Addictions Advisor: Pregnancy and Substance Use — Unveiling the Myths
By Iris Jones, LPC, LCADC, CCS, NCC
Social Work Today
Vol. 20 No. 5 P. 8

“I don’t understand how she is pregnant and still using.” Throughout our different disciplines and professional workspaces, we’ve all heard these whispered words—words tinged with anger and blame or even genuine confusion when encountering a pregnant woman struggling with substance use. Common reactions of condemnation for her and sympathy for the unborn, coupled with judgmental phrases, keep this vulnerable population ostracized from the comprehensive care they desperately need.

Scope
The number of women struggling with opioid use disorder (OUD) has more than quadrupled since 1999 (Haight et al., 2018). The toll this disease is taking on maternal and neonatal outcomes is startling. The opioid epidemic is causing mass destruction, and the belief that pregnant women are immune is dangerous. These figures do not include the use of other substances such as benzodiazepines and methamphetamines, which also appears to be rising. They do not include alcohol or nicotine use, the most commonly used substances in pregnancy, both of which have known detrimental effects.

Maternal substance use affects families and communities and has broad-reaching consequences for government and economic systems. Families are unable to support those with substance use disorders (SUDs) and care for newborns. Communities lack infrastructure, funding, and resources to address addiction, mental health, and trauma. Financial ramifications are astounding and continuing to escalate. Between 2004 and 2014, U.S. hospital costs for the treatment of babies with neonatal abstinence syndrome totaled more than $3 billion (Winkelman et al., 2018). Child welfare systems struggle to manage these cases with overburdened foster care systems.

Despite new laws and funding, the rates of maternal substance use do not seem to be waning. The number of children in foster care has continued to increase over the last five years, with the majority of children removed for neglect or parental substance use (U.S. Department of Health and Human Services, 2018). Overdose rates are not decreasing significantly and continue to increase in some states.

The honest question is: Why aren’t pregnant women with SUDs getting help? However complex the answer, there are a few clear barriers that must be surmounted: stigma, fear of retribution, lack of access to evidence-based treatment, and a lack of innovative ways to support family unification.

Stigma
There are few subjects as controversial as the ethics of actions that affect the unborn. The notion that a mother would intentionally harm her unborn child by using substances elicits extreme reactions. Professionals have historically shied away from working with those struggling with addiction, justifying substance use as a problem of the “deserving,” the morally bankrupt, or impoverished/minority communities.

The crack epidemic of the 1980s resulted in the influx of “crack baby” propaganda into mainstream media. This media attention did not generate concern, funding, or resources for an illness that was disproportionately affecting urban African American communities. Instead, punitive laws with disproportionately inflated mandatory minimums, overpolicing, and mass incarceration served as the decided form of treatment. Stigma was deemed appropriate and even expected. Shame was considered an avenue to motivation, and punishment a necessary means to an end.

The current opioid crisis, an epidemic that followed the overprescribing of opioid pain medications, affected more white, middle-class families. Treatment now prevails as the optimal path. Drug courts have surged, and there is finally recognition that stigmatizing individuals with SUD does not increase the likelihood of recovery. Stigma-free campaigns launched by state governments and billboard marketing remind the viewer that anyone can experience addiction.

Despite this push to normalize SUD and destigmatize medication for addiction treatment through such methods as medication-assisted treatment (MAT), pregnant women are often excluded from this effort. Professionals and families alike hurl shameful accusations at this already vulnerable population and struggle to understand why women cannot discontinue their use. “Think of your baby” is the pregnant equivalent of “just say no,” a patronizing, unrealistic description of the true struggles that encompass the disease of addiction.

Access to Treatment
The stigma of SUD is so pervasive that many health care professionals do not provide care for this population. For the perinatal population specifically, stigma is compounded by fears of liability and a dearth of resources, further limiting treatment availability. Inpatient programs screen for pregnancy at entry, and individuals with positive results are often turned away with referral to a specialized programming or the local emergency department. Specialized residential programs, often termed “mommy and me” programs that house pregnant women and women with young children while providing intensive medical, addiction, and mental health care, are few. Only 10 states have laws in place that prohibit publicly funded drug treatment programs from discriminating against pregnant women (Guttmacher Institute, 2020).

Beyond provider availability and lack of treatment infrastructure, access to the basic, life-saving medications for the treatment of OUD is limited. The overregulation of medications such as methadone and buprenorphine, the recommended treatments for OUD (Substance Abuse and Mental Health Services Administration, 2018), restrict access even further.

Methadone for the treatment of OUD can be obtained only from a federally regulated opioid treatment program. Buprenorphine, which can be prescribed in an office-based setting, requires the prescriber to have a special Drug Enforcement Agency–issued x-wavier, which sets limitations on the number of active prescriptions the prescriber can write. The x-waiver and the strict regulations surrounding buprenorphine have been demonstrated to be major barriers to primary care providers opting to offer this treatment. These restrictive regulations do not exist for the prescribing of more dangerous opioids, such as oxycodone or morphine, and serve not as a protection but as a further barrier for patients to receive the medications used to treat OUD.

