Expand Perinatal Treatment and Support for People with SUDs

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Introductory Paragraph

The National Institute of Health haas documented that almost 6% of pregnant people used illicit substances, 15.9% endorsed using tobacco, and over 8% drank alcohol. [1] This accounted for well over a quarter of a million infants exposed to illicit substances in utero, over half a million exposed to alcohol, and one million exposed to tobacco. [2] The detrimental impact of prenatal substance use continues to be a public health concern. Pregnant people who use substances are highly stigmatized by medical professionals, family members, and society. Stigmatization often leads to isolating and not getting proper prenatal care. [3] Lack of prenatal care, or inconsistent care, can cause more health problems for the mother and unborn child. These facts call for increased interventions for those of childbearing age before they become pregnant in order to reduce the number who develop a substance use problem during pregnancy.

It is extremely important for infants to be well-nourished and well-cared for the baby to thrive. While this is critically important to both mother and baby, making healthy choices isn’t so clear-cut for some pregnant people. Those who become pregnant while facing a substance use disorder face great challenges in caring for their body and the baby they are carrying. Substance use at any time, but especially during pregnancy, is a highly stigmatized issue which has worsened over the decades. [4] Substance use during pregnancy can have detrimental health effects on the baby and the mother, but the stigma may prevent the mother from seeking prenatal care or substance use treatment. [5].

Most doctors recommend that pregnant people with a substance use disorder undergo a long-term treatment plan called drug-assisted stabilization using Methadone. This harm reduction therapy remains financially sustainable after birth, because it is covered under Medicaid. So they can still access the treatment, even after their six-week Medicaid-provided postnatal care is done. In addition, the treatment does not subject the mind and body to the stress of full withdrawal, allowing her to focus on caring for herself and her baby.

Key Information

Statistical Prevalence

The CDC reports that the most commonly substances used during pregnancy include tobacco, alcohol, marijuana, and opioids, each carrying its own risks. [6] The prevalence of alcohol and substance use amongst pregnant people is a growing problem, with 10% using alcohol and 4.5% reporting binge drinking during pregnancy. Of these, 40% also reported using one or more substances, the highest of which is tobacco, and 5% reported use of illicit drugs. [7] The majority of use occurs during the first trimester, a vulnerable phase for the baby, making intervention during the first trimester a critical time frame to minimize potential harm.

Risk Factors

While substance abuse occurs within every demographic, there are certain factors which create higher risk of use during pregnancy. It is important to note that demographic data collection is scarce, should be taken as a “minimum” amount, and is highly biased based on policies that disproportionately threaten young ages and people of color and low socioeconomic status. Most available data are taken from enacted policies, discussed below, which are meant to deter prenatal substance use but instead promote maternal prosecution. [8] [9] The following reflects non-prosecutorial risk factor data indicating categories of being high risk to use substances while pregnant: [10] [11] [12]

  • ages 15-24
  • education level high school or below
  • at or below the poverty level
  • concurrent psychiatric disorders (mood/anxiety & eating disorders most common)
  • history of trauma (childhood or adulthood sexual/domestic/interpersonal abuse)
  • poly-substance use
  • family history of substance use
  • people of color and those on public health insurance had higher rates of prenatal substance use [13]


Best Practices in Treatment and Therapy

Despite the fact pregnancy motivates some people to begin treatment, several studies indicate that pregnant people do not remain in treatment as long. Researchers have also linked retention to the stage of pregnancy and if the individual has co-occurring psychiatric disorders. Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for people and their newborns to support a sustained recovery as well.

Offering holistic, integrated support for pregnant people with substance use concerns is an emerging best practice to support pregnant people with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated-support models can improve maternal and fetal outcomes and successfully support people to reduce alcohol use in pregnancy. [14] Best practices should take the following approaches into consideration:

