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Ep. 93- Breastfeeding and Opioid Use Disorder Treatment: Interview with Kelly Lemon, APRN, CNM, WHNP

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This is Maureen Farrell and Heather ONeal and this is The Milk Minute. We’re midwives and lactation professionals bringing you the most up-to-date evidence for all things lactation. So you can feel more confident about feeding your baby, body positivity, relationships, and mental health. Plus, we laugh a little or a lot along the way. So join us for another episode.

Heather: Welcome back to the Milk Minute Podcast, everybody. Today, we have a very special guest and a dear friend of mine. Her name is Kelly Lemon, and she is an advanced practice registered nurse certified nurse midwife, who is the director of midwifery at West Virginia University hospitals.

And that is very cool, but she also spends a great deal of time working towards quality improvements for care of pregnant and postpartum patients who are struggling with opiate addiction. So this lady is really busy. This is a very busy midwife we have wrangled for you today. She has multiple research projects going, including WVU drug-free moms stuff.

And she works with the West Virginia perinatal partnership, and there’s so much more that she has done and that she is doing for patients who are struggling with opiate addiction. And we can’t wait to talk about it because obviously opiates are a huge topic in the world right now. And it’s affecting the lives of so many families, but I really feel like when it comes to pregnancy and breastfeeding, not many people are having open conversations about it.

And there’s a lot of judgment and stigma. So Kelly Lemon, thank you for coming on to The Milk Minute, to clear up some of this misinformation for us about breastfeeding opiate use. We really appreciate you sharing your expertise and perspective on such a prevalent issue.

Kelly Lemon: Thanks for having me guys. I’m excited.

Maureen: Yeah. We are super, super pleased to have you. And I’m just gonna, like, let’s just jump right in. Well, I, I mean, really what are we even talking about? Why does it matter? You know, what is Suboxone? What’s Subutex? You know, can midwives even handle this shit? I mean, let’s just jump right in.

Kelly Lemon: Oh, heck yeah. This is a topic in terms of just talking about substance use and opioid use that hits everybody. Even if you don’t realize it, everyone has a friend, a neighbor, a family member, somebody that they work with and that they know that has a history or a current substance use disorder. This does not discriminate. So very prevalent if you open your eyes up to it. And it’s interesting how the more people who realize that they’re touched by it and the more kind of engaged and passionate they get about it.

Otherwise everyone’s just kind of living in their bubble with maybe a little bit of bias. A couple of misconceptions with the different meds that we’ll get into, but the main meds that we’re going to talk about are Suboxone and Subutex. We’ll mention methadone a little bit as well. Suboxone and Subutex are two different types of medications that you can use for medication assisted treatment, so for opioid use disorder treatment.

They’re called buprenorphine. The only thing that makes those two drugs different is if there’s Naloxone in the drug or not. And that’s easy to remember because Suboxone which ends in oxone has Naloxone in it. Subutex, which does not have that lovely oxone on the end, it does not have Naloxone in it. When you look at who should or shouldn’t have the Naloxone and the benefit of it really, that just prevents the drug from being misused as easily. So if you’re taking your medication like you’re supposed to, your gut gets rid of that Naloxone component, nothing happens with it.

It digests it, kicks it out. Your body doesn’t notice it. If you snorted your Suboxone film, if you injected it, if you smoked it, any other kind of way that gets it directly into the bloodstream, that Naloxone kicks in, binds the receptors and goes to work and stops any other drugs from hitting it. That’s your main difference.

Historically, we gave pregnant women Subutex cause it doesn’t have Naloxone. Only reason we did that was, why give a baby exposure to another thing we don’t have data about? So that’s your main difference. A lot of pregnant women will be on Subutex. If you’re listening to this and you’re currently on Suboxone, it’s safe and okay.

And you can be on either one. The reason we’re going to talk about it today is because a lot of people don’t realize that there’s a lot of safety with use in pregnancy and with breastfeeding. And a lot of people don’t realize that midwives and OB GYN and nurse practitioners and all other types of providers are actually able to prescribe this medication and be an expert on it and take care of people with it.

Heather: That’s really interesting. So if, if the Naloxone component is safe to take when you’re pregnant, why are any pregnant people left taking Subutex? Why don’t we transfer all of them over to Suboxone?

Kelly Lemon: Some of it’s just not up-to-date information. I know that the, the group that I work with out of behavioral medicine with WVU, they’ve done a lot of research on outcomes, which are completely similar between Subutex and Suboxone.

Most providers are still just going off of the older guidelines, which are just a little bit outdated. And again, we only are using Subutex still, just because we don’t have a lot of data on Naloxone.

Maureen: I mean, frankly, I think a lot of providers are going off of really old information and telling people they can’t breastfeed on any of those.

Kelly Lemon: That is correct. That’s also made it a lot tougher because when you read the manufacturer insert, it says thou shall not breastfeed on this medication. Pretty much. Yeah. Which is crazy.

Heather: Yeah. But also let us remember that if you buy a foot scrub with menthol in it of any kind, it says do not use this foot scrub while breastfeeding.

Maureen: Let me, let me tell you what guys, this is a good day for it cause this is the, like I’ve dealt with three people today who were given misinformation about the medication they can breastfeed on and I’m just like, I’m ready. I’m fired up about it.

Heather: Well, you know, I think part of the issue is people don’t understand what happens to a fetus when someone is taking opiates regularly, and then they stop cold turkey. So Kelly, would you mind explaining to us the process of like, why we put people on drugs, like Subutex and Suboxone?

Kelly Lemon: Yeah. So there’s an, and this is one of my high horses I get on is that people think you’re just swapping a drug for another and that you’re damaging your baby if you are taking Suboxone or Subutex. Not true.

I will say that again. You are not harming your baby by being stably on Subutex or Suboxone. You are not swapping a drug for another. What you are doing is getting on a maintenance therapy and consistently keeping your body in a safe space.

