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Innovative Methods for
Addressing Substance Use in
Pregnancy
Grace Chang, MD, MPHProfessor of Psychiatry, Harvard Medical School
VA Boston Healthcare System
Tuesday, October 23, 2018
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Disclosures
• Royalty payments for 2 chapters from Up to Date
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Target Audience
• The overarching goal of PCSS is to train a diverse
range of healthcare professionals in the safe and
effective prescribing of opioid medications for the
treatment of pain, as well as the treatment of
substance use disorders, particularly opioid use
disorders, with medication-assisted treatments.
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Educational Objectives
• At the conclusion of this activity participants should
be able to:
▪ Identify which types of substances are most
problematic.
▪ Review what has been a transformative
development in the identification and modification
of prenatal substance use.
▪ Examine what areas need further research.
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What is the magnitude of
prenatal exposure?
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Prevalence of Prenatal Substance Use
• Legal substances are the most problematic in terms
of effect and magnitude
▪ Alcohol (18% in the first trimester)
▪ Cigarettes (15.4%)
▪ Prescription opiates (<2.5%*)
• Illicit substances are less common and less
problematic (5.4%)
▪ Marijuana, Cocaine, Heroin
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Alcohol is a Known Teratogen
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Fetal Alcohol Spectrum Disorders
• Caused by prenatal alcohol use
• No known amount of alcohol that is safe
• No safe kind of alcohol to drink
• No known safe time to drink
• Half of all US pregnancies are unplanned
• Prevalence Rates
▪ FAS, .2 to1.5 children per 1000 live births
▪ FASD, three times the FAS rate
▪ 1 in 100 children are born with some exposure to
alcohol
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Prenatal Cigarette Smoking
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Prenatal Cigarette Exposure:
Pregnancy Complications
• Pregnancy complications
• Ectopic pregnancy
• Placenta previa
• Prematurity
▪ Decreased birth weight, birth length, head
circumference
• Intrauterine death
▪ Sudden infant death syndrome
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Effects on CNS Development,
Cognitive Function, & Behavior
• Disturbed maternal
infant interaction
• Excitability
• Hypertonia
• Stress abstinence
signs
• Reduced IQ
• Aggression
• Conduct disorder
• Antisocial behavior
• Impulsivity
• ADHD
• Tobacco use and
dependence
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Illicit Substances, Including Non-
Medical Use of Prescription RX
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Specific Illicit Drug Dependence or
Abuse, Aged 12 or Older
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Prenatal Marijuana Use
• Fetal growth restriction
• Attentional deficits
• Other neurodevelopmental
effects
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Screening and Brief
Intervention
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Transformative Development
• Pregnant women are ideal recipients
▪ Highly motivated to change behaviors
• Screening
▪ Assess substance use and its severity
• Brief Intervention
▪ Increase motivation to change [reduce or abstain]
• Referral to treatment
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Examples
• Prenatal clinic, including their partners
▪ Chang et al., 2005
• PHFE-WIC program
▪ O’Connor & Whaley, 2007
• Early Start program at Kaiser Permanente NC
▪ Goler et al., 2008
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Identification of Prenatal
Substance Use
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Some Challenges
• Patients are reluctant to disclose alcohol or other
substance use
▪ Fear of stigma or sanction
• Biological tests of exposure
▪ Urine, hair, breath
▪ Need informed consent
• Limitations of biological tests
▪ Measure recent exposure (alcohol)
▪ None clearly superior
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Questionnaires
• Offer many advantages
▪ Quick, inexpensive
▪ Well studied for prenatal alcohol exposure
• Major disadvantage
▪ Lack a validated measure that reflects current
patterns of use, including multiple substances
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A Multi-Site Comparison of Five Self-Report
Screening Questionnaires for Substance
Use in Pregnancy
Centers for Disease Control and Prevention,
5R21DP006082-02 (PI: K. Yonkers)
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Purpose
• Evaluate 5 promising screening tools that might be
given to pregnant women
▪ 5Ps
▪ SURP-P
▪ Crafft
▪ WIDUS
▪ NIDA Quick screen
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5 Ps Screener: Yes to Any is Positive
5P1
Did any of your parents have a problem
with alcohol or drug use?
5P2
Do any of your friends have a problem
with alcohol or other drug use?
5P3
Does your partner have a problem with
alcohol or drug use?
5P4
Before you were pregnant, did you have a
problem with alcohol or drug use?
5P5
In the month before you knew you were
pregnant, did you drink any beer, wine, or
liquor, or use other drugs
Ewing, 1990. Born Free Project
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Substance Use Risk Profile-Pregnancy
Yes/No 0=LOW RISK 1=MODERATE RISK 2-3=HIGH RISK
SURP-P1 Have you ever smoked marijuana?
SURP-P2
In the month before you were pregnant, how
many beers, how much wine, or how much
liquor did you use?
