The Criminalization of Addiction in Pregnancy: Is This What Justice Looks Like?

by Cayce M. Watson, MSSW, LAPSW, MAC and April Mallory, MSW, LCSW, MAC

     Ann is a married 28-year-old female living in the rural south. She has a history of endometriosis, ovarian cysts, and severe migraines. Two years ago, a family doctor prescribed opiates to manage her pain. She recently lost her job and insurance coverage, but is working part time. For several months, Ann has needed more medication to manage her pain. She takes more pills than prescribed because she feels much better after taking them. Ann knows she should not be taking extra pills, and she had planned to get help from her doctor as soon as she got back on her feet and found a full-time job. However, Ann just discovered she is pregnant. She frantically phoned her doctor who prescribed the pain medication, and he insisted she immediately seek detox. Ann has limited means, no insurance, and unreliable transportation. Ann desperately calls nearby rehabs, only to realize that there are few options for her since she is pregnant and has no insurance. Ann is directed to go to the emergency room, and upon arriving, the staff immediately reports her drug use to DCS. She is treated poorly and overhears the staff saying, “What kind of mother would use drugs? She shouldn’t be allowed to have children!” Ann is hurt and fearful she will be charged with fetal assault, go to jail, or lose custody of her baby. She is confused, because she followed her doctor’s orders. Ann is admitted to the hospital detox unit where they contradict her family doctor’s advice and explain detox is unsafe. She is told, “Methadone is the safest option for your baby” and Ann begins the treatment. The medication costs $85 a week and Ann has to visit the clinic, 45 minutes away, every day. Ann returns home and attempts to make her daily appointments, but she is overwhelmed and finds it difficult to get to the clinic every day. Ann begins to miss appointments and is often seen as noncompliant. In addition to feeling as though she is failing her baby, Ann experiences mild withdrawal symptoms when she misses her dose.

    Because she is pregnant, she is granted temporary Medicaid, but she cannot locate an OB-GYN who is comfortable providing prenatal care while she is on methadone. She has learned that her baby may develop neonatal abstinence syndrome (NAS), and she is worried about her upcoming court appearance from the DCS report. Ann feels hopeless and out of options. If she continues methadone, she will need to pay out of pocket after the birth of her child or find detox within 30 days of having her baby before Medicaid drops her. This, coupled with trying to work and preparing to be a mother, creates toxic stress for Ann and her baby. This stress will only increase the risk of adverse birth outcomes.

     Ann’s story is the harsh reality for many pregnant women with addiction to prescription drugs. Pregnant women battling opiate use disorders face multiple barriers when seeking treatment. Barriers include punitive measures, potential incarceration, lack of access to specialized services, conflicting treatment approaches for opioid dependency, and stigma regarding their ability to mother. Social work practitioners must be prepared to handle these barriers and advocate for interventions that preserve dignity and increase options for pregnant women.

    According to the Centers for Disease Control and Prevention (CDC), opioid use is a rising problem for women of reproductive age, with seven out of 10 drug-related overdose deaths including some form of prescription painkiller (CDC, 2013). Females are more likely to receive opioid prescriptions for issues such as chronic pain, and they tend to develop drug dependency faster than their male counterparts (Salter, Ridley, & Cumings, 2015). Prescribing disparities also exist among women living in poverty. On average, 39 percent of women on Medicaid fill an opioid prescription at a pharmacy, compared to 28 percent of women with private insurance (CDC, 2015). Overdose deaths among women resulting from the use of prescription opioids has increased since 2007, and has surpassed deaths from motor vehicle-related accidents—with a “5-fold increase between 1999 and 2010, totaling 47,935 during that period” (CDC, 2013, SAMHSA, 2016).

Neonatal Abstinence Syndrome

    Although prescription opioids are often less stigmatized than street drugs like heroin, they are plagued with the same consequences. In addition to the individual, social, and familial devastation that substance use brings, there are unique risks for pregnant opioid users. Opioid abuse in pregnancy includes the use of heroin and/or the misuse of prescription opioid medications (American Congress of Obstetricians and Gynecologists, 2012). The primary concern is that a baby will be “addicted.” However, this term is misleading and deeply stigmatizing. Addiction has been described as a set of compulsive behaviors that continue despite negative consequences, whereas the withdrawal symptoms in newborns are associated with evidence of only physiological dependence (Newman, 2013). The term for withdrawal in newborns is neonatal abstinence syndrome, or NAS.