Heather: Do you say that because you find that some people are managed in a program and they’re taking Subutex or Suboxone, and then some random family member is like, you shouldn’t be taking that. You’re killing your baby. And then they just, they decide to self-manage and kind of wean off of it without calling their provider. Does that happen a lot?

Kelly Lemon: Yeah, that happens a lot. That’s something that frequently occurs when people get pressure from CPS or child protective services or child and youth services.

That’s something that we see frequently when they enter the family court system. What happens when you stop taking your medication in pregnancy is you start going through withdrawal symptoms. Any single person listening to this that has ever experienced a withdrawal can immediately start telling you man let me, you feel like garbage. You’re crapping your pants.

You’re vomiting. Your whole body aches. You’re like nothing is feeling good. Most people that continue any kind of substance use in pregnancy are literally just using so they avoid feeling like that. When you go through that experience when you’re pregnant, you’re changing all of your vascular system. You’re causing really swift, vasodilation and constriction.

What ends up happening to baby is you get less blood flow to baby. It increases your risk of having a growth restricted baby, or from having a placental abruption. So where the placenta actually separates. So those are your biggest risk to baby. If mom is stable and safe and okay, then baby is stable and safe and okay.

Heather: So then what happens after the baby’s born? So say you do stay on Subutex and Suboxone, stable, managed, good communication with your provider the entire time. Baby comes out and do we experience withdrawals and like what, how does Subutex and Suboxone play a part in that postpartum time?

Kelly Lemon: Yeah, that’s the piece that everyone that’s talking about opioid use disorder in pregnancy, like that’s the piece everyone’s focused on. Which is very appropriate. Like how’s my baby going to be? What am I going to be looking at? If you are stable, usually, hopefully, ideally in a program as that’s always going to increase your stability, your risk of baby having withdrawal symptoms to the severity where they need medication, where baby actually needs a morphine taper is significantly lowered.

Now babies will still go through a little bit of withdrawal and that’s called neonatal abstinence syndrome, or people will hear it called NAS or NAS. That is all of the symptoms that they’re looking at to see, is baby experiencing withdrawal? How bad is it? Do we need to treat it or not? We don’t have a dose correlation.

So that’s really hard. So it’s not like if I’m on eight milligrams, my baby will have less withdrawal symptoms or lower NAS scores than if I’m on four milligrams. So there’s so many other factors and I find that very intriguing. Just because mama’s metabolize things differently and there’s differences in was she breastfeeding or was she not breastfeeding?

How long was she on that medication and how tolerant was her body to, to that level? So there’s not a dose correlation. That’s really hard for people to wrap their heads around when they’re pregnant.

Heather: Is that why we typically don’t wean people during pregnancy?

Kelly Lemon: Correct. Yep. Cause the, the best benefit comes from stability, not from decreasing it. And my patients have a really hard time with that. They all want to taper down as low and as quick as they can, but that’s not actually found to help much in the literature.

Maureen: I imagine that’s really emotionally hard too, when they’re like, I’m in this place where I’m motivated and I really want to get as clean as I can and get off these medications. And you’re like, actually, no, not, not yet.

Kelly Lemon: Right. Right. And that’s one of the struggles. And, and honestly, that’s something I have a hard time with because I’m, I’m very like pro we should make a, like a treatment that’s going to work for you. And there’s not just like this one size fits all to the medication, but there are some people that are very motivated and very early want to wean off their meds and not be on them. And if you are doing other things to enhance your recovery, then that’s a conversation you have with your prescriber. And you monitor really closely. Most people when they go through that, they do experience a return to use or experience a relapse which is a lot riskier.

Maureen: Right. So I’m curious, Kelly, if when we have our parents who are managing addiction, if they’re breastfeeding, do their babies have lower rates of NAS or lower, or like less symptoms of NAS?

Kelly Lemon: Yeah. So there’s a lot of misinformation that people get whenever, especially in the hospital. So just a couple weeks ago, I was lucky enough to actually be able to catch a baby for one of the ladies that I take care of in our, in our treatment group for women with substance use disorder. And baby came out, she latched like pretty much immediately in the like recovery period. It was great. She had an amazing nurse that gave her lots of lactation support. And then she went through the rest of her hospital stay.

I saw her a week later in group and asked her how breastfeeding was going. And she told me that she had quit breastfeeding because by the time she got to her postpartum nurse, that nurse had told her that her baby had already started getting rid of some of the Suboxone from its system. It was already starting to go through withdrawal and she was just going to make it worse if she just kept giving her baby breast milk with the medication in it and then taking it away.

And she even said in group that she knew that that wasn’t right and didn’t seem right, but she didn’t really feel comfortable or like confident, like getting in an argument and she didn’t want to make it look like, well, I’m just this troublemaker that’s coming in and arguing with the nurse. The other really sad part was she didn’t want to seem difficult because she’d heard that the nurse’s notes could be pretty damning to you whenever CPS comes to see you. So she was trying really hard to play it cool with everybody, so she switched to formula. So now you have a mom with limited transportation, probably a limited income, multiple children in a pandemic having to go out and acquire formula all the time.

Heather: Yeah. So, but my question is where is the pediatric team in all of this?

Because you have to have an order anymore to do formula. So when the nurse goes to the pediatrician and said, I need an order for formula, what conversation ensues after that? Because it’s actually more of a risk at that point. It sounds like to switch to formula for so many reasons. First of which being the baby is no longer getting a small, microscopic dose through the breast milk, which is preventing incredible withdrawals and also risks for access issues.

Like you were talking about access to clean water. What if they have only well water? What if there’s only one family car and what if there’s not enough money to go to the store and buy formula? And what if there’s no transportation to get to the nearest WIC office? Or what if the nearest WIC office is an hour away?

So, I mean, these risks are huge. So what happens between that time that the nurse makes this judgmental decision and goes to the pediatrician?

Kelly Lemon: Well in that one, that’s a case I’m still actually following up, but a lot of times they’ll just say to the pediatricians, like, yeah, she wants to do formula. And then, oh, well she’s someone that’s on Suboxone. So like, yeah, she probably just doesn’t want to breastfeed and off we trot.