  • Evidence-Based Practice (EBP) is increasingly becoming more popular in many health care disciplines. One of its main characteristics is its focus on the interaction between hard scientific evidence, clinical expertise, and patient needs and choices. There are many different EBPs that are effective, including traditional programs (which center around the pregnancy period), comprehensive treatment, and home visitation. Contemporary approaches include newer methods such as motivational interviewing and contingency management. They concentrate on the mother-infant relationship, collaboration among social service systems, including child protective services and family treatment drug court, and pharmacotherapy. [15]
  • Mental Health. Mental health care is an integral aspect in treatment of substance use disorder. There is a need to increase identification of co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders. Integrated treatment for co-occurring disorders differs from traditional approaches. For example, this would mean that there are assessments provided that screen for both mental illness and substance use. [16] Behavioral therapies help to discover what may have prompted initial drug abuse, and they can teach participants new ways of thinking which will promote future healthy behaviors and habits. Another benefit for pregnant people is that counseling can help teach them how to manage childbirth and the pain and medical concerns which might occur during pregnancy and in childbirth. Creating a plan for these potential difficulties in combination with addiction treatment can be helpful. For example, after childbirth, pain medications may need to be monitored or switched for non-habit-forming ones. Such relational approaches take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.
  • Trauma-Informed Approaches include screening and assessing people for trauma history. Many pregnant people with SUDs have experienced trauma which was perpetrated by someone close to them. This contributes to their treatment needs.[17]
  • Integrated Treatment and Coordinated Care works with the whole person, including their family and parenting responsibilities. Integrated treatment programs include on-site pregnancy services, parenting services, or child-related services with substance use services. These were developed to break the intergenerational cycle of substance use, potential child maltreatment, and poor outcomes for children. Collaborative care models offer a multidisciplinary approach to clinical care. Connection to psychosocial support services can improve the chances of treatment success for pregnant people with substance use disorders. Additionally, they can benefit from behavioral health referrals, connection with peer and community supports, services for addressing social determinants of health, such as housing or food insecurity.
  • Medication-Assisted Treatment (MAT) is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include Methadone and Buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. MAT provides a whole-patient approach and is a recommended best practice for the care of pregnant people with opioid use disorders. [18] In considering the appropriate medications for pregnant people, Buprenorphine is safer than Naltrexone or Methadone to ensure better outcomes for newborn children.
  • Group-Based Treatment & Peer Support. Comprehensive care includes individual or group therapy sessions. Group sessions may take place with other pregnant people and focus on specific issues for this population. People can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. This serves to provide recognition of cultural expectations and to help improve engagement and retention in treatment programs. In a study using online health communities, 58.5% of the pregnant people in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the online community. [19] Five themes of self-management support needs were identified for online communities
    • information regarding the potential adverse effects of gestational opioid use
    • protocols for self-managed withdrawal
    • pain management safety during pregnancy
    • hospital policies and legal procedures related to child protection
    • strategies for navigating offline support systems.

Relevant Research

  • This website has a literature review in the form of an annotated bibliography on almost 50 topics on substance use during pregnancy. It highlights the main findings on a variety of topics, from prevalence and disparities to impacts and policy implications. [20]
  • This research report suggests that a collaborative, integrated approach to managing SUD in pregnant people provides the best chance to counteract obstacles and minimize or eliminate substance use. A wraparound approach is backed up by evidential research and provides comprehensive services by social, family, criminal justice, social service, medical, and mental health professionals. [21]
  • This article identifies three dominant approaches to antenatal substance use -- contingency management, motivational interviewing, and cognitive-behavioral therapies. It notes that there is little research done on perinatal psychological interventions, but suggests that these practices may have similar benefits in perinatal treatment for substance use. It gives in-depth descriptions and benefits of each modality. [22]
  • This article provides support for use of pharmacotherapy as an effective treatment and lists its benefits. For pregnant people with opioid use, Methadone and Buprenorphine are standard pharmacotherapy. [23]
  • This qualitative study used interviews to explore common factors that motivate pregnant people with SUD to seek comprehensive care during pregnancy and common hesitations and barriers to treatment. [24]
  • This guideline titled "Substance Use Disorder Treatment in Pregnant Adults," contains an extensive review of the literature. It was developed by the New York State Department of Health AIDS Institute in order to establish a statewide standard of care. The goal was to ensure that healthcare providers in New York provide appropriate options for SUD treatment during pregnancy. [25]
  • This article provides recommendations specific to expanding and improving treatment care for pregnant people with opioid use disorder. [26]
  • This literature review is titled, "Psychosocial Interventions for Substance Use During Pregnancy." The author notes the limited amount of research that has been done on MI with this population and focuses on early investigations into the practicality and efficacy of contingency management, motivational support, and cognitive behavioral therapies adapted for pregnant people. [27]
  • This study with medical students in an obstetrics and gynecology rotation documented the benefits of placing students in a residential treatment center for pregnant people. The results of their specialized training showed improvements in assessing and educating patients about substance use during pregnancy compared to those in a regular rotation. [28]