    NAS is a result of fetal exposure to certain drugs, primarily opioids, and manifests as clinical symptoms in newborns with withdrawal. Symptoms may include uncoordinated sucking reflexes leading to poor feeding, neurological excitability, gastrointestinal dysfunction, and a high-pitched cry (ASTHO, 2014). Although this outcome is not ideal, it may pose less harm to a pregnant mother and her baby than detoxification or the behaviors associated with high-risk drug use, such as frequent physical withdrawal or exposure to infectious disease, tainted street drugs, criminal activity, or violence. NAS is treatable and anticipated in pregnant women using opioids, including those being treated on methadone (Terplan, Kennedy-Hendricks, & Chisolm, 2015). On average, between 50 and 60 percent of opioid-exposed infants will experience NAS and require some form of pharmacological intervention (Salter Ridley, & Cumings, 2015; ASTHO, 2014).

    Because of the unclear outcomes of opioid detoxification during pregnancy, the current standard of care remains the use of medication-assisted therapy (MAT) during pregnancy (American Congress of Obstetricians and Gynecologists, 2012). However, current research is being done (Bell, et al., 2016) to include detoxification as an option for women. Unfortunately, practitioners across disciplines don’t always agree on best treatment practices, and such ideological disagreement creates conflicts among providers and community resources. This leads to improper or incomplete care for mothers and babies, including pregnant women being treated with non-therapeutic levels of medication to limit exposure to the fetus (Jones, et al., 2008).

Treatment Options

    Methadone has been used for decades to treat opioid dependency, and research shows it to be a safe option during pregnancy. However, one risk includes NAS (Substance Abuse and Mental Health Services Administration, 2008). Another treatment option for women is buprenorphine, which acts on the same receptors as morphine and heroin. This option may provide fewer drug interactions, fewer overdose risks, less severe NAS, and more flexibility in dosing and treatment schedules (ACOG, 2012). Buprenorphine is prescribed by approved and specially-trained physicians in an office setting, and often leads to increased patient compliance and reduced stigma (ACOG, 2012; SAMSHA 2008). In a 2010 study, infants exposed to buprenorphine, as compared to methadone, required an average of 89% less morphine to treat NAS symptoms, a 43% shorter hospital stay, and a 58% shorter duration of medical treatment. These results may support buprenorphine as best practice medication for pregnant opioid-dependent women. However, treatment should be individualized (AGOG, 2012). Ceasing opioid use during pregnancy may result in pre-term labor, risks to the fetus, and loss of pregnancy. Pregnant women who stop using opioids and relapse also have increased risk of overdose (SAMHSA, 2016). Therefore, MAT (Medication Assisted Therapy) is currently considered best practice (ACOG, 2012) but should include both medication and behavioral therapies.

Policy Considerations

    The rise in prescription drug abuse directly correlates with a rise in rates of the NAS epidemic, and this trend is a public health crisis. Further, despite the scientific evidence that addiction is a chronic relapsing condition, fears have prompted legislators in many states to focus their efforts on criminalizing pregnant substance abusers instead of expanding treatment options and increasing training on opioid use and medication-assisted therapies (Salter, Ridley, & Cumings, 2015). Although these laws are made with the intent to protect babies, they can discourage women from seeking appropriate treatment, including prenatal care, and in many instances they fail to rehabilitate the mother by forcing her into a treatment system that is plagued with inadequate resources.

    Additionally, these policies neglect to preserve the dignity and worth of the relationship between mother and baby. Bonding should be promoted by keeping mother and baby together, encouraging breast feeding when possible, and providing space for mothers to “room in” with their babies, providing skin-to-skin contact in a calm environment. In a 2010 study, infants with NAS required less pharmacological therapy and shorter hospital stays when roomed with their mothers on a postnatal unit than when admitted to a traditional neonatal care unit (Saiki, Lee, Hannam, & Greenough, 2010).

    The American Congress of Obstetricians and Gynecologists (2011) states, “Seeking obstetric-gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing. These approaches treat addiction as a moral failing.” A more effective treatment approach requires coordinated community intervention focused not only on the newborn’s health, but the dignity and worth of the pregnant woman. This can be achieved through interagency collaboration with social service providers, women’s health providers, and pediatric care providers.

Recommendations

    We recommend the following to improve individual and community practice.