Maureen: Right. And it just, just letting those judgments fly.

Kelly Lemon: And I will take a minute to say, like, I, I am lucky. I work at an institution that is overall pro breastfeeding and trying to support women that have like substance use disorder.

And it’s sad that every now and then you just get one case where they got the wrong person that didn’t know or had a bias, or just was really thinking that they were helping the baby and they were not. So then of course that scares me of what’s happening in all the places where they don’t have that information.

Or for this lady where she didn’t have someone to talk to. When she knew it was not correct. When she told me the story, my eyes started just like visibly twitching and she called it out. She was like, I see Kelly twitching. I’m guessing that that was not a correct.

Heather: Okay. But, so, you know, you had mentioned how quickly they’re willing to put these patients who are struggling with opiate addiction in a certain camp, like, oh, of course they’re formula feeding. Oh yeah. So can we just for a second talk about how being so quick to give patients formula because of your biases, widen the health disparities for lower socioeconomic families and just make the whole situation worse.

Kelly Lemon: Yeah. The assumption that everyone’s going to formula feed is, is huge. The, the thing that I’ve recently found that compounds that is the assumption that everyone in recovery deserves or is going to have their baby taken away. That’s another theme that keeps coming up is people in healthcare and in families and in CPS telling them that they need to be on formula so that when their baby goes to a foster family, they will not have a disruption in the food they get.

Maureen: Right. When, when. No inevitable.

Heather: Well, how does it work? I mean, you know, if everybody is assuming that, you know, if you test positive, the baby’s going to be taken. What, what is it supposed to look like? So people that are going through this, listening to this podcast right now can kind of maybe squash some of those fears or at least know how to ask the right questions as far as expectations go.

Kelly Lemon: Yeah. So the, the lady who, that I just told the story about with breastfeeding and then not breastfeeding, her case, she was very nervous the entire pregnancy that they were going to come in and she had multiple other children and was afraid that they were going to come in and take all of her children away.

She was super engaged in treatment. She came to all of her scheduled appointments. If she had to miss, she let us know in advance, stayed stable on her medication. Did that initial breastfeed, transitioned over to formula, baby’s scores were very low and reassuring, never needed treatment. She got discharged from the hospital at 24 hours, roomed in with her baby for the five days.

CPS met her at her house on the day the baby was discharged, did one walkthrough home visit. She handed them the letter that I had written that said this patient is great and engaged in treatment and is amazing and working so hard. CPS closer case that same day. Everything’s good and fine. She kept custody of her children.

So that is how the system should work. And that’s what I try so hard to reassure all of my people is if you’re engaged and that doesn’t mean you’re perfect. That just means that like you’re showing up and you are honest and you are engaged in your treatment. Like those are the cases where they’re going to come in, do their visit, say, okay, great and walk out.

Maureen: And that means that you have a support system so if something goes wrong, you don’t fall through the cracks.

Kelly Lemon: Right. And it’s not penalizing you for a disease that we know is periods of recovery and remission. It’s recognizing the disease and that you are on top of managing it.

Maureen: Right. And you know, we, Heather and I are big proponents of harm reduction services. And we know also they are severely lacking in West Virginia. You know, because that’s how this should work in general is that you need treatment. You go get it. You’re not worried about a penalty, regardless of the legality of whatever substance you use, you get the help and then, you know, great, you have support systems.

You can thrive, you can survive. Because when we fear those penalties, guess what fucking happens? You don’t get treatment.

Kelly Lemon: And people overdose. Yep.

Heather: People overdose, but also people self-treat with quote-unquote street Subutex, street Suboxone. So I think this is also something that I’ve heard kicked around in conversation at hospitals is when you’re giving report and you hear, oh yeah, and this patient’s on Subutex. And the other nurse says, well, street Subutex, or are they in a program? And is she breastfeeding? Oh, she got it off the street? She’s breastfeeding? So like help us figure out Kelly, what is protocol for that scenario for someone that should not be judged, you know, for trying to manage it on their own because what parent hasn’t tried to manage something completely out of their scope on their own anytime?

Every single one, every single one all the time. I haven’t been way out of my league on so many things that I’ve tried to manage as a parent. And we do the best we can. But, so what is, tell us what you do in that scenario?

Kelly Lemon: Yeah, so the, the overall goal is that people are in a program because you’re going to get a controlled amount of medication at appropriate times and in hopefully timeframes where you’re not experiencing periods without your medication, where you have to stretch your med. What we find a lot of times when people are getting like street Suboxone to put quotes around it or off the streets, or it could be any dose. So people don’t realize that like a sub isn’t a sub there’s 2, 4, 8 milligram formulations.

When you get into films, there’s a bunch more. So maybe someone gives you a tablet and they all kind of look the same. And you thought you were getting a four milligram, but you got an eight, let’s say that you thought you got an eight and you got a two. So there’s that inconsistency, which is where you’re going to get into more withdrawal symptoms like periodically.

When you look at that with breastfeeding, when they’re in the hospital, usually we can get them started on a stable dose. So it’s not as much of an issue. If they’re using it not in the confines of a program and they’re not using their med correctly, then you can get into a risk of, is it laced with other things? So, as an example, I think examples always help.

I had one person before who was using Suboxone from the street, didn’t know that you were supposed to tuck it in your cheek and let it dissolve. Was told that you could use it really anyway, as long as it got in your system. So she was smoking it. She was smoking it, or maybe snorting, I can’t remember, but using it in an incorrect manner with items that other people had used.

So didn’t realize that every single time she was also ingesting traces of fentanyl and methamphetamines. So that’s where you kind of get into a risk of dabbling in other things inadvertently. And that’s another risk with breastfeeding.

Heather: So, does that put you completely out of the game for breastfeeding or is it like a we’ll see or what?