Impactful Federal, State, and Local Policies

Federal. The Family First Prevention Services Act (FFPSA) permits states to use title IV-E foster care funding for children placed in foster care with their parent in a licensed residential family-based treatment facility for substance use. However, few states currently use this funding, due to barriers such as competing priorities and lack of facilities. [29]

States. Policies surrounding pregnant people with SUD vary from state to state. These state-level policy variations include:

  • Reporting and testing requirements
  • Standards for child abuse
  • Grounds for civil commitment
  • Targeted program created
  • Pregnant people given priority access in general programs
  • Pregnant people protected from discrimination in publicly funded programs

There are substantial policy barriers to prenatal substance abuse treatment that have lasting consequences for the mother and baby. Since 2000, the number of states that criminalize prenatal substance use has more than doubled, with 25 states plus D.C. classifying it as child abuse, and the same amount has medical reporting requirements. [30] These laws had the intention of deterring prenatal substance use, but have instead had severe adverse effects. With so few states offering pre-or postnatal drug treatment programs as an alternative to prosecution due to liability issues, many mothers have instead reported self-isolation and avoidance of both prenatal medical appointments and substance use treatments. [31] It is vital to advocate and lobby for states to adopt impactful treatment policy, while also negating or varying the consequences of legal action taken against the mothers. Examples of states which have adopted successful legal policy that focus on pre-natal and post-natal SUD treatment to avoid infant removal and punitive action are provided below:

  • Kentucky and Arizona, while having punitive laws, have also implemented an alternative to immediate criminal punishment, giving mothers 90 days to enroll in a treatment program while also giving them priority access to these programs. This shows promise in preventing continued drug use and infant removal from care.
  • Texas offers prenatal and postnatal health support to people with substance use disorder and access to residential treatment centers for both mothers and their new infants.
  • Montana has allowed pregnant people to seek treatment to avoid prosecution, as long as they maintain active treatment, but it isn’t clear if they provide available pathways.

The National Academy for State Health Policy has published a document titled, "State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder." This provides information on funding streams for state initiatives. [32]

The Guttmacher Institute provides a state-by-state index of policies on substance use during pregnancy and provides information on states that qualify prenatal substance use as child abuse, require reporting, have criminal commitment requirements, etc. This index currently reveals the following: [33]

  • 24 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 states consider it grounds for civil commitment.
  • 25 states and the District of Columbia require health care professionals to report suspected prenatal drug use, and 8 states require them to test for prenatal drug exposure if they suspect drug use.
  • 19 states have either created or funded drug treatment programs specifically targeted to those who are pregnant, and 17 states and the District of Columbia provide pregnant people with priority access to state-funded drug treatment programs.
  • 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people.