• Expand and fully fund current policies supporting family-centered residential treatment for pregnant opioid users and access to mental health and substance abuse services.
• Promote comprehensive medication-assisted therapy (MAT), which includes prenatal care, individual and group therapy, resource allocation, psychosocial support, parent-skills training, family education, and standardized scoring for NAS among treatment providers.
• Expand training on screening (SBIRT) for substance use and addiction in pregnancy, as well as reproductive justice among social service providers, medical students, OB-GYNs, and pediatric nurses and physicians.
• Educate elected officials and policy makers on treatment options, and advocate for fair policies that preserve the relationship between mothers and babies by promoting bonding and attachment and discouraging separation.
• Expand Medicaid coverage for one year post-delivery to ensure completion of treatment plan, cover the costs associated with MAT, and continue vigorous opposition to fetal assault laws.

Resources for Working With Pregnant Women

American Congress of Obstetricians and Gynecologists

CDC Guidelines

MAT/SAMHSA

National Advocates for Pregnant Women

Screening, Brief Intervention, and Referral to Treatment

References

American Congress of Obstetricians and Gynecologists (ACOG). (2012). Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. 19, 1070-6.

American Congress of Obstetricians and Gynecologists (ACOG). (2011). Substance abuse reporting and pregnancy: The role of the obstetrician–gynecologist. Committee Opinion No. 473. 117, 200-1.

Association of State and Territorial Health Officials (ASTHO). (2014). Neonatal abstinence syndrome: How states can help advance the knowledge base for primary prevention and best practices of care. [PDF Document]. Retrieved from: http://www.astho.org/prevention/nas-neonatal-abstinence-report/.

Bell, J., Towers, C. V., Hennessy, M. D., Heitzmen, C., Smith, B. , & Chattin, K. (2016) Detoxification from opiate drugs during pregnancy. American Journal of Obstetrics Gynecology, 215, 374. e1-6.

Centers for Disease Control and Prevention (CDC). (2015). Press release: Opioid painkillers widely prescribed among reproductive age women. Retrieved from: http://www.cdc.gov/media/releases/2015/p0122-pregnancy-opioids.html.

Centers for Disease Control and Prevention (CDC). (2013). Prescription painkiller overdose Infographic. Retrieved from: http://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/infographic.html.

Jones, H. E., Martin, P. R., Heil, S. H., Kaltenbach, K., Selby, P., Coyle, M. G., Stine, S. M., O'Grady, K. .E, Arria, A. M., & Fischer G. (2008). Treatment of opioid dependent pregnant women: Clinical and research issues. Journal of Substance Abuse Treatment (35) 3, 245-259.

Newman, R. (2013). Open letter to the media and policy makers regarding alarmist and inaccurate reporting on prescription opioid use by pregnant women. [PDF Document]. Retrieved from: http://advocatesforpregnantwomen.org/Opioid%20Open%20Letter%20-%20March%202013%20-%20FINAL.pdf.

Saiki, T., Lee, S., Hannam, S., & Greenough, A. (2010). Neonatal abstinence syndrome–postnatal ward vs. neonatal management. European Journal of Pediatrics 169, 95-98.

Salter, M., Ridley, N., & Cumings, B. (2015). Tennessee Association of Alcohol, Drug, and Other Addiction Services white paper on implementation of Chapter 820 opportunities to address pregnancy, drug use and the law. [PDF Document]. Retrieved from: http://taadas.org/TAADAS%20White%20Paper%202015.pdf.

Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment (SAMHSA). (2008). Medication-assisted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). A collaborative approach to the treatment of pregnant women with opioid use disorders. HHS Publication No. (SMA) 16-4978. Rockville, MD: Substance Abuse and Mental Health Services Administration. Available at: http://store.samhsa.gov/.

Terplan, M., Kennedy-Hendricks, A., & Chisolm, M. (2015). Prenatal substance use: Exploring assumptions of maternal unfitness. Substance Abuse: Research and Treatment 9 (S2) 1-4.

Cayce M. Watson is a Licensed Advanced Practice Social Worker and Master Addiction Counselor. Her practice experience is in mental health and addictions treatment. She is an assistant professor and Field Coordinator in the Social Work Department at Lipscomb University in Nashville, TN. She has also served as Research Coordinator of a NIH and NIDA funded study concerning opiate use among pregnant women.

April Mallory, MSW, LCSW, is a social worker with many years of experience working within the psychiatric and criminal justice systems. She evaluates impaired physicians as part of the team at Vanderbilt’s Comprehensive Assessment Program and is an assistant professor of practice at the University of Tennessee College of Social Work.