Pregnant women often cite several failed attempts at treatment prior to accessing help. Even those with insurance face access challenges when insurance companies refuse to cover necessary services or require prior authorizations that delay treatment and create excessive administrative burdens. Pregnant and parenting women also face traditional barriers such as childcare, transportation, and insurance coverage, which, when combined with the lack of available services, all but ensure that the women who need treatment will not receive it.

Fear
If the stigma and limited treatment options are not enough to make care inaccessible, legitimate fear of prosecution, mandated reporting laws, and the involvement of the child welfare system often seal the deal. According to the Guttmacher Institute (2020), 23 states consider perinatal substance use to be child abuse and three states allow for civil confinement.

When a pregnant woman asks for help, it can be used to terminate her parental rights and in some states could land her behind bars or in mandated inpatient treatment. Laws that criminalize substance use in pregnancy do not result in women receiving the care that they need. Cases such as Ferguson v. the City of Charleston and Beltran v. Loenish et al., exist decades apart but still reveal the same important information: Criminalizing substance use in pregnancy is more harmful then helpful. The notion that a woman needs to be confined in order to protect her unborn child is not only a myth but also is a human rights violation.

Antiquated child welfare systems created to investigate abuse and neglect struggle to accommodate new substance use referrals. Most child welfare workers lack training in SUD treatment and are unable to effectively partner with families to make informed decisions about the best options for their children. Community parenting models that support safe parenting without restricting a mother’s access to her children are extremely limited. As they are currently structured, the legal and child welfare systems fail to support the mother-infant dyad, resulting in separations days after birth, a detriment to both the mother and the infant that carries long-lasting negative generational effects.

Innovative Treatment
When pregnant women are given access to comprehensive, compassionate treatment, outcomes improve. Like any chronic disease, SUD requires appropriate medications and behavioral change. No one protocol can ensure every patient does well every time. Those statistics just do not exist in medicine. However, programs that include MAT, trauma-informed care, therapy, and prenatal care and that emphasize patient autonomy are more likely to be successful.

Obstetric concerns can be mitigated with access to MAT and appropriate medical care. Addressing the social determinants of health also improves outcomes.

With regard to neurodevelopment, a healthy home environment is more important than intrauterine exposure to opioids (Ornoy et al., 1996). Withdrawal in newborns, known as neonatal abstinence syndrome, is a treatable condition and protocols, such as the one developed at Yale by Matthew Grossman, MD, reduce the need for pharmacotherapy and highlight the importance of breast-feeding and the mother-infant dyad.

Final Thoughts
“Perinatal substance use disorders are treatable conditions, and not offering the evidence-based, life-saving treatment that is available is a violation of the core ethics of medicine. By creating systems of care that preserve family unity and offer nonpunitive, long-term, evidence-based care, we will see improved outcomes that have lasting effects well beyond the walls of our clinics,” says Kaitlan Baston, MD, who oversees Cooper University Health Care’s Center for Healing, which houses one of the most robust perinatal addiction programs in New Jersey.

Patient outcomes improve when there’s a focus on motivational interviewing and treatment strategies such as nonpunitive engagement and harm reduction are utilized. The idea that practitioners are not accountable for such poor outcomes with this population may be the most dangerous myth of all. When practitioners support patients by meeting them where they are and assist them in achieving patient-driven goals instead of penalizing them for perceived wrongdoings, we set the stage for a relationship dynamic that fosters change and promotes healing.

Eliminating stigma, increasing treatment access, advocating for policy change, and respecting autonomy are not mere suggestions for improved outcomes but are our responsibility as providers.

— Iris Jones, LPC, LCADC, CCS, NCC, manages the clinical operations for the Cooper Center for Healing and provides oversight for the perinatal clinic, emergency medical services, and Bridge programs. In 2016 she began working in Cooper’s Addiction Medicine department as a behavioral health therapist, where she has worked to develop and implement the perinatal addiction clinic, individual, family and group therapy, as well as hospital consults and protocols. She is the owner and CEO of Wellness Clinical Innovations, a training and development firm focused on organizational development and positive systems change.

References
Guttmacher Institute. (2020, September 1). Substance use during pregnancy. https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy

Haight, S. C., Ko, J. Y., Tong, V. T., Bohm, M. K., & Callaghan, W. M. (2018). Opioid use disorder documented at delivery hospitalization — United States, 1999–2014. Morbidity and Mortality Weekly Report, 67(31), 845-849.

Ornoy, A., Michailevskaya, V., Lukashov, I., Bar-Hamburger, R., & Harel, S. (1996). The developmental outcome of children born to heroin-dependent mothers, raised at home or adopted. Child Abuse & Neglect, 20(5), 385-396.

Substance Abuse and Mental Health Services Administration. (2018). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants. https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf

U.S. Department of Health and Human Services. (2018, November 8). AFCARS report #25. https://www.acf.hhs.gov/cb/resource/afcars-report-25

Winkelman, T. N. A., Villapiano, N., Kozhimannil, K. B., Davis, M. M., & Patrick, S. W. (2018). Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014. Pediatrics, 141(4), e20173520.