Available Tools & Resources

  • SAMHSA has published "A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders." This manual offers best practices on collaborative treatment approaches for pregnant people living with opioid use disorders. It addresses the risks and benefits associated with medication-assisted treatment. [34]
  • SAFE Project:
    • The dedicated website titled "Addiction and Mental Health Resources for Women" includes various resources specifically relevant for support during pregnancy. [35]
    • See the wiki titled "Improve Care for Babies Born Drug Dependent" for more information on babies who are born with Fetal Alcohol Syndrome (FAS) or Neonatal Abstinence Syndrome (NAS) and how they can better receive compassionate treatment/care.[36]
    • Motivational Interviewing (MI) has high potential to help pregnant people who are using substances, because of the choice-space it creates. This is an immediate benefit in relieving the challenges associated with pregnancy and SUD. See the wiki titled "Expand Motivational Interviewing" for more detailed information on this evidence-based practice and how it inspires change for those who are pregnant and struggle with substance use issues.[37]
    • "Have A Safety Plan" instructs drug users on how to create a safety plan to prevent overdoses. [38]
  • Harvard Kennedy School. The Government Performance Lab has published "Supporting Substance-Using Caregivers: Pregnancy, Birth, and Early Childhood" which explores ways to better support substance using caregivers and their families on the journey to recovery.[39]
  • From Research to Recovery Town Hall brings together speakers from across the country to address mental health, substance use and other facets of behavioral and emotional health. One example includes this YouTube titled “Gender & Use, Misuse, Treatment and Recovery," by Dr. Mishka Terplan, MD, MPH, Professor of Obstetrics and Gynecology and Psychiatry and the Associate Director of Addiction Medicine at Virginia Commonwealth University. It addresses how developing addiction to opioids and other drugs vary across gender, and how expectations impact the conception of treatment and stigma around use. [40]
  • The Northern New England Perinatal Quality Improvement Network provides a comprehensive toolkit that includes best practices recommendations, treatment facilitation, screening tools, specific substance information, breastfeeding support, mental health access, social needs assessment, and implementation tools. [41]
  • Drugabuse.com is a website that addresses the benefits of group therapy when led by a trained professional. It includes information on recovery education, social support, and motivation in recovery. It also provides observations on various issues and methods within recovery, such as peer empowerment and healthy coping skills to build a sense of optimism and connectedness. [42]
  • Drug Treatment and Referral Services:
    • The American Psychological Association [43]
    • National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better [44]
    • Maternal, Infant and Early Childhood Home Visiting Program Funding [45]
    • Healthy Safe Children [46]
    • Obstetric-Fetal Pharmacology Research Centers [47]
    • Alliance for Innovation on Maternal Health (AIM) [48]
    • Recovery Research Institute [49]

Promising Practices

  • Center for Addiction and Pregnancy (CAP), at The Johns Hopkins Bayview Medical Center, offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by substance use. CAP is an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile. It provides a comprehensive, coordinated, and multidisciplinary approach to drug-dependent mothers and their drug-affected babies. [50]
  • Dartmouth Hitchcock Medical Center has a perinatal treatment program based upon an integrated care model that includes maternity care, substance use treatment, behavioral health, and pediatrics. It has a participant-driven design that provides SBIRT screening and an 18-week parenting class. Outcome successes include an average gestational age of over 38 weeks, average birthweight in the normal range, and decreased NAS treatment rate. Two thirds of participants remain in treatment postpartum. [51]
  • Centering Pregnancy. While not specifically focusing on issues of substance use among pregnant people, the Centering Pregnancy approach has the potential to cost-effectively improve prenatal and perinatal care among people who may be using opioids or other substances. It is a group approach to prenatal and perinatal care. [52]
  • Colorado. The Special Connections Project provides gender-responsive treatment for pregnant and parenting people who are Medicaid-eligible to maximize the chance of a healthy birth. They provide postpartum treatment services in order to maintain gains made during pregnancy. Special Connections providers offer pregnancy risk assessments, care coordination services, group counseling sessions, individual counseling sessions, health education groups, and residential SUD treatment in a women-only setting. [53]
  • Massachusetts. Project RESPECT (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment) is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and the Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant people and their newborns. [54] 
  • New Jersey. The Child Protection Substance Abuse Initiative (CPSAI) is a program that targets parents engaged in the Division of Child Protection and Permanence. Although only 9% of the participants completed treatment, CPSAI is examining individual factors associated with successful treatment and continuing to facilitate treatment engagement for parents being evaluated by the child welfare system.

[55]

  • North Carolina. Project CARA is housed at MAHEC Ob/Gyn Specialists. It has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. The Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices. [56]
  • Oregon. Project Nurture integrates maternity care with substance use treatment and features coordination between the health care and human services sectors. It integrates care and services to improve outcomes for opioid-dependent mothers and their children. Project Nurture is a team-based approach to prenatal and postpartum care which includes prenatal clinician, a substance use specialist, mental health support, case management, peer support, and parenting resources. Project Nurture provides extended postpartum support for a full year, with integrated pediatric care, ongoing SUD support, and peer support for parenting. It has a strong commitment to a planned, coordinated approach to the inpatient maternity stay, with protocols for pain management, DHS and social work involvement, and discharge planning. The model provides pregnant people with services in an environment which patients view as respectful and nonjudgmental.  It is tracking pre-term birth rates and documenting cost savings. [57]