Kelly Lemon: So I look at it as a, as you’ll see. And this is where I had to actually butt heads with some of the breastfeeding, American Breastfeeding Medicine Protocols. Where technically, if you have had a relapse in or return to use in the last 30 days before you birthed, that is an absolute contraindication to breastfeeding.

That is based off of the assumption that that person is not going to be stable in their recovery and they are more likely to relapse when they are breastfeeding. And that is what you’re trying to avoid. You would consider Suboxone not prescribed to be a relapse because it’s not something, it’s an illicit use of that substance. So I honestly talk with people.

Heather: But so as far as your rights as a human being, what if a parent said I’m going to breastfeed. Sorry.

Kelly Lemon: I always tell them I am here to give you information and counseling and to tell you about your risks and what you choose to do with that information is entirely yours. And this is a conversation that I’ve gotten into with other providers where I’ve asked what are, what is our consequence of this?

Are we going to refer her to CPS for this? Interesting. She already has been. Are we going to physically remove her baby from her? We don’t have the power to do that. Only the state of West Virginia or wherever you’re practicing can. Are we going to write punitive snarky notes in her chart? Like that’s at the end of the day, I mean, you can only give the counseling and they can do with that, what they will.

So I’ve had people who have been stable taking Suboxone from the street. They’re like, yep. I know exactly how much it is because this is my route of how the medication comes to me. I will get into a program, but I will be breastfeeding now. Thank you. And I say. That’s fine.

Heather: Sounds good. So, but I just wonder, I mean, I’m sure there are providers out there who would consider breastfeeding at that point harmful. You know, like now you’re harming your baby and it’s, I can’t imagine that someone that has got to the point in their life where they are struggling with an addiction, that they haven’t already been in situations where they have felt vulnerable, where they have felt like the system is not set up for them.

And so like that one thing happens. And I can only imagine that that does not help the situation. Just like further unravels, whatever progress that you had made. I don’t know.

Kelly Lemon: You’re absolutely right, because I haven’t met a single person in recovery yet who hasn’t felt just guilty and ashamed. That’s one of the hardest things when you newly enter recovery is you start really having to like, and especially if you’re working the steps, man, then you’re going to go through, you’re going to think of your old grievances. You’re going to reconcile things. All of that stuff comes back to you. And then you think of all of the things that people have said to you.

You’re selfish. I have a list of things that I’ve heard people that I work with say about people with substance use. And it is my favorite slide on my substance use in pregnancy presentation that I give every now and then is all of the stigmatizing comments I’ve heard from people in the healthcare system.

And that’s always a flag for them to stop. But everyone going through recovery has been told that they are selfish and that they’ve hurt their baby. Nobody wants to do that. So unfortunately, when people do come into a place where they’re like, all right, I need to, I need to stick to my guns. Like I want to breastfeed and I’m going to try to do this.

They bulk really quickly. As soon as somebody says, you’re hurting your baby. They, they bulk.

Maureen: So when you’re having these conversations with your patients, do you think you could kind of walk us through the risk factors that you cover and how you talk about them in a respectful way that doesn’t sound like, here’s the ways you’re going to hurt your baby.

Kelly Lemon: Are you meaning, like for people who have like been taking their Suboxone off the street?

Maureen: Yeah. Or just people who take Suboxone when it’s prescribed or, you know, what are the risks if they relapse? Like, I’m sure this is a multi-faceted conversation, but related risk factors.

Kelly Lemon: Yeah. Yeah. So in terms of effect on newborn, which is why the manufacturer says don’t breastfeed is, I mean the small little bit of it’s going to go to their baby, the goal would be that they’re slowly going to taper out over time, right.

With any medication that you’re starting, there can be good things and bad things that happen. So we know that those are some of the good things is that we could decrease your baby’s risk of having NAS. You are going to know your baby best. You’re going to watch your baby’s behaviors. So if you’re noticing that our feeds are dropping off, if we’re a little bit more tired, if you can’t like wake your baby up for feeds regularly, those can be signs that maybe we’re getting too much medication, and that could be harmful to baby.

If you’re going to the pediatrician and they’re doing weight checks and the supply is good, but the weight gain is poor, then that can be something that we would want to consider if that’s a risk with the medication. The quick thing that everyone jumps to, as soon as their baby comes out is that they want to taper off the meds.

That’s one of the worst things that you can consider doing in the postpartum period. I can understand why, I have not personally grown and birthed a human and been in the postpartum life, but it looks really freaking hard. I worked with a lot of people in the postpartum period and it looks like it just kicks you in the ass man.

So I can think of nothing more stressful than trying to go through that life change and then also getting off my meds very quickly.

Maureen: That doesn’t sound like fun. Oh, man. What, so what is the timeline then? You know, cause everybody’s like, get me off of these. When, when do you actually consider that?

Kelly Lemon: Like a year, a year postpartum. Yeah, because I mean, that’s like ideal, like you think like it took forty weeks to grow your baby. It takes 40 ish weeks to recover from your baby, then your body maybe feels like itself.

Maureen: I get it. Yeah. I mean, I’m like nine months postpartum now. And I’m like, I don’t know, like there could be a light at the end of that tunnel. Maybe a little bit.

Kelly Lemon: Well, usually about a, at least a year. I mean, your best benefit is going to be with two. But usually people are chomping at the bit. Yeah. Well before that two-year mark.

Heather: Well, I’m glad you said that because I feel like the, probably one of the things that people think, one of the stigmas is that they don’t want to quit, that they want to do it forever. That it’s a never-ending train.

Kelly Lemon: That’s one thing too is some people need to be on buprenorphine, Suboxone or Subutex for a long time. And I break this down for, for people when I’m talking to them about, especially when they’re really resistant to taking it. Like someone put them on it and they’re just really upset about it.

When you have somebody with high blood pressure, they can change their diet. They can exercise. They can pull in all of these lifestyle changes, but they probably need medicine. And some people change their lifestyle and all of these things, take their meds and then eventually they taper away their medications and they don’t have high blood pressure anymore.