SURP-P3
Have you ever felt that you needed to cut down
on your drug or alcohol use?
0= low risk; 1=moderate risk; 2-3 high risk
Yonkers et al, Obstet & Gynecol, 2011
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CRAFFT: >2 is Considered Positive
CRAFFT1 C
Have you ever ridden in a car driven by someone
(including yourself) who was "high" or had been
using alcohol or drugs?
CRAFFT2 R
Do you ever use alcohol or drugs to relax, feel better
about yourself, or fit in?
CRAFFT3 A
Do you ever use alcohol or drugs while you are by
yourself, alone?
CRAFFT4 F
Do you ever forget things you did while using alcohol
or drugs?
CRAFFT5 F
Do your family or friends ever tell you that you should
cut down on your drinking or drug use?
CRAFFT6 T
Have you ever gotten into trouble while you were
using alcohol or drugs?
Knight, Arch Pediatr Adolesc Med, 2002
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Wayne Indirect Drug Use Screener > 3 is considered positive
CRAFFT1 C
Have you ever ridden in a car driven by someone
(including yourself) who was "high" or had been
using alcohol or drugs?
CRAFFT2 R
Do you ever use alcohol or drugs to relax, feel better
about yourself, or fit in?
CRAFFT3 A
Do you ever use alcohol or drugs while you are by
yourself, alone?
CRAFFT4 F
Do you ever forget things you did while using alcohol
or drugs?
CRAFFT5 F
Do your family or friends ever tell you that you should
cut down on your drinking or drug use?
CRAFFT6 T
Have you ever gotten into trouble while you were
using alcohol or drugs?
Ondersma et al, Addiction 2012
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NIDA Quick Screen
NIDA Resource Guide: Screening for Drug Use in General Medical Settings;
In the past month*, how often have you used
the following?
NIDA1 4 or more drinks per day?
NIDA2 Tobacco products?
NIDA3 Prescription drugs for non-medical reasons?
NIDA4 Illegal drugs?
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Methods
• 1220 pregnant women
▪ 3 sites: New Haven, Boston, Detroit
• Phase 1
▪ Complete the 5 questionnaires given in
counterbalanced order
• Phase 2
▪ Diagnostic interview
▪ Timeline follow-back interview for the past 30
days
▪ Urine Toxicology screen
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Results
Self-Report/Urine Toxicology Screen
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Participant Characteristics
Characteristic MGH WSU Yale
Age in years (mean,sd) 32.6 (4.4) 26.1 (5.1) 28.7 (6.1)
Race
Non-Hispanic Black 6.9% 84.1% 38.9%
Non-Hispanic White 71.2% 4.8% 33.4%
Hispanic 11.1% 3.6% 25.5%
Mixed/Other 1.8% 6.3% 4.0%
Education
<High School 0.9% 17.1% 11.6%
High School/GED 5.1% 34.5% 37.4%
Some College or Higher 94.0% 48.4% 51.0%
Married/Cohabitating (Yes) 91% 17% 41%
Public Assistance (Yes) 12.6% 70.9% 47.1%
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Participant Characteristics
Characteristic MGH WSU Yale
Trimester
First 26.4% 47.7% 33.0%
Second 35.1% 27.0% 33.8%
Third 38.4% 25.2% 33.2%
Positive Urine or Self Report
Alcohol 13.2% 18.9% 6.9%
Tobacco/Cotinine 3.9% 27.0% 17.7%
THC 3.3% 29.4% 13.7%
Opiates 2.7% 4.9% 4.0%
Illicit drugs other than THC 3.3% 5.7% 6.1%
Any Substance 18.6% 48.1% 31.6%
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Alcohol
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Tobacco
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Illicit Substances
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Any Substances
37.5
40.8
70.6
78.8
80.1
82.5
97.0
0 20 40 60 80 100
SURPP-moderate
5 P's
SURPP-high
NIDA-pre-pregnancy
CRAFFT
WIDUS
NIDA
Specificity
34.9
44.5
50.9
52.4
63.4
79.2
84.7
0 50 100
CRAFFT
NIDA
SURPP-high
WIDUS
NIDA-pre-pregnancy
5 P's
SURPP-moderate
Sensitivity
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Any Substances
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Any Substances Except for Tobacco
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Results
MINI Diagnostic interview 6.0
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Frequency of Diagnoses by Site
Diagnosis Overall MGH WSU YALE
AUD 5.7% 6.7% 9.3% 2.9%
SUD 6.1% 2.1% 10.2% 6.0%
AUD OR
SUD
9.6% 7.3% 15.4% 7.4%
AUD & SUD 7.1% 5.8% 11.2% 5.4%
CANNABIS 5.2% 1.5% 9.6% 4.7%
STIMULAN
T
1.0% 0.6% 0.9% 1.3%
RX, NON –
MEDICAL
0.4% 0.3% 0.3% 0.5%
HEROIN 0.4% 0.3% 0.3% 0.5%
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Alcohol Dependence or Abuse
Sensitivity Specificity Accuracy
SURPP-high 87% 66% 68%
SURPP-moderate 98% 32% 36%
CRAFFT 80% 79% 79%
WIDUS 59% 73% 72%
Five Ps 94% 36% 39%
NIDA 35% 85% 82%
NIDA-alcohol 6% 98% 92%
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Substance Dependence or Abuse
Sensitivity Specificity Accuracy
SURPP-high 77% 66% 67%
SURPP-moderate 100% 32% 36%
CRAFFT 62% 78% 77%
WIDUS 72% 74% 74%
Five Ps 96% 36% 40%
NIDA 54% 86% 84%
NIDA-substance 36% 95% 92%
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Either AUD or SUD
Sensitivity Specificity Accuracy
SURPP-High 80% 68% 69%
SURPP-Low 99% 33% 40%
CRAFFT 69% 80% 79%
