Paths to Recovery: Appendices

Paths to Recovery

A mixed-methods report on pregnancy and substance use in Oklahoma

Appendices

Appendix A:
Informed Consent Document

Appendix B:
Ethical Considerations

Appendix C:
Informal Treatment Center Calls

Appendix D:
Participants

Appendix A:

Informed Consent Document

“Metriarch, in partnership with the Fetal and Infant Mortality Review project housed at the Tulsa Health Department, is conducting an analysis to determine the state and impact of policies relating to substance use in pregnancy. Participation in the study is not expected to provide individual benefits, rather the results from this study will be used to advocate for more beneficial policies for communities impacted by substance use in pregnancy.

Your participation is voluntary. Questions will be asked about your experiences, perspectives, and activities. This will include questions about your pregnancy and substance use recovery/treatment. Thus the questions being asked may sometimes cause you to become uncomfortable or emotional. You do not have to answer every question and you may stop the interview at any time and for any reason, and this reason does not need to be disclosed.

The interview is expected to last for 45 minutes to an hour. With your permission, the audio from the interview will be recorded for transcription. Interview audio and transcripts will be kept in a secure/encrypted folder. Your responses will be completely anonymized for the purpose of sharing stories on the impact of the current Oklahoma policy relating to substance use and pregnancy. The findings of this research will be reported on in their anonymized or aggregated form to highlight opportunities for improving programs, tools, and resources to better support those working with pregnant and/or substance-involved people.

After the interview, you can always reach out to the interviewer for questions or to share additional things that come to mind that you would like to share. After you have participated, if you change your mind and do not want your data to be used you may inform the researcher until one month after participation.”

Appendix B:

Ethical Considerations

Pregnant people who use drugs (PPWUD) are a marginalized and vulnerable group of people because of their specific needs and barriers to social participation and care. Because of this vulnerability, this research project followed harm reduction principles as laid out by The National Harm Reduction Coalition (NHRC).¹⁸¹ This protocol involves using person-first language, using motivational interviewing methodology, and avoiding stigmatizing language. All interviewers read the Pregnancy and Substance Use Harm Reduction Toolkit¹⁸² and notes on language use and positive regard were included in our interview guide.

Interviews used elements of the motivational interviewing style outlined by NRHC. Although intended for providers regarding PPWUD treatment, the guide provided a structure and philosophy that was beneficial to interview conversations. For example, interviewers avoided stigmatizing language and instead approached questioning using person-first language, positive regard, and compassionate listening.

Before data collection, the interview guide was shared with subject matter expert partners for guidance. Partners from substance use disorder organizations read the questions, provided feedback, and expressed approval before agreeing to share recruitment materials with their clients.

An informed consent statement was shared with each participant before their interview via email. At the start of each meeting, the interviewer would clarify questions and confirm understanding of the document before beginning the interview and recording.

Both interviewers and participants were aware that the questions involved in the interview process may cause some interviewees to become upset. Interviewers paid attention to cues that the interview should be paused or stopped. If a participant did need to stop the interview, they would have been provided with contact information for mental support services. The interviewer would then check back in on the participant informally 3 days after the interview. None of the interviews collected for this study were disrupted for this reason.

In addition to the individual risk of emotional distress, there is a larger community risk of criminalization and stigmatization of substance use during pregnancy. To safeguard participants’ identity in regard to this wider risk, all names in this document are pseudonyms, and all data is stored in a secure and encrypted folder.

Appendix C:

Informal Treatment Center Calls

Methods. Treatment centers were identified using the Oklahoma listings by the Drug and Alcohol Rehab Headquarters. This list uses data from the SAMHSA Behavioral Health Services Information System (BHSIS): National Directory of Drug and Alcohol Use Treatment Facilities. The final data frame included 53 facilities that were indicated by both organizations to have special programming for pregnant and postpartum women. To select the centers, researchers went through the list twice and pulled a systematic sample of every 8th center. Informal, semi-structured interviews were conducted using a “conversational secret shopping” approach, which the researcher used to assess program accessibility and responsiveness of treatment center staff. Notes taken during each call covered the answers to research questions as well as behaviours that could be observed over the phone.

Sample description. The selected sample included 6 centers from urban centers (Oklahoma City, Norman, Muskogee, and Tulsa) and 8 from rural areas (Henryetta, Miami, Jay, Guthrie, Commerce, Sallisaw, Waynoka, and Valient).

Questions. Each interview started with an introductory statement such as “I’m trying to find recovery programs in Oklahoma for someone who’s pregnant and your program came up. Can you talk to me about eligibility and admission?”

The researcher then asked the following questions:

- Does your program accept pregnant people?
- Do you accept Medicaid?
- Eligibility requirements?
- Is there a waitlist? (How long?)
- Do you need a referral?/ Is self-referral accepted?
- Do you offer inpatient/outpatient services? (differences in referral process/insurance coverage/waitlist)
- How long is the program?

Outcomes.

- Of the 14 calls placed, 5 resulted in interviews, 6 lines were disconnected, 2 centers were mislabeled and did not accept women, and 1 center redirected the call after speaking to the researcher and was unavailable in subsequent follow-up calls.
- The interviews (n=5) cover 3 rural and 2 urban treatment centers.
- Only one of the programs had a 2-week waitlist (Rural/Inpatient). All others mentioned that screening and admission could start right away.
- All programs accepted Medicaid (Soonercare) and only two mentioned additional costs for those covered by Soonercare. In one case (Urban/ Outpatient), every service provided incurred a $4 fee. In another case (Urban/Outpatient), mandatory random drug testing during the program cost $30 and was not covered.

Reflections.

- The calls that resulted in being transferred to another person could possibly intimidate a caller, not meeting people where they are when they first call for information could be a barrier, especially in the context of criminalization concerns.
- For some centers, asking about eligibility requirements led to long wait times on hold before getting answers. During this time, someone could become intimidated and leave the call without getting help or a referral to services.
- Calls went most smoothly when the person answering the phone was prepared with a speech detailing program specifics and eligibility requirements.
- Researchers looked into disconnected numbers online and often found no new numbers/leads. If websites were running, they would often list the disconnected number.

Appendix D:

Participants

Rebecca	Case manager for a family preservation organization.
Ellie	Lived-experience-expert with 3 children.
Emma	Lived-experience-expert and community-based doula with 2 children.
Ivy	Young adult lived-experience-expert with 2 children.
Bella	Leadership level employee at a substance use counseling agency.
Norah	Leadership level employee at a substance use counseling agency.
Megan	Leadership level employee at an Oklahoma anti-violence agency.
Kiara	Young adult lived-experience-expert with 1 young child.
Sophia	Lived-experience-expert with 2 children and advocate for a family preservation and advocacy organization.
Kennedy	Public health nurse.
Lisa	Program coordinator for a family preservation and advocacy organization.