Should Pregnant Women Who Use Drugs Be Punished?

A growing list of states have criminalized pregnant women who use drugs if they don’t seek treatment. These laws are doing more harm than good.

pregnant-bellyThe issue of drug use is fraught with stigma and strong opinions, but no topic causes such lightning rod reactions as pregnant women who use drugs or have drug-exposed newborns. Last week, North Carolina joined a growing list of states that have introduced or passed bills criminalizing pregnant women who use drugs, even punishing them with jail time if they don’t seek treatment. But while the intention behind these laws may be to deter pregnant women from using drugs, they often have the opposite effect, driving a resource-poor population away from treatment and towards behaviors that can further harm mothers and babies.

We believe that when a person is condemned by others, it is harder to make productive change.

April W. of Durham, North Carolina, was seven months along with her third child before she realized she was pregnant. Immediately, she enrolled in a methadone treatment program where she was given a daily dose of methadone to control her cravings for heroin. But stigma made it hard to keep up with the program.

“I was judged a lot for being pregnant,” she said. “In treatment programs there is a hierarchy. People who snort drugs think they are better than people who shoot them. People who use alcohol or pills think they are better than people who use illegal drugs. But pregnant women, no matter what they use, are always viewed as the worst.”

Senga Carroll is the training director at UNC Horizons, a program that provides counseling, case management and medical care to pregnant women with substance use dependency in Chapel Hill, North Carolina. She sees the practical consequences of the condemnation of pregnant women who use drugs.

“Pregnant women with substance use disorders face shaming by health care practitioners and society when they seek medical treatment,” says Carroll. “Hospital staff often condemn the women by saying, ‘The baby is having a hard time because you are a bad person.’ When women feel judged they may lie to health care providers, and [the] lack of information makes is harder to provide the best treatment for the mother and baby.”

Currently, protocols for how to respond to a pregnant woman who may be using opioids, or a baby born with evidence of dependency, vary widely from hospital-to-hospital. Some staff members may even call Child Protective Services to separate the baby from its mother, even when the mother is on medication-assisted treatment such as methadone. Fear of judgment and condemnation drives pregnant women who use drugs underground, away from drug treatment or prenatal care. Some women try to detox off drugs on their own, though the abrupt cessation of opioids can lead to pregnancy complications. Other women opt for home births to avoid hospitals altogether. Home births are risky for babies born with exposure to opiates, as specialized medical care may be necessary to relieve their symptoms.

Part of the misinformation about the effects of drugs on birth outcomes can be traced back to the 1980s when images of “welfare queens,” “dope fiends” and “crack babies” swept the media. The public was whipped into a frenzy of anger against the perpetrators, who were overwhelmingly portrayed as poor minorities. Though scientific studies later debunked the myths of the “crack baby” by demonstrating that cocaine-exposed infants exhibited few to no withdrawal symptoms compared to babies not exposed to drugs, the demonization and criminalization of pregnant women continued. Eighteen states now address drug use by pregnant women in their civil child neglect laws, some even going as far as to make it possible to take away children based on one positive drug test.

Whitney Englander, Government Relations Manager for the Harm Reduction Coalition in Washington D.C., advocates for standardized procedures to help treat women who use drugs instead of exposing them to shaming and stereotypes.

“Just because a woman is pregnant doesn’t mean she can magically overcome a chronic condition,” says Englander. “You can’t overcome diabetes while pregnant, but you can manage it. The same holds true for addiction. There is an opportunity to reach those women because of the pregnancy. We need to make sure that laws aren’t criminalizing them and pushing them further away.”

Unlike the symptoms wrongly attributed to crack (later determined to be caused by poverty and poor nutrition), there are legitimate symptoms in many babies born to mothers who use opiates. These symptoms, called neonatal abstinence syndrome (NAS), include excessive crying, irritability, poor feeding, trembling or diarrhea and occur in about half of babies exposed to opiates in the womb. With a duration typically ranging from one to four weeks, they can be treated through non-pharmacological methods, such as swaddling, skin-to-skin contact with the mother or breastfeeding, or, in some cases, with small doses of methadone or morphine administered over a period of days or weeks.

The symptoms of NAS are manageable and treatable, especially if medical providers are made aware of the situation early. This requires a level of trust between patient and provider. As Senga Carroll explains, simply leaping to the conclusion that all pregnant women who use drugs are bad and should be punished makes the situation worse.

“We believe that when a person is condemned by others, it is harder to make productive change,” says Carroll. “The best way to be helpful is to approach from a stance of non-judgment and figure out a way to address the problem.”

The recommended treatment for pregnant women who use opiates is medication-assisted treatment (MAT), such as methadone or buprenorphine, in the context of broader services such as screening, assessment, a treatment plan and evaluation. But MAT can be controversial. Opponents of MAT often call it a substitution of one drug for another. They point out that half of babies born to mothers who used methadone or buprenorphine treatment while pregnant still exhibit withdrawal symptoms.

For Carroll, such criticism ignores five decades of research that clearly point to MAT as the better alternative to abrupt detox while pregnant.

“Research shows that MAT is extremely important to prevent spontaneous abortion,” says Carroll. “A woman who ceases opiate use abruptly can abort the fetus. To maintain the health of the mother and fetus it is best to engage the mother in prenatal care, substance use treatment and peer support. Medication also reduces cravings for opioids and helps avoid fetal exposure to the highs and lows of active addiction.”

MAT is recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA), the American Society of Addiction Medicine, the World Health Organization (WHO), and the American College of Obstetricians and Gynecologists (ACOG). The 2014 WHO and ACOG guidelines state that “pregnant women dependent on opioids should be encouraged to use opioid maintenance whenever possible.”

Even with support for MAT from scientific research and the majority of the medical community, states continue to introduce bills that punish pregnant women who use drugs. In many cases, misinformation and stigma guide policy more than facts or science.

“This is an emotional issue for people,” says Whitney Englander. “People see babies with withdrawal symptoms and they want someone to blame. But punishing the mother is not best for the baby. A fetus can die if the mother tries to detox quickly because she is ashamed of how people will judge her if she takes methadone. We need to create a standard best practice policy for how to treat pregnant women that is based on science and decades of evidence-based research, not knee-jerk reactions and anger.”

Advocates agree that it will take time, patience and education to convince lawmakers and the public of what the medical community has known for a long time—MAT can help manage the symptoms of opioid addiction and the criminalization of pregnant women who use drugs causes more harm in the long run. Read more “the fix”…


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