And that’s really great, but that’s because we treated them as a whole person. This is the same exact way that opioid use disorder works. You have a medication to control symptoms, can cut your cravings, keep you safe. You work on lifestyle. You get people the resources that they need and that is very complex.

Getting them like a support system in place. And then if they’re stable and doing great, you take away the medication. Some people are like red flag. I can’t do it. And they need to go back on their medication. And that doesn’t mean that they’ve failed. That just means they are someone that on like, like in the levels in their brain, all of their receptors, like they need that activation of that receptor. And that doesn’t mean they’re failing. It’s just the nature of the disease.

Maureen: Yeah. I, I hear a lot of similarities to the way that we think about mental health issues, like depression and anxiety in the postpartum where, you know, there’s a lot of stigma around it. But also we’re just barely getting there where people are like, oh, maybe you should take Zoloft while you breastfeed?

And maybe we shouldn’t talk about tapering you off until, you know, a year postpartum and maybe you don’t need to be tapered off and you should stay at a stable dose for a long time.

Kelly Lemon: Right. And it’s just trying to, I think the big thing is like getting the support, which is huge. You can’t just slap meds at somebody and think that that’s going to change their life and cure everything. That’s the huge misconception you get into with buprenorphine.

Heather: And, you know, can I just say also that I’ve seen a lot of patients who really benefit from the empowerment of being able to do something for their baby, like breastfeeding. You know, people that maybe never felt like they had choices in life, and that’s how we ended up in this situation in the first place. And it feels like life is happening to you. And that you’re just getting kind of like strung along in life. And then that moment that they realize like, oh my God, I can provide food for my baby. Just me that no one else can. Not my mother, not anybody else in my family that’s potentially caused me emotional damage before.

This is literally just a thing for me and my baby. And I love watching patients have that experience, which is why I get so mad when it gets taken away. And they, it gets taken away in such a way that their worst emotional buttons are pushed and they are manipulated into that same place that they were in before. And I just can, do you have any stories about people emotionally healing through breastfeeding while they’re going through opiate addiction issues?

Kelly Lemon: Oh, my gosh. Yeah. Like, so there’s two I can think of right now. The one is a year postpartum now. The other one will be a year here in a couple months. And just the there’s so many times that they say things in group and I’m like, oh my gosh. It’s very illegal. I could never record you, but I just want to write it down.

And just like, I want you to just share that everywhere. I can remember one lady telling me postpartum that there was something really amazing about being like the one person in the world that somebody needed. Coming from a place where she’d been kind of like rejected.

She had a pretty expensive like abuse and assault history, which was really tragic and hard. So I was amazed that she could and wanted to breastfeed given that history. Just the fact that all she could think of was like, you know, I can’t even imagine using because my baby needs me and I’m, I’m everything to that baby.

I’m giving it its entire life support right now. Like I couldn’t use anything else. That would be absurd. So it can be a really powerful tool to keep people connected to their recovery. There’s another lady that I remember rounding on in the hospital and she was very worried about her baby’s NAS scores.

We had brought her back down from her nervousness cause she also got the, you shouldn’t do that, you’re giving your baby medication. So I happened to catch her as she was clutching her baby sobbing and was able to get, it was great timing on my part. I was very lucky cause I walked in like an angry hen like, and we corrected that and that was good. But we then got to sit down and just go over all of the other things besides just breast milk, that she was giving her baby just by breastfeeding. So like that attachment, that bonding. Skin to skin, holding her baby, touching her baby, speaking to her baby when they were breastfeeding, how those are all tied in with decreasing your NAS score that they do in the hospital.

Maureen: You’re supposed to do that first. Right? Hold your baby and comfort them.

Kelly Lemon: Yeah.

Maureen: Before giving babies medication for NAS, correct?

Kelly Lemon: Yeah. A lot of people don’t realize that like all of those pieces, like, I don’t really know anyone who wants to breastfeed in a very loud, bright overstimulating room. So usually people get in like, they’re little quiet, I’m going to go over here away from everybody. And yeah. I have my baby time and breastfeed. So like all of that, like lower stimulation, like touching your baby and talking to them and them smelling you and hearing you and feeling you decreases their NAS scores. So beyond just like I’m getting nourishment and all the good oxytocin flow, and you’re also getting all of these great physiologic feedback benefits that people don’t even realize.

Heather: Let’s just talk about the NAS score for a second, because, you know, we have some listeners who use Subutex and Suboxone regularly, but we also have other listeners that maybe have a family member who are going through this and maybe it’s their sister. And like when they are with this person in the postpartum period, and first of all, your baby’s NAS scores are nobody’s business. You do not have to share them with anybody, but,

Kelly Lemon: and also I’m going to rudely cut in, your NAS score are your right to know as a parent. So any time you ask your nurse or your provider or your anybody who scored your baby, what the score is, you have a right to know that.

Heather: For management, like all of the management, like personally, your choices, you can make choices based on the knowledge that you gain from your baby’s healthcare information.

So, and like, don’t let anyone take that away from you. And actually just a little story. When I was a floor nurse, I was actually training somebody. I was orienting somebody and we had an NAS score to do. And the person I was orienting said, oh my God, are you going to tell her the score? It’s really high. And I said, absolutely.

And she’s like, well, don’t you think you’re going to make her feel bad? And I said there’s different ways you can tell people things, but I’m not going to withhold information as if she is a child. I mean, she knows what’s going on. This is not the first time that she’s had a conversation about what’s happening here.

And so by me ignoring it, we are further validating that it should be something with a stigma attached to it. Okay. This is like, when you talk about mental health issues and it’s like, oh, just tell them that daddy’s sick. Don’t tell them that daddy has chronic depression. Just say he doesn’t feel well. And it’s like, no, that makes it seem wrong and dirty. We’re not doing that today or ever.

