And she's doing great. Her nightmares went away. She's doing totally fine at about 24 milligrams of bupe per day and she's back to work, no issues. And so yes, that's got from before pregnancy, through pregnancy, delivery, postpartum and back to work, all right.

Speaker 1:

Case two is not so happy. So a 39-year-old female came to me for opioid use disorder and she and her husband were both in recovery from opioids and they were both on buprenorphine. She was taking 16 milligrams of bup a day. She got sober during her pregnancy so she didn't have a lot of prenatal care. So it was really a lot of catch-up in the second trimester and we got her treated with bupe in the second trimester. So once she got on bupe we didn't really need to make any changes.

Speaker 1:

She got taken care of at our hospital in Monterey. She had a healthy delivery, no issues, no neonatal abstinence. They were able to go home within about two, three days. They monitored the baby for an extra day just to be sure there wasn't any withdrawal and the baby did totally fine and they got home from the hospital. They were staying with some family. They were first-time parents and they were really excited. I checked in with them about every two weeks after the delivery. They were both doing fairly well and, unfortunately, even with family support, the stress of being new parents led to a relapse for both of them. Fortunately, they called my clinic right away. Her parents offered to help with childcare. She ended up well. Actually they both ended up doing fairly well. They realized this was a, you know, a major detriment to their child. They were really supporting each other, getting a lot of support from family, a lot of support from the peer support folks in my clinic. And the mother enrolled in an IOP and got back on bupe at a higher dose. She's at 24 milligrams and so parents help with child care while she's in the IOP.

Speaker 1:

Okay, so what are some take-home points around? Opioid use disorder in pregnancy. So treat opioid use disorder in pregnancy with methadone or buprenorphine. The best choice is whatever works to keep the patient sober. There's maybe some small effect size in some of the studies that buprenorphine has a little bit better outcomes in pregnancy, but not in any meaningful way to ever change what you're doing. If someone's doing great on methadone, keep them on methadone. If someone's doing great on bup, keep them on bup. We're going to continue methadone and buprenorphine through the pregnancy, delivery and the postpartum period. We want to keep them away from having cravings and relapse. And again, treating a patient with opioid use disorder involves thinking about everything housing, trauma, mental health, whatever it's going to be. And then the last thing is parenting a newborn is hard. Just period, new sentence. Parenting a newborn is hard and in my mind I think of that as a major risk factor for relapse and hopefully those two cases were helpful. I think that that is a major risk factor for relapse and hopefully those two cases were helpful.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives. Bye.