Women who are pregnant are a top-priority population for treatment for a substance use disorder (SUD) in the federally funded system. The Substance Abuse and Mental Health Services Administration (SAMHSA) pays for this treatment in two ways: through the $16 million residential grant program for pregnant and postpartum women (PPW) and through the Substance Abuse Prevention and Treatment (SAPT) block grants to states, which prioritize pregnant substance-using women for treatment.
Under the residential grant program, women get residential treatment, but there isn’t enough to meet the demand. Under the SAPT block grant, the women get whatever is available, which may be intensive outpatient or outpatient if there are no residential slots.
For pregnant women who are addicted to opioids, the first line of treatment is medication — either methadone or buprenorphine — as well as supportive treatment, either residential or outpatient.
We talked to SAMHSA about its recommendations, as well as to providers and stakeholders about some of the challenges in the states.
“The SAPT block grant has a woman’s set-aside that makes pregnant and postpartum women a priority population, and that’s in our authorizing legislation,” said Sharon Amatetti, women’s issues coordinator at SAMHSA’s Center for Substance Abuse Treatment (CSAT). The discretionary programs also provide funding.
Whether women should get residential or outpatient treatment should be determined the same way treatment is assessed for all SUD patients, said Amatetti: using criteria from the American Society of Addiction Medicine (ASAM). “Evidence-based practice tells us that women should be screened and assessed using the ASAM criteria, and those criteria drive the level of care that would be appropriate,” she said.
What’s special about SAMHSA’s PPW is that postpartum women can stay with their babies, said Amatetti. Other residential programs may not accommodate this, she said.
Becky Vaughn, vice president for addictions at the National Council for Behavioral Health, agreed. “The value of residential is tremendous when she and the baby are living there on site,” she said. Congress is considering legislation that would add money to the PPW discretionary program, allowing for a step-down to outpatient care, where the woman would still receive recovery support postpartum. This would be added to the PPW program.
However, in the SAMHSA budget request for FY 2017, the plan is for up to 25 percent of residential funding to be used for outpatient, which concerned Vaughn, because that would cut into existing residential programs. The House of Representatives has already agreed to put extra funding into the program to add step-down outpatient; the Senate is “still not sure,” said Vaughn. “Ideally, we’ll get more money.”
NAS and agonist medications
The main challenge for treatment providers comes from policies that criminalize pregnant women who use drugs; these women may be afraid to seek treatment because it could mean loss of custody of their baby and of any existing children, and even incarceration. SAMHSA and the experts we talked to urged treatment providers to help educate the child protective services (CPS) agencies, as well as labor and delivery departments in hospitals, about neonatal abstinence syndrome (NAS) and the importance of keeping the mother and her children together.
One problem that has been escalating with the opioid crisis is the number of babies born with NAS. For women who are in treatment with methadone or buprenorphine, their babies are likely to undergo some NAS after delivery, but it is transient and treatable. Still, some hospitals may end up reporting the mother to CPS, so SAMHSA is “providing technical assistance so that there are no surprises at the hospital,” said Amatetti, noting that this is available to all providers, including opioid treatment programs (OTPs) and office-based buprenorphine providers. “Well in advance of a woman giving birth, all of the social service agencies should have coordinated their effort, not just talking about SUD treatment, but child welfare,” she said. “Sometimes there’s a drug court involved, and there needs to be education during the prenatal period so that everybody knows what to expect,” she said. The National Center on Substance Abuse and Child Welfare, a joint project of SAMHSA and the Administration for Children and Families, both agencies within the Department of Health and Human Services, is providing some of this technical assistance, said Amatetti. In addition, CSAT’s Division of Pharmacologic Therapies can provide technical assistance to OTPs and buprenorphine providers.
Sometimes the woman does not get treatment before the birth, said Amatetti. It’s also important to plan for care for this woman, she said. “When she shows up at the hospital, everyone needs to know what to do,” she said.
Reporting to CPS
While treatment providers must protect the confidentiality of their patients under 42 CFR Part 2, there is nothing to prevent some other health care provider, such as a nurse at the hospital where the mother delivers, from reporting the mother of a baby with NAS to CPS. In fact, that is where most of the reports come from, according to National Advocates for Pregnant Women.
Different state policies regarding mandated reporting to CPS when a baby is born with NAS — or even a report if a mother or pregnant woman has an SUD — make the situation of treating pregnant women complicated for some providers. R. Corey Waller, M.D., director of the Spectrum Health Center for Integrative Medicine in Grand Rapids, Michigan, noted that “in extreme states like Tennessee, the woman can be put in jail, which we all see as draconian and ridiculous.” Waller, who is also SUD medical director of Lakeshore Regional Partners, staff chief of the Division of Pain Management for Spectrum and president of the Michigan Society of Addiction Medicine, said that for women and providers “these realities show up every day, and unfortunately it’s more of a political issue than a medical one.”