Kelly Lemon: Right. And especially cause that woman is probably or person or dad, it could be dad involved too and nervous. Like they are waiting with bated breath, wanting to know what that score is and it’s gonna make them feel real angry if all of a sudden, nobody says anything and then someone just waltzes in their room and says, well, your baby’s score has been increasing and is really high. And we’re going to transfer them to the NICU and give them morphine when nobody told them. There’s also things that you can do. So if they’re scoring higher on, let’s say like, they’re just extra, like jittery, like jitteriness, like doing more skin to skin with them, decreasing the stimulation in the room.

Like there’s an entire list that I will give people that’s like, if your baby is scoring higher on this, you can do this. And that’s not cheating the score.

Maureen: That’s giving babies adequate care.

Kelly Lemon: That’s responding appropriately to your baby. Just like how, if I, if it was my kiddo and I didn’t have an opioid use disorder and I was just like working on taking care of them, if my baby was having a really exaggerated Moro reflex and startling itself and waking itself up, I would swaddle it.

Heather: Right. Exactly.

Maureen: Yeah. Well, and, and by, you know, being honest with parents and giving them tools to help their babies, we’re also helping to, you know, create their bond and maybe giving them an experience that maybe they’ve never had before, because their providers, you know, called CPS and had all kinds of crazy stuff happen the first day their baby was born or whatever. You know and giving them an opportunity to be a good parent, to be a responsive parent and building that bond is then putting in the work for the long-term relationship and keeping people in recovery and keeping families together, which, you know, reminder everybody, like that is the goal of child protective services.

After keeping everybody safe is then keeping everybody together if it’s safe. Correct. And if we have to remove children from parents, the goal is then to bring them back. So like, we want to start working at this goal from the beginning.

Heather: Yeah. And you know, there’s a song and I don’t remember who sings it, but I will look it up after we’re done here. And I will, I will put it in the show notes, but one of my favorite lyrics from it is babies aren’t the only ones that grow. And that really hit me because I’m like, oh duh, like we’re spending so much time, like as soon as the baby comes out, it’s like mom who? You know, it’s like, what’s going on with the baby and is the baby gaining weight and is the baby eating and blah, blah, blah.

But really the same way that a baby is growing, the mom or the parent is also growing at the same time and hopefully at the same rate. If you interrupt the growth of the parent, they’re not gonna match anymore. The baby is going to continue to grow and the, and the parent’s just going to grow in a different direction if they’re not growing together. So that should also be the goal too. And I want to get that like cross stitched on a pillow. Kelly, I’ll give it to you for next Christmas.

Kelly Lemon: No, that’s one of my biggest things though. And there’s so much funding and programs trying to be developed and everything to try to decrease the severity and the incidents of NAS.

And it’s interesting to me because the programs are a lot of times missing the mark. Like everyone is so focused on the baby and like, I love me some babies, but if you’re only focusing your effort on the baby, then you missed a huge piece of it, right? Because for every baby, there’s a mom that grew the baby and maybe a partner involved and family members and all kinds of other people involved around the babies. So you can’t just, just put like, you know, like blinders on and ignore everybody else and just focus on the baby.

You got to look at the mother attached.

Heather: There’s the midwife. Midwife means with woman and Kelly Lemon is absolutely with woman in every single way.

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Maureen: Well, we have a question from our Patreon that I wanted to read to you and see if you can help at all in this area. So this is from our patron, Lisa, who’s wonderful. And she said, Hey Kelly, I am a school-based occupational therapist, and I’m really seeing major differences in the incoming students. Overall, they have greater difficulties in school, motor skills, self-regulation, sensory processing.

I hypothesized it’s due to many factors, but I believe the opioid crisis is a huge factor. What do you recommend for the babies once they’re discharged from you? Do they continue treatment? Are they referred for early intervention? As an OT in the school system I’m kind of freaking out to be completely honest because I simply do not have the resources that these children need and they deserve. My referrals have skyrocketed over the last couple of years and of course the pandemic did not help. I’d love to find a way to bridge the gap for these babies so that they have the absolute best outcomes. Do you have any suggestions or ideas?

Kelly Lemon: The number one thing that all of these families need is referrals to early intervention in birth to three. And those services are going to be free and really any provider, if you’re an OB provider, if you’re a pediatric provider, if you’re a community health worker, when you come across somebody who is in recovery, they are going to benefit from a birth to three referral.

The best-case scenario is that they come in, they do an assessment and say, everything’s great and fine. But putting in that referral, making sure that they’re getting those follow-ups is crucial. And that’s your number one thing. When you look at families that got separated, they will end up having higher developmental delays.

And everyone wants to relate that over to, well it’s because the mom was on drugs and that’s why, or the mom was on Suboxone and that’s why. That’s my snarky person.

Maureen: I’m sorry. I’m so here for your snarky voice.

Kelly Lemon: That’s an easy assumption to jump to and just say, ah, was the drugs, but really it’s more so probably from like environmental factors and then just like any kind of separation or just stress within the family.

Maureen: Well, yeah, and if we have a young baby or a child, who’s had their environment changed, their caregiver changed like that’s going to set them back in a lot of ways. Just having things being consistent. And it’s not that that’s not repairable and we can’t move forward from there, but like you said, we need the right referrals.

Kelly Lemon: Right. And a lot of those come through from like appropriately, like taking your baby to the pediatrician. And that sounds like such a simple thing. But if you’re every time you walk in the pediatrician’s office, the first thing they read on their chart is about the baby like going through NAS or the ICD 10 code of like infant with intrauterine substance exposure, you’re probably not going to be treated as well.

If you experienced stigma and bias whenever you’re going to the pediatrician’s office, you’re sure not going to want to keep going back. So that can put delays and then there’s entire just difficult time people have with appropriate access to transportation and care in general and the barriers we have in a rural state.

That’s, I mean, there’s so many layers to that. So noticing like that those people need those referrals early and that they need them before they leave the hospital. And that’s something that I never was aware of when I was a bedside labor and delivery nurse. And it’s only when I got into this role. If I did not work with so many women in recovery, I honestly just in my typical like life as a midwife, I wouldn’t have thought to ask about if their baby is enrolled in those services at their postpartum visit.

