Pregnancy and Addiction Treatment

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Pregnancy and Addiction Treatment

By Jeanene Swanson 10/29/14

The number of pregnant women who receive treatment for substance abuse is shockingly low, but options do exist.

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According to recent nationwide data from SAMHSA, 11.6% of pregnant women aged 15 – 44 years old used alcohol, while 17.3% used tobacco, 6% used prescription medications, and 4.3% used illicit drugs.

Using any amount of alcohol or drugs while pregnant can harm the unborn baby. Risks include premature delivery, low birth weight, neurological and congenital problems, increased chance of SIDS (sudden infant death syndrome), developmental delays, higher likelihood for neglect or abuse, as well as mental health and substance abuse problems as the children age.

While scare tactics abound—the recent Tennessee Pregnancy Criminalization Law would charge a pregnant mother with aggravated assault if they have a pregnancy complication due to the use of illegal narcotics or if the child is born addicted to or harmed by the narcotic drug. Research has shown that providing comprehensive drug treatment and prenatal care for mother and child significantly improves birth outcomes and the child’s development. Contrary to what some believe, pregnant women who are dependent on substances of abuse can—and do—deliver healthy babies.

Treatment trends

Unfortunately, the number of pregnant women who receive treatment for substance abuse is shockingly low. According to data from the 2013 Treatment Episode Data Set (TEDS), the number of pregnant women between 15 to 44 years who were admitted to substance abuse treatment facilities hovered between 4.4% and 4.8% from 2000 to 2010.

While statistics are hard to come by for the number of women, pregnant or otherwise who seek treatment and don’t receive it; or the number who simply don’t seek treatment but need it; the most is known about those women who have received substance abuse treatment services through publicly-funded programs. Research indicates that women treated in these programs are likely to have co-occurring mental health disorders, experienced trauma as a child and/or adult, be on Medicaid or lack health coverage, be impoverished and/or lack stable housing, experienced partner and/or community violence, and have legal problems.

The truth is, not everyone needs treatment to get off drugs—and most don’t get it, pregnant or not. According to Dr. Margaret Chisolm, former director of psychiatry and former co-medical director of the Center for Addiction and Pregnancy (CAP) at Johns Hopkins Bayview Medical Center in Baltimore, “We know that only 10% of people who are using substances that need treatment are accessing treatment,” she says. “I think pregnant women are more likely to access treatment because they’re more motivated to get help. They’re interested in the health of the child and not having the child taken away from them.”

Drugs of choice

While data dating back to 1999 shows that among admitted pregnant women, cocaine, alcohol, and opiates were the most popular drugs; more recent data from the 2013 Treatment Episode Data Set (TEDS) found that among pregnant admissions, alcohol abuse decreased from 46.6% in 2000 to 34.8% in 2010, and drug abuse increased from 51.1% in 2000 to 63.8% in 2010.

According to Dr. Hendree Jones, Executive Director at the University of North Carolina (UNC) Horizons substance abuse treatment program for pregnant women, about 40% of the women who are treated there are dependent on opioids—mostly prescription Vicodin and Oxycontin. She says that both at her program and in the state of North Carolina, they are seeing an uptick of use of IV heroin. They also still see cocaine, at about 30-33%, alcohol at about 30% and “a smattering of benzodiazepines, marijuana, and poly-substance abuse.” She says that of all the substances known to have deleterious effects on the fetus, “alcohol and tobacco are the worst.”

Barriers to treatment

Pregnant women face additional barriers to substance abuse treatment than the average user. Many need intensive treatment, but few treatment programs provide the necessary programs and aftercare. Many traditional residential programs don’t want the liability of treating pregnant women. Pregnant women face increased societal stigma, fear they will lose custody of their children, lack access to gender-specific treatment, lack insurance coverage for aftercare, and lack childcare and/or transportation.

The National Survey of Substance Abuse Treatment Services (N-SSATS) reported that in 2011, of the 13,720 substance abuse treatment facilities in the US, only 12.7% of these were programs for pregnant or postpartum women, and a mere 3.9% had residential beds for their clients’ children.

Treatment options

If women opt to find treatment, how do they? “Part of the challenge of answering that question, which is seemingly so simple, is that it’s so community dependent,” Jones says. The main way is through word of mouth—and even then women might not get a bed at the facility without having to wait. There are only 21 programs in North Carolina, for instance, that serve pregnant women.

Most women are eligible for the Children’s Health Insurance Program (CHIP), and Medicaid covers many low-income mothers. “I think most women are aware if they don’t have money, they are eligible for insurance,” Chisolm says. “Most of our women have been pregnant before—sometimes it takes losing custody of their first child to get motivated.”

Once accepted to a program, the process of treatment is not mysterious. At UNC Horizons, Jones will do a six-pronged evaluation that aims to review the whole person, looking at physical factors, psychological factors, readiness for treatment, social factors, level of intoxication or withdrawal stage, and access to recovery support. After the assessment, she’ll direct the patient to the appropriate care, which can include detoxification in a hospital and then residential treatment for the most intensive needs, or outpatient for less severe addiction.

Opioids on the rise

Use—and abuse—of opioids is rising among pregnant women. In the past decade, the use and misuse of prescription opioids (codeine, hydrocodone, and oxycodone, for instance) by pregnant women has increased “dramatically” from 1.2 per 1000 hospital live births in 2000 to 5.6 in 2009. Neonatal abstinence syndrome (NAS) incidence increased from 1.2 to 3.4 per 1000 hospital live births.