Sources

  1. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870985/
  2. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4870985/
  3. ↑ https://www.samhsa.gov/data/sites/default/files/report_2724/ShortReport-2724.html
  4. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116049/
  5. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  6. ↑ https://www.cdc.gov/reproductivehealth/maternalinfanthealth/substance-abuse/substance-abuse-during-pregnancy.htm
  7. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  8. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  9. ↑ https://www.drugpolicyfacts.org/chapter/pregnancy
  10. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  11. ↑ https://www.drugpolicyfacts.org/chapter/pregnancy
  12. ↑ https://www-clinicalkey-com.echo.louisville.edu/#!/content/playContent/1-s2.0-S170121631730508X?returnurl=null&referrer=null
  13. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  14. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  15. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/
  16. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf
  17. ↑ https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273
  18. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  19. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335
  20. ↑ https://www.drugpolicyfacts.org/chapter/pregnancy
  21. ↑ https://canfasd.ca/wp-content/uploads/publications/FINAL-CCE_Report_Mar-8-for-web.pdf
  22. ↑ https://www.nursingcenter.com/ce_articleprint?an=00005237-201407000-00006
  23. ↑ https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/what-treatment-available-pregnant-mothers-their-babies
  24. ↑ https://pubmed.ncbi.nlm.nih.gov/31704383/
  25. ↑ https://www.ncbi.nlm.nih.gov/books/NBK572854/
  26. ↑ https://link.springer.com/article/10.1007/s13669-016-0168-9
  27. ↑ https://alliedhealth.ceconnection.com/files/PsychosocialInterventionsforSubstanceUseDuringPregnancy-1414431617928.pdf
  28. ↑ https://pubmed.ncbi.nlm.nih.gov/23154692/
  29. ↑ https://aspe.hhs.gov/reports/ffpsa-room-board-brief
  30. ↑ https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy
  31. ↑ https://healthandjusticejournal.biomedcentral.com/articles/10.1186/s40352-015-0015-5
  32. ↑ https://nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf
  33. ↑ https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy
  34. ↑ https://store.samhsa.gov/product/collaborative-approach-treatment-pregnant-women-opioid-use-disorders/sma16-4978
  35. ↑ https://www.safeproject.us/resource/women/
  36. ↑ https://www.yoursafesolutions.us/wiki/Improve_Care_for_Babies_Born_Drug_Dependent/
  37. ↑ https://www.yoursafesolutions.us/wiki/Expand_Motivational_Interviewing_for_Pregnant_People/
  38. ↑ https://www.safeproject.us/safety-plan/
  39. ↑ https://govlab.hks.harvard.edu/sites/hwpi.harvard.edu/files/govlabs/files/supporting_substance-using_caregivers_vf.pdf?m=1727274424/
  40. ↑ https://www.youtube.com/watch?v=siC6Cd4Q3MQ&t=33s
  41. ↑ https://www.nnepqin.org/a-toolkit-for-the-perinatal-care-of-women-with-opioid-use-disorders/
  42. ↑ https://drugabuse.com/treatment/therapy/group/
  43. ↑ https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf
  44. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  45. ↑ https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview
  46. ↑ https://healthysafechildren.org/trending-topics
  47. ↑ https://www.utmb.edu/nichd-oprc/
  48. ↑ https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim
  49. ↑ https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/
  50. ↑ https://www.hopkinsmedicine.org/psychiatry/patient-information/bayview/substance-abuse/comprehensive-addiction-pregnancy
  51. ↑ https://www.dartmouth-hitchcock.org/about/
  52. ↑ https://www.centeringhealthcare.org/what-we-do/centering-pregnancy
  53. ↑ https://hcpf.colorado.gov/special-connections
  54. ↑ https://www.bmc.org/obstetrics/pregnancy/addiction
  55. ↑ https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/
  56. ↑ https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome
  57. ↑ https://www.healthshareoregon.org/health-equity/project-nurture
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