I also probably wouldn’t have been as focused on, oh, she didn’t come to her postpartum visit. I should call her and check on her instead of just laughing it away and being like, oh, it’s fine. She got her birth control in the hospital. That’s all the postpartum visits for. She’s fine. And just sending her on her way. Like you, we should call them and follow up and make sure that everything they need is there. It’s pretty simple.

Heather: So true. Absolutely.

Maureen: But it’s hard when you see the volume of patients that you do also. Just give you all some credit.

Kelly Lemon: But yeah, I mean the, the that’s a whole other podcast, man.

Maureen: We don’t need to dip our toes in everything.

Heather: Well, Kelly, I actually have another question for you from a listener, Becca. She says, did you find that at the start of the COVID-19 pandemic that people using opiates or misusing opiates has increased, and if you are a new user, where should you go?

Kelly Lemon: Use skyrocketed. And the scary thing was that it wasn’t, that increase in use wasn’t proportional to the increase in referrals that we got into our program. So what did increase were the number of people who were coming in actively using substances with limited to no prenatal care, mainly because they were scared of the pandemic and, and exposures with that.

So it’s really hard whenever, especially people find that they are pregnant. If they’re already in treatment, a lot of times sharing with your treatment provider that you’re pregnant means that you’re going to get kicked out. Sometimes yeah, that happens quite frequently. I just took in a referral today for someone who is getting transferred out of their current program, because she is pregnant, which is fascinating to me.

There’s information for providers, which is not answering the question, but I will circle back around, I swear. SAMHSA’s website has an entire beautifully written, easy to follow, Clinical Guidance for the Treatment of Pregnant and Parenting Women with Opioid Use Disorder and Their Infants. It’s a very long title. I probably got it wrong.

Heather: We will put it in the show notes.

Kelly Lemon: In the show notes. It is free. F R E E free. And it walks through everything from like, I am pregnant to now my baby is a year old. Beautifully lays things out. So people who are uncomfortable managing women in pregnancy or just pregnant persons with opioid use disorder can access it through there.

If you are somebody that’s out and about in the world and doesn’t know what to do, Free. If anyone who is registered to provide medication assisted treatment or any appropriately filed like healthcare center, that’s like a treatment center is going to fall into that search. So you can literally just type in your zip code and it will bring up all the different treatment facilities that are available.

So anyone who has a family member that’s using, that they’re using, they need help finding treatment, you can do that. There’s been massive expansion in terms of like public based insurance, where you can get access to insurance if you are using. Especially if you are pregnant, if you are a pregnant, don’t have insurance and are actively using, like you will get Medicaid coverage. And those centers are all pretty familiar with the process to how to get you enrolled in Medicaid so that you can get benefits.

Heather: That is so helpful. And I think I can actually hear several listeners breathing, a sigh of relief on the other end, just because it is so stressful to take that first step. And you’ve given them the first three steps so they don’t have to think about it.

Kelly Lemon: I mean, obviously if you’re, if you’re in a really scary place, you can always go through any kind of like emergency department as a gateway into treatment.

That’s always a hard, the hardest way I think, in terms of really just like getting slapped into the exposure of the healthcare system. That can be really daunting, but it certainly, if it’s any kind of like really emergent situation, then that’s always an access point. And that’s how I get a lot of people referred into my program.

Right. But if you’re just wanting to like, it’s 2:00 AM, everyone’s downstairs using, and I’m really trying really hard not to and I’m feeling that motivation, like you can go to and you can, you can search and just blast out some, some emails and stuff.

Heather: Thank you so much, Kelly. This has been very enlightening. I think and I hope that a lot of healthcare providers are listening, nurses, occupational therapists, anyone that is working directly with pregnant patients and postpartum patients, breastfeeding patients. Because this is the linchpin you guys. This information between getting somebody off of the wagon and off of breastfeeding and putting a wedge between their relationships sometimes with their family and their baby and an empowering postpartum experience where they feel like they have the strength to move on and to be, you know, whatever they want to be.

Give them a leg to stand on, a very strong foundation. And you could help them get there. So I hope that you took everything Kelly said today, put it in a little satchel and carry it around with you because this isn’t going away anytime soon. We’re going to deal with it. Okay.

Kelly Lemon: No, and it’s not like, it’s hard. And I mean, there’s like new things that I learn every day where I’m like, oh my gosh, I can’t believe that I used to use that verbiage. Like,

Heather: Yeah. And so, by the way, I’ve, I’ve said several times throughout this episode, people struggling with opiate addiction, is that verbiage okay or should I be saying something different?

Kelly Lemon: Oh, that’s fine. There’s I mean, you can use anyone with opioid use disorder. Anyone that’s like using the, the one thing you want to avoid is just like calling people addicts basically. Is unless you’re like within the community is generally not cool. And you shouldn’t do that. The other thing too is that, and this is a bit of a side note and I’m sorry cause I know we’re wrapping up, but we have a lot of focus on opiates because that’s what we have medication for. But there’s like a whole other realm of like substance use and substance exposure. With many other things on the rise as opiate access starts to slowly decrease and a lot of the, a lot of the treatment modalities besides just like medication is very similar. So that gets like lost a little bit too with people.

Heather: Is there any one drug that is absolutely contra-indicated with breastfeeding if you’re in the program?

Kelly Lemon: Meth. Yeah. Okay. Meth is not good. Too bad. Yeah. Okay. Meth is not a good one.

Maureen: Do we have like a medication treatment protocol for people managing that? No?

Kelly Lemon: The tough thing, and I’ve had people in our program that were like, I am so upset because like, I don’t know what’s wrong with me. I’m on this med and I can’t, I, I still use meth and marijuana and I just feel so bad. And I’m like the medication you’re on doesn’t treat methamphetamine use or marijuana use, like this is for opiates.

So unfortunately the only way to not do meth is to not do meth. And if that was easy, right, then nobody would do meth. Like that one is like literally the root of, of, of being in like treatment with like getting like appropriately recovery resources and abstinence-based programs and supporting the whole human.