WIDUS 63% 75% 74%
Five Ps 96% 38% 43%
NIDA 44% 87% 83%
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Conclusions
• Prenatal substance use is common
▪ Protective effect of pregnancy on risk for substance use
• DSM IV Diagnoses , ~7 to 15%
• Rates for recent use, 18 to 48%
▪ Diverse participant sample
▪ Anonymous
▪ Estimates are based on urine toxicology screens and self-report
• Head to head comparison of screening measures
▪ There is room for improvement!
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Brief Interventions
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Core Components
• 4 core components
− Assessment and Feedback
− Goal Setting and Contracting
− Behavioral Modification
− Written Materials
▪ Reduce drinking in nondependent drinkers
▪ US Preventive Services Task Force Grade B
recommendation to reduce alcohol misuse in
adults, including pregnant women, in primary
care settings
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Implementation
• Not universal, despite recommendations otherwise
▪ Time limitations
▪ Privacy and mandated reporting
▪ Competence /ability of the clinician
▪ Innovative approaches
• TECHNOLOGY
▪ CBT4CBT
▪ Computer based technology for cognitive
behavioral therapy
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A RCT of Screening and Brief Interventions
for Substance Misuse in Reproductive
Health
Martino, Ondersma, Forray, et al., 2018
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Purpose
• To determine whether “screening, brief intervention,
and referral to treatment” that is delivered either
electronically or by clinician are more effective than
enhanced usual care in decreasing days of primary
substance use
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Study Design
• Women from 2 reproductive centers who smoked cigarettes or misused alcohol, illicit drugs, or prescription medications
▪ Urn randomization to one of 3 conditions:
▪ 1) E-SBIRT
▪ 2) Clinician delivered SBIRT
▪ 3)Educational pamphlet + treatment as usual
• Assessments completed at baseline, 1-, 3-, and 6-months after the baseline
• Co-primary outcomes
▪ Days/months of primary substance use
▪ Post intervention treatment use
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Results
• 2421 women approached for screening, 439 randomized
▪ Women who were seeking reproductive healthcare needs, 18% were pregnant
• 99% received the intervention on the same day as baseline assessment
• >84% retention rates at follow up points for all groups
• Baseline Primary Substance
▪ 57.2% Nicotine
▪ 11.6% Alcohol
▪ 20.5% Cannabis
▪ 10.7% Other
• Baseline Days/month using Primary Substance: 23.7 +7.9
• Baseline Days/month using Any Substance: 25.7 + 5.9
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Mean Days of Substance Use by
Treatment Group
• E-SBIRT and SBIRT significantly reduced days of primary substance use of Enhanced TAU
• No interaction for pregnancy status, response similar
• At 3 months: 4 (E-TAU) vs. 7 (ESBIRT) vs. 6.3 (SBIRT)
• Differences attenuated at 6 months
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Treatment Seeking
• 121 women (27.6%) used substance use treatment
or self help programs after SBIRT
• Half of the services sought were for smoking
cessation
• Study treatment group had no impact on substance
use treatment seeking afterwards
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Conclusions
• Both e-SBIRT and SBIRT significantly reduced days
of primary substance use compared with enhanced
TAU
▪ Mode of delivery did not appear to affect
outcomes
• No interaction for pregnancy status
• Most effect at 3 months follow up
• No impact on Substance Use Treatment seeking
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Summary
• Substance use in pregnancy is common and may have an adverse impact on pregnancy outcome
• Some examples of innovation
▪ Head to head comparisons of current screening measures
▪ Utilization of technology to extend the reach of approaches such as Brief Interventions
• More research is needed
▪ Best methods to identify prenatal use
▪ Best approaches to modify prenatal use
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Clinical Bonus
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Medication Assisted Treatment
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Alcohol
• FDA approved medications are all Category C
• Disulfiram, Acamprosate, Naltrexone, Extended
release naltrexone
• Psychosocial interventions
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Cigarette Smoking
• Smoking cessation counselling is the mainstay of treatment
• US Preventive Services Task Force (2009, 03-2018 update pending)
▪ Grade A recommendation for counseling
▪ Inadequate evidence to evaluate the safety/efficacy of prenatal pharmacotherapy
• Cochrane Systematic Review (2009)
▪ 72 controlled trials of cessation interventions
▪ 6% of pregnant women will be helped
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Opioid Use Disorders
