Women’s History Month is a reminder to lift up all women, including those who are traditionally left out of the conversation. A group we need to start talking about: women, particularly mothers, who struggle with substance use disorder. Pregnant women and new mothers struggling with opioid addiction elicit harsh and often harmful responses from others. What we need instead: Compassion in place of criticism. And science instead of assumptions.
Drug overdose deaths more than doubled among pregnant and postpartum people between 2017 and 2020. In 2020 alone, fentanyl-related deaths also doubled in this same population. Tragically, the vast majority of these deaths—approximately 80%—were preventable, per the CDC. According to a recent review of maternal mortality released by the CDC, about 1 in 4 deaths related to mental health, including substance use disorders, occur during pregnancy or within the first year of postpartum. The risk of overdose is highest after delivery. Perhaps unsurprisingly, treatment barriers for those who are pregnant or new parents can be insurmountable. Socially and often legally, these parents are stigmatized as unloving, unfit, and undeserving of their children.
Two of the biggest misconceptions that contribute to this stigma are 1.) women who use drugs are bad parents, and 2.) babies are born drug-addicted. The media has used derogative and degrading terms for decades to describe children born to mothers struggling with substance use disorders, such as “crack baby” and “oxytot”. These terms, which have no basis in science or in medical research, were created to shame those struggling with addiction, point fingers, and keep people from getting the care they need.
So what is the reality? Neonatal Abstinence Syndrome (NAS), now more commonly referred to as Neonatal Opioid Withdrawal Syndrome (NOWS), occurs when a fetus is regularly exposed to opioids, whether prescription or nonprescription, and develops physical dependence. After birth, the infant can experience degrees of withdrawal, including high-pitched crying, irritability, difficulty feeding, and respiratory problems. Thankfully, these symptoms are treatable and transitory. In fact, breastfeeding and skin-to-skin contact are among the first-line recommended interventions. Not all babies exposed to opioids will experience NOWS, and no long-term complications have been identified.
While the Department of Health & Human Services emphasizes that a diagnosis of NOWS should not be used to assess a child’s social welfare risk, it often is. Positive drug screens during pregnancy are considered child abuse in almost half of the US, with healthcare reporting obligations. These states consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and healthcare providers often obtain drug tests without a mother’s consent. Although a positive drug screen during pregnancy should not be ignored, it is not in itself a diagnosis of a substance use disorder, nor does it determine the likelihood of a parent to abuse or neglect their child. Punitive policies deter pregnant people from disclosing drug use to medical providers, limit access to treatment, and perpetuate the dangerous stigma that substance use disorder is a choice rather than a chronic condition. What is clear is that both NOWS and positive drug screens indicate more support is needed.
Treating a pregnant mother’s addiction is critical, as the cycle of withdrawal is dangerous for the growing baby. The gold standard of care relies on medication, meaning it replaces illicit opioids with a controlled dose of Suboxone®, a brand of buprenorphine/naloxone, or methadone. These medications decrease potential harm to both mother and baby. Because opioids cross the placenta, repeated cycles of withdrawal from chronic opioid use can impact the fetus and increase maternal and fetal complications. Medications like Suboxone work by creating a steady blood level of opioids which helps to control cravings, eliminate withdrawal symptoms, and allow a patient to spend more time engaging in healthier choices such as prenatal care.
There are critics who will see that it’s better for women to quit “cold-turkey” than to rely on these medications. But research emphatically disproves this. Not only that, but Suboxone may have a particular edge. Studies have found that in-utero exposure to buprenorphine, a partial opioid agonist, is associated with a lower risk of fetal complications, including preterm birth, higher birth weight, and possibly less severe NOWS when compared to methadone, a full opioid agonist. Further evidence continues to support that the combination product buprenorphine/naloxone (Suboxone) is safe and has similar pregnancy outcomes when compared to the mono-product buprenorphine.
Both medications are FDA-approved and extremely effective at treating OUD during pregnancy. This, in turn, helps decrease risks associated with untreated OUD, prevent maternal return to use and overdose risk, limit the separation of families due to CPS involvement, and assist parents to provide a healthy environment for their children.
Of course, accessing medications for opioid use disorder, such as buprenorphine, is another hurdle, with stigma, childcare issues, and transportation obstacles becoming barriers to obtaining the medications people need. That’s why telehealth plays such a crucial role in bridging the treatment gap for mothers and new parents. By offering virtual care, holistic support, and prescriptions online, those with substance use disorders (and their children) are supported before, during, and after pregnancy.