We just don’t have a med that helps curb those cravings. So that’s something that’s really the hardest to get off of.

Heather: So I think there’s a misconception that methadone is what gets you off of meth.

Kelly Lemon: It doesn’t. Methadone is just another type of opiate management technique and methadone I mean, everything pretty much across the board that we talked about with Suboxone and Subutex is directly translatable to methadone because methadone is your OG treatment. Before there was buprenorphine, there was methadone.

Okay. Methadone’s great if you’re like, I need accountability. Do not give me that medication to take home. I want to go to the clinic and take my meds and I need that accountability. It is excellent for those kinds of uses. Some people get take homes and they do better with it and that’s okay. But no, methadone does not help with meth meth.

Heather: Okay. Thank you for clearing that up for so many people.

Kelly Lemon: Yeah. I’ve had that question a lot.

Heather: Yeah, for sure. I would love to know Kelly, what is the one thing that you want people to take away from this conversation?

Kelly Lemon: I mean, I think the biggest thing is obviously breastfeeding when you’re stable and safe on medication assisted treatment is safe and important.

My biggest takeaway, I think, is that you, person listening, if you are a pregnant person with an opioid use or any other substance use disorder, you are very valid and you are very important and you deserve all of the same resources and the access to providers and other community health workers that have correct unbiased information.

And then if you feel like you are not receiving like the care and the treatment, that is correct and unbiased, you’re not being difficult by one informing somebody of their bias and their misconception, or two, reaching out and trying to seek out the appropriate information. You’re not lesser than anybody else.

Maureen: Perfect. I love that.

Heather: Hey guys, Heather here with a very special message for you. I wanted to let you know that if you’ve attempted to breastfeed your baby even once or began pumping after an unexpected postpartum complication, you’ve taken the first step to a beautiful journey. I also want to let you know that you can breastfeed no matter what kind of labor you had, no matter what kind of baby you have, no matter what kind of job you have. There is a way to breastfeed that can work for you.

The thing that I really want to get across here is that the fear of what if I don’t have what it takes to breastfeed? What if people think I can’t do this? What if I fail? What if I can’t do my job? What if I’m not enough? Here’s the truth. Everyone has those thoughts, but some people push through and succeed at breastfeeding anyway.

So what’s the difference? Consistent support. Yeah. Consistent support is the linchpin in the breastfeeding plan. Having support available to help you through the natural hiccups of feeding your baby is essential to decreasing that anxiety and making those doubtful voices in your head disappear.

Throughout the pandemic I’ve been accepting virtual, private lactation clients to meet people where they are, despite the crazy circumstances with COVID. At first, I honestly wasn’t sure how it would go, but as it turns out, it was better than ever. I’ve decided to continue doing virtual consults and help people all over the world.

As an IB CLC, I hold an international certification and breastfeeding is a universal language. If you find yourself needing that personal support and would like to work with me one-on-one, you can schedule at your convenience at my link in the show notes, or by going to

Let’s get you to where you want to be with breastfeeding and start asking new questions. What if I succeed? What if I can breastfeed and do my job? What if you are enough? What if it works? We got this.

All right. Well, that was an awesome interview with Miss. Kelly Lemon, nurse midwife. I am so thrilled that she finally cleared up a lot of those misconceptions for us. I really hope you all got a lot out of that. Before we let you guys go, we have to do an award in the alcove.

Maureen: All right, hit me with it, Heather. Who’s it for today?

Heather: I’m going to give this to Rachel Z. She says, I know I can’t really explain to anyone else that will understand, but this breastfeeding group. We’ve made it nine months. My little one is so busy during the day, and he has gotten used to getting bottles at daycare so we’ve been doing bottles and pumping during the day, mostly, but still nursing at night.

I’m going through a divorce with a very unsupportive person, especially when it came to breastfeeding. So for me to still be able to breastfeed and put him down for bed every night is just the greatest blessing. He actually just randomly went on a nursing strike and I’m constantly having to change it up.

I was worried he wasn’t going to nurse to sleep anymore so I was preparing myself to be done. But yesterday and tonight he did. I’m just cherishing these nights before March 4th. That’s when I don’t get him every night. So until then I’ll keep rocking, nursing him, and praying over him every night.

Rachel, I’ve been through it myself. I actually went through a separation and divorce while I was breastfeeding and my son also went on a nursing strike, but guess what? I did not persist through it. I did not have the right information or support. So the fact that you persisted through a nursing strike, despite all of the stress in your life is absolutely incredible.

And I have worked with patients in the past who have gone through a divorce while breastfeeding, and we’ve managed the pumping situation on the off days and it is absolutely possible. So thank you for sharing that and for being an inspiration to so many other people who are vulnerable and going through this difficult time. We’re going to give you the Girl With Some Grit Award.

Maureen: Yes, I like that because it takes a lot of grit to persevere through nursing strikes, divorce, pumping, all kinds. Like all of that is a lot.

Heather: Yeah, it’s actually too much, if you want to know the truth. No one should ever have to do it, but you are doing it. And I used to tell people all the time when they’d say, oh my gosh, how are you doing it?

And I used to, snarkily say, well, it’s amazing what you can do when you have no choice, right? So, you know, good job. We are here for you if you need anything. And we’re very, very proud of you. And thank you so much for your participation in the Breastfeeding for Busy Moms, Facebook support group.

Maureen: And thank everybody out there for listening to another episode of the Milk Minute Podcast.

Heather: The way we change this big system that is not set up for lactating families is by educating ourselves, our friends, and our children.

Maureen: If you guys want to learn more, if you want behind the scenes information, special merch, all kinds of stuff, you can head over to our Patreon at to become a VIP member.

You can join us for just a dollar a month on Patreon, but if you’re not able to do that right now, that’s okay. What we would really love is for you to tell one friend about this podcast. That helps us. It helps them. Win-win.

Heather: Win-win. Value for value. We love you guys. Kiss your babies for us and thank you for tuning into another episode.



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