It’s good to involve CPS early on when a pregnant woman is in treatment, said Waller. “I treat patients every day with the disease of addiction who are pregnant, and we absolutely do get CPS involved — but in a positive way,” he said. “We all want the same thing — they want the baby to be safe, we want the baby and the mother and the family to be safe.” So Waller tells women: “We don’t want CPS to take your baby, but we want them to help you get the wraparound services that I can’t help you with — to get you extra housing, to get you transportation,” or whatever is needed.
The American College of Obstetrics and Gynecology is strongly in favor of methadone or buprenorphine for pregnant opioid-dependent women, and most obstetricians are on board with it as well, said Waller. But they still need help from the SUD treatment provider with advice for labor and delivery. “We write a birth plan for the OB, including a recommendation for treating pain,” said Waller. “We say what medications she’s on.” And the obstetrician gets this birth plan even if the woman isn’t stable — or if she just comes in twice for SUD treatment and then leaves.
“We train everybody in the hospital, including labor and delivery, and the physicians, so they know what to do,” said Waller. “We ask them to include us.” Waller gets a salary from the health system, and there is no extra fee for this training, he said. “This is what most addiction doctors see as part of their job,” he said.
Breaking the cycle
Waller said that in general it’s better for the baby to stay with the mother, for both mother and child. “Even if she’s not perfect, and maybe has a relapse here or there, there’s no data that says there’s a risk involved with the mom keeping the baby if she’s in treatment,” Waller said. “The foster care system creates attachment disorders for kids — they feel abandoned multiple times.”
And it's a cycle of addiction and trauma that gets handed down from mother to child unless someone stops it, said Waller. Many child protective services workers, as well as judges, “make an emotional decision instead of a pragmatic one” in removing the child. “If they looked at the early life trauma that many of these moms had, they would be a lot less aggressive,” he said. Allowing the mom to stay with her baby facilitates her recovery and helps break the cycle of passing addiction to the next generation, he said. “I still have to treat mom, and I have to deal with the massive amount of guilt and suicidality,” he said. “If you want to really destabilize a mom, take her baby away.”
While the job of CPS is to protect the child, the job of the addiction treatment provider is to protect both child and mother, he said. “We should be working together as a team, because CPS can do an evaluation and then decide to close the case prior to going to a judge,” he said.
It’s even more difficult to educate the criminal justice system, said Waller, but it’s important. “I still have judges who refused to even talk to me,” he said. “I see that as an ego problem.”
Full range of options
Pregnant women with SUDs have a unique set of needs from the general population with SUDs, said Mishka Terplan, M.D., medical director of Baltimore's behavioral health system in Maryland. “But the principles of the system of care should be the same — there needs to be a full range of options for anyone with an SUD, and they need to be in a setting that is appropriate for their disease state until they are stable and in recovery.”
Many pregnant women with SUDs have far more negative backgrounds than pregnant women without SUDs, said Terplan. They are far more likely than the general population to have suffered childhood physical or sexual abuse, and they are more likely to be in a violent relationship, he said. On top of this, they often have other children and are single mothers. “So what their treatment looks like should reflect their unique set of needs,” he said. “That’s why residential services have been pushed for this population.”
In some ways, Terplan thinks residential treatment makes more sense for pregnant women than for most other women, but he also said residential treatment is overutilized and expensive.
“There are jurisdictions in Maryland that have very little money and are putting it all into one small residential program,” said Terplan. “There’s nowhere local to go for intensive outpatient.”
The idea of using the ASAM levels of care, allowing women to move between them, is a good one, said Terplan. “But there are very few places that function that way. In reality, the kind of care people get is the door they walk through,” he said.
One problem with residential is that it’s “artificial,” said Terplan. “People’s behaviors change when they’re not in their regular environment — they have to go home sometime, and then what?”
The bottom line is that treatment should be individualized, said Terplan. “I’ve taken care of women for whom residential would be the worst option. The working mom, who is pregnant and has an opioid use disorder — taking her out of all that is wrong,” he said. “Office-based buprenorphine would be best for her.” But there’s a problem there, too: many buprenorphine physicians won’t take a pregnant woman, he said. “Also, that’s just a medication, and it doesn’t speak to any of the other treatments she might need,” he said.
Finally, alcohol use disorders still predominate. For alcohol use disorders, treatment is primarily behavioral, said Terplan. And the setting would depend on the severity of the illness. Ultimately, some people do have a need for housing — they are homeless or marginally housed, he said. “But that’s not the same as a need for residential treatment,” he said.
And Waller said that treating pregnant women with SUDs is very important. “If you get mom stable, you stop the cycle,” he said. “This is one of my favorite groups to treat — the baby goes home with mom, and I have stopped the cycle,” he said. “We can eliminate the cycle of anger and frustration and trauma and addiction. This is an amazing group of people to treat, and we should all support them and surround them with care.”
Pregnant women with SUDs need a broad array of choices for treatment, from residential to medication-assisted treatment to recovery support in the postpartum period, with the aim of keeping mothers and their children together.
Editor's note: The original version of this story gave the total funding for PPW as $8 million. This story has been changed to reflect that it is $16 million.