Two studies published this year showed a noticeable increase in prescription opioids to pregnant women. In one study from Brigham and Women’s Hospital and Harvard Medical School, almost 23% of the 1.1 million pregnant women on Medicaid filled an opioid prescription in 2007, up from 18.5% in 2000. In another study from Harvard, researchers found that 14% of privately insured pregnant women filled a prescription for opioids. What’s as alarming is that doctors are prescribing these pain medications to pregnant women even in light of several studies that have shown their use during pregnancy to be associated with birth defects.

Dispelling myths: detox and opioid replacement medications

There are a lot of myths surrounding medically-assisted treatment, including detox, opioid replacement medication, and NAS.

First, most doctors would agree that using replacement medications—namely methadone or buprenorphine—during pregnancy is safer than detoxing and risking miscarriage, or relapsing and not getting any prenatal care. “People think the baby will suffer because of the symptoms associated with the child,” says Dr. Steven Margolies, the medical director at Phoenix House in New York City. “It’s safer than detoxing in utero, which can kill the fetus.”

While there’s limited data for detoxing from opioids, “one thing we do know is that it is possible to safely detox from opiates during pregnancy during any trimester, if it’s done in a controlled, slow [or] gradual taper,” Jones says. In a recent paper, she emphasized “research strongly supports maintaining pregnant women on opioid-agonist pharmacotherapy throughout pregnancy and the postpartum period.”

Chisolm also advocates for the pregnant mother to be maintained. At CAP, which specializes in treating pregnant women dependent on opioids, they will send mothers to an off-site hospital only when they need to detox from alcohol or benzodiazepines. These are the most dangerous drugs to withdraw from because of the risk of seizures. Some of her opioid-dependent women request to be detoxed, and Chisolm is not necessarily opposed to this. “The only time we wouldn’t is a few weeks of their due date,” she says. They can also do it early in the pregnancy, but she doesn’t recommend it. “It’s recommended to be on medication-assisted treatment during pregnancy because the women who are not usually end up using illicit drugs and not getting prenatal care and [having] worse outcomes.”

NAS

Each year, an estimated 400,000 to 440,000 infants (10 to 11% of all births) are affected by prenatal alcohol or illicit drug exposure. That’s not to say that all of them will have NAS, a treatable condition that includes withdrawal symptoms in the infant. While mothers who detox and recover before delivering their babies are for the most part protecting their babies from NAS, “I don’t think that there are any guarantees,” Jones says. It’s likely that if the baby hasn’t been exposed several weeks before giving birth, the chance of it having NAS “will be minimal.”

NAS is scary, but it’s not life-threatening if it is appropriately diagnosed and treated. “So much of the severity of NAS has to do with the way that we identify it and the way that we treat it,” Jones says. “We know that NAS with benzodiazepines…is an expected complication following prenatal exposure but it is also treatable,” meaning the long-term consequences of NAS are actually minimal in this case.

In fact, Chisolm says, smoking during pregnancy—90% of her women do—carries much more risk than any illicit drug use. “What is labeled at NAS, a part of that may be withdrawing from nicotine,” she says. “We don’t know for sure that all the babies being diagnosed with NAS are really having signs and symptoms specific to opioid withdrawal.”

This isn’t to undercut the toll NAS can take. Chisolm says that about two-thirds of babies exposed to opioids during pregnancy end up having withdrawal, and about half of them need medication treatment. “Yeah, it’s a bad thing, you do not want to have your baby not treated,” she says. “Is it that bad when they’re getting medication for it? Probably not, because they’re getting treated for it to make the withdrawal slow.”

Challenges

One of the most discussed issues these days is criminalizing drug use instead of treating it as a medical disorder. That’s probably exemplified best in the new law passed in Tennessee that would charge a woman with aggravated assault if she tests positive for drugs during her pregnancy. Most doctors agree that this is a health issue—and one of primary concern for pregnant women, most of whom don’t have access to comprehensive drug and prenatal treatment; punishing women is not the answer.

“It shows a lack of understanding of the narrowing of choice in substance use disorders,” Chisolm says. “There has to be some volitional component involved. I don’t think they’re making that choice.” Especially for women seeking medication-assisted treatment, she says, “they made the right choice.”

“I don’t think we can legislate our way out of this health issue,” Jones says. “The best way to address this problem is to have better and more access to treatment.” It’s also time to start asking the hard questions. “What are the structural drivers of this increase in opioid use disorders, which is driving NAS? What’s changed in society to change our perception of risk?”

Another challenge is the fragmented nature of the insurance system, which both refuses to pay for certain necessary aspects of treatment and cuts funding for aftercare. “We provide so many services that we don’t receive reimbursement for or grossly inadequate reimbursement for,” Jones says, like transportation to and from group therapy sessions or child care during these sessions. “The connective tissue to making treatment work is not reimbursed.”

Aftercare is a big problem, too. “Compliance is the most challenging—comply with medication, with their obstetrician/gynecologist, making all the appointments and keeping to the treatment plans, are the toughest challenges,” Margolies says.

“The biggest challenge is not having a seamless continuity of care for after they leave the program,” Chisolm says, and this includes gaps in insurance, finding long-term housing for mothers and their babies, and continuing psychiatric care. In fact, addressing trauma that led to substance use in the first place is key to long-term recovery. “Every single woman I’ve seen had some kind of trauma in her life,” Jones says, and that usually ends up revolving around a relationship with a man. “[It’s necessary to help] women understand the role that trauma has played, to know they deserve better.”

Jeanene Swanson is a regular contributor to The Fix. She last wrote about substituting addictionserasing your traumas and alcoholism and genetics.

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Jeanene Swanson is a science journalist who specializes in mental health and addiction. As a science writer with a background in biotechnology, she enjoys turning complex subjects into stories that everyone can understand—and apply to their lives. You can find Jeanene on Linkedin.

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