• Prevent complications of illicit opioid use and
narcotic withdrawal
• Encourage prenatal care and drug treatment
▪ Include prenatal care to reduce the risk of
obstetric complications
• Reduce problematic behaviors
• Avoid risks of “drug culture”
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Opioid Antagonist
• Naloxone
▪ Only to save the woman’s life
• Medically supervised withdrawal is not recommended
▪ High relapse rates
▪ If MAT is not an option
− 2nd trimester, under the supervision of a physician experienced in perinatal addiction, is preferred
− 1st trimester is preferable to continued illicit drug use
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Methadone
• Registered substance abuse treatment program
• Comprehensive package of treatment
▪ Prenatal care
▪ Counselling
▪ Family therapy
▪ Nutritional education
▪ Medical and psychosocial services
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Perinatal Methadone Doses
• Initiated at 10-30 mg per day
• Adjusted throughout pregnancy to avoid withdrawal
symptoms
▪ Third trimester
• Rapid metabolism may require split dosing
• Not all women require dosage adjustments
• Methadone has pharmacokinetic interactions with
many other drugs
• Severity of Neonatal Abstinence Syndrome is not
associated with methadone dosage
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Buprenorphine
• Informed consent about lack of longitudinal data
• Advantages
▪ Lower risk of overdose
▪ Fewer drug interactions
▪ Outpatient basis
▪ Evidence of less severe neonatal abstinence syndrome
• Disadvantages
▪ Hepatic dysfunction
▪ No long-term data about infant and child effects
▪ Clinically important drop out rate
▪ More difficult induction, risk of precipitated withdrawal
▪ Increased risk of diversion
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Buprenorphine
• Single agent product recommended
▪ Same dose for mono-product if switching
• Monitor for diversion
• Inappropriate for patients needing more intensive
structure and supervision
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Buprenorphine vs. Methadone
• Indications for buprenorphine are in flux
▪ Past: refuses/unable to take methadone,
methadone unavailable
▪ Current: prefers to methadone, gives informed
consent, capable of adherence and safe
administration, understands potential of adverse
long-term outcomes
• Transition from methadone to buprenorphine is not
recommended
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Breastfeeding
Recommendations from the American Academy of
Breastfeeding
Clinical Protocol #21
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Breastfeeding
• Challenging balance of risks and benefits
• Evaluation and Management
▪ Prenatal plan to prepare for parenting,
breastfeeding, and SUD treatment
▪ Understanding of the consequences of relapse to
drug or alcohol use during lactation
▪ Teaching about donor milk, formula preparation,
bottle handling, and cleaning
▪ Engagement in treatment pre and post-natally
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Alcohol and Breastfeeding
• 5107 infants and their caregivers
• First assessed in 2004 and then q 2 years
• Children aged 6-7 had lower scores on reasoning
tests if their breastfeeding mothers drank alcohol –
dose response relationship
• Risk factors alcohol while breastfeeding
▪ Older maternal age, increased education, longer
breastfeeding duration
Gibson & Porter, 2018
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PCSS Mentoring Program
▪ PCSS Mentor Program is designed to offer general information to
clinicians about evidence-based clinical practices in prescribing
medications for opioid addiction.
▪ PCSS Mentors are a national network of providers with expertise in
addictions, pain, evidence-based treatment including medication-
assisted treatment.
• 3-tiered approach allows every mentor/mentee relationship to be unique
and catered to the specific needs of the mentee.
• No cost.
For more information visit:
https://pcssNOW.org/mentoring/
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American Academy of Family Physicians American Psychiatric Association
American Academy of Neurology American Society of Addiction Medicine
Addiction Technology Transfer Center American Society of Pain Management
Nursing
American Academy of Pain Medicine Association for Medical Education and
Research in Substance Abuse
American Academy of Pediatrics International Nurses Society on Addictions
American College of Emergency Physicians American Psychiatric Nurses Association
American College of Physicians National Association of Community Health
Centers
American Dental Association National Association of Drug Court
Professionals
American Medical Association Southeastern Consortium for Substance
Abuse Training
American Osteopathic Academy of Addiction
Medicine
PCSS is a collaborative effort led by the American Academy of Addiction
Psychiatry (AAAP) in partnership with:
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