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Treating substance abuse during pregnancy: What approach works?
Coercive legal measures are ethically problematic
In recent years, efforts to address substance abuse among pregnant women have moved from being barely visible public health initiatives to controversial political battlegrounds.
A recent survey from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that approximately 12% of pregnant women and girls between the ages of 15 and 44 used alcohol in the month prior to being surveyed, and 3% used illegal drugs.1
Over the past decade, a number of states have passed laws requiring health care providers to report substance abuse by pregnant women, compelling pregnant women to undergo treatment for substance abuse problems or face incarceration, and allowing addicted pregnant women to be charged with child abuse and endangerment.
Most professional medical societies have condemned such legislation as compromising the provider-patient relationship and violating the civil rights of the women involved.
Now, some researchers argue, these laws not only are unsound ethically, but largely ineffective at addressing the problem of substance abuse during pregnancy.
"Society does have a compelling interest in preventing substance abuse during pregnancy as a public health issue, but the criminalization approach is inadequate and wrong," says Mary Faith Marshall, PhD, professor of medicine and bioethics at the School of Medicine at the University of Kansas Medical Center in Kansas City. "This is such a complex problem, and research into addiction medicine is showing more and more that it is not just a social construct in the sense of someone being able to say, I want to stop being addicted today.’"
Marshall and several colleagues published a paper in the Journal of Law, Medicine, and Ethics questioning not only the ethics of laws attempting to coerce treatment, but also the suitability of clinical treatment encounters to sufficiently address the problem.2
Forcing women into treatment implies that addressing the clinical aspects of addiction will be enough to stop the drug abuse — an assumption that Marshall and others say has been shown to be questionable.
"Most of the factors that contribute to addiction, such as poverty, level of education, job skills, and the like are outside anything the clinical encounter can effect," Marshall says.
Experts in substance abuse treatment generally agree that effective programs should include residential care, combine inpatient and outpatient services, are gender-specific, and offer vocational and educational services, transportation, and childcare. Yet, most of the public policy initiatives designed to address substance abuse in pregnant women have no support for these additional services, and pregnant women most at risk of substance abuse and addiction do not have access to such programs.
If society really were interested in addressing the problem, why not spend public funds on improving treatment rather than incarceration for addicted pregnant women, Marshall asks.
Financial constraints and political support for punitive approaches have limited the spread of such treatment facilities and created concerns about cuts in addiction treatment and services, she adds. And empirical evidence continues to suggest that drug addiction resists a clinical solution, even when measures are taken to provide appropriate social supports.
It doesn’t help that most women who end up in the criminal justice system for addiction during pregnancy come from poor, minority populations that are easy for the rest of society to marginalize, Marshall adds.
"There was a really interesting study several years ago down in Pinellas County, FL, where they anonymously screened every pregnant woman presenting at three different medical centers, to see whether they had a positive screen for drugs or alcohol," she recalls. "They followed up on that and found that the people who fell into the social welfare system or who were brought to the attention of authorities were poor women of color, even though the data were there that showed that other women, too, tested positive. The only ones gone after were the ones who were politically not in a position to make a whole lot of fuss."
A public health angle
A more comprehensive, public health approach to address the core influences of substance abuse and addiction could be much more effective, but will be much more difficult, in terms of political will, to implement, Marshall argues.
Efforts to place treatment centers in at-risk communities could reach some women before they become pregnant. Training lay health advisors to educate peers about healthy and unhealthy behaviors has been shown to be effective in other public health initiatives, such as anti-smoking programs. Job training and education programs also could play a role.
However, Marshall notes, the current U.S. health system overall emphasizes individual clinical care at the expense of public health initiatives and substance abuse treatment continues to focus on improving access to clinicians — albeit through coercion — rather than pursuing larger, population-based initiatives.
"In terms of bioethics in general, we tend to concern ourselves with sexy issues like genetics, which are important, but access to health care and substance abuse is a huge public health issue, and people in the bioethics world have not paid a whole lot of attention to it," she says.
Some health systems, however, have decided to alter their clinical models for treating addiction in pregnant women, adding social supports and tailoring interventions specifically for this at-risk population, says Mary Anne Armstrong, MA, a biostatistician and researcher at Kaiser Permanente Medical Care Program’s Division of Research in Oakland, CA.
In the late 1980s, physicians at Kaiser Permanente Medical Center in Oakland became concerned about the number of babies born there who had been exposed to alcohol and drugs.
They designed several different interventions aimed at easing referrals for pregnant women into existing treatment programs, but few of the efforts were successful, she says.
In 1990, the hospital designed a new approach, known as Early Start, which combined substance abuse screening and treatment with obstetric and prenatal health services.
Under Early Start, pregnant patients complete a screening questionnaire on their first prenatal visit, and undergo a urine toxicity screen if they consent, and about 95% of patients do, she notes.
If the questionnaire and/or urine test indicate substance abuse, the patient is referred to a social worker who is stationed in the obstetricians’ office full time.
The social worker conducts an in-depth assessment of the patient and designs an individual diagnosis and care plan. Women at moderate to high risk of substance abuse during their pregnancy are seen for follow-up visits by the social worker at subsequent prenatal checkups. The follow-up visits are designed to be similar to other brief intervention treatment programs and use a number of different therapies, including motivational therapy, cognitive/behavioral therapy and psychodynamic therapy.
Early Start clients also receive routine follow-up toxicology screens and are referred to other available treatment programs.
Studies conducted by Armstrong and colleagues indicate that women who undergo screening and treatment through the Early Start program have babies with fewer drug-related complications than women who do not participate in the program.3
Combining screening and treatment with prenatal care was a key element in successfully treating many women where previous efforts had failed, Armstrong notes.
"Early Start was developed because referral to treatment in the psychiatry department — where substance abuse treatment takes place in the Kaiser system — wasn’t working," she explains. "The women weren’t going there; it wasn’t convenient to go and make appointments at another clinic in another building, and there is also the stigma of being pregnant and a substance abuser. Most substance abuse treatment is in a group setting, and nonpregnant patients look down on pregnant substance abusers."
The most unique feature of Early Start is its location of a treatment provider in the obstetric clinic and the linking of treatment appointments with prenatal appointments.
"And certainly, all information obtained by the Early Start specialist in the course of treatment is confidential," Armstrong adds. "The fear of criminal prosecution does not prevent patients from participating. On the contrary, they know that participation will prevent them from being prosecuted."
Armstrong and others in the research division currently are involved in more follow-up studies on substance abuse in pregnancy, including: a study to determine how women utilize inpatient and outpatient services before and after treatment during pregnancy and their substance use postpartum; research on why some women deny substance abuse on the screening questionnaire but have a positive toxicology screen; and a method of tracking cases of fetal alcohol syndrome in the northern California Kaiser Permanente region. And she is finishing a five-year study examining ways to help women who drink alcohol during pregnancy better quantify how much they actually drink.
"The two most important things health care systems can do are to provide adequate screening and convenient treatment," she contends. "In general, individual clinicians need to become more comfortable discussing substance abuse with their patients and support innovative programs like Early Start."
1. Substance Abuse and Mental Health Services Administration. National Household Survey on Drug Abuse, 1999 and 2000. Rockville, MD.
2. Jos PH, Perlmutter M, Marshall MF. Substance abuse during pregnancy: Clinical and public health approaches. J Law Med Ethics 2003; 31:340-350.
3. Armstrong MA, Lieberman L, Carpenter DM, et al. Early Start: An obstetric clinic-based, perinatal substance abuse intervention program. Qual Manag Health Care 2001; 9:6-15.