Fran Lowry

December 07, 2015

HUNTINGTON BEACH, California ― In states that have laws making illicit drug use during pregnancy a form of child abuse, pregnant women with opioid use disorders are less likely to seek appropriate prenatal care, a new study shows.

Currently in the United States, 18 states have laws by which pregnant women who use illicit drugs can be charged with child abuse. The rationale for such laws is the belief that they act as a deterrent to drug use and that they encourage women to seek treatment via drug courts.

There is no empirical evidence to support that belief, and such punitive laws have the opposite result, causing pregnant women who use illicit drugs to forgo medical care altogether, senior investigator Carol Weiss, MD, from Weill Cornell Medical Center, New York City, told Medscape Medical News.

Dr Carol Weiss

"It does drive them underground, and it does worsen maternal child care. If the women think they are either going to be arrested or lose their child, they are not going to get the prenatal care they need, so absolutely, unquestionably, in my mind, this type of law diminishes the likelihood that they will get appropriate treatment," Dr Weiss said.

Her study was presented here at the American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting.

Dangerous to Quit Cold Turkey

The standard of care for opioid dependency in pregnancy is medication-assisted treatment (MAT), using either methadone (multiple brands) or buprenorphine (multiple brands), Dr Weiss said.

"There is a very clear, medically defined treatment for pregnant women with opioid dependence. There's a lot of literature showing that if you try to detox a woman during pregnancy from opioids, she has a greater chance of miscarriage, so it is not medically safe for the fetus or for the mother to undergo detox at that time. The treatment of choice is to be on a medically maintained medication and then be detoxed after she delivers. That is safest for both mother and child," she said.

Owing to rising rates of opioid use during pregnancy and subsequent increases in neonatal abstinence syndrome, more state legislatures are considering adopting prenatal child abuse laws.

This prompted Dr Weiss and her colleague Cara Angelotta, MD, from Columbia University School of Medicine, in New York City, to take a closer look at patterns in the use of MAT for pregnant women who have opioid use disorders and to compare the use of MAT in states with child abuse laws with the use of MAT in states without these laws.

The investigators analyzed data from the Treatment Episode Data Set–Admissions (TEDS-A), a national census of admissions of individuals aged 12 years or older to public and private substance abuse treatment facilities that receive any public funds, for the year 2012.

In that year, 8292 treatment episodes were recorded of pregnant women with an opioid use disorder for which data on MAT use were available in TEDS-A.

The analysis showed that most of the women were between the ages of 18 and 29 years, were white, were high school graduates, were not married, and were unemployed.

Overall, MAT was used in 47% of treatment episodes of pregnant women with a primary opioid problem.

However, in states with prenatal child abuse laws, MAT was used in 33% of treatment admissions, compared with 51% of admissions in states without a law (P < .001).

"This is amazing," Dr Weiss said. "I don't think this has been shown before. Those very states that have laws charging child abuse for pregnant women who use illicit drugs are referring these women to medically endorsed treatments at a significantly lower rate than the states that do not have those laws.

"And in the year of the study, 2012, there were a bit more than 8000 women who sought help, so you can imagine that there is double that number of women who are affected, at least. These are women who are motivated to seek help when they find out that they are pregnant, and at a time when there is a very good window of opportunity to treat them," she said.

"Medical illness in general, but pregnancy in particular, represents a window of opportunity to capture these women and get them help. They are not only motivated to get help, they are also hooked into the medical system, so help is more available to them. If you make help available to them as opposed to punishing them, it's a double win, but if you threaten them with child abuse, that's not going to work. It's just going to drive them away," Dr Weiss said.

I cannot imagine what this law accomplishes. It doesn't prevent illicit drug use, and it doesn't help the women get help. What is more likely to happen is that these women simply don't get prenatal care. Dr Carol Weiss

"So not only are the states with these child abuse laws being punitive, they are not referring women to medically endorsed care. That's the irony," she said.

"I cannot imagine what this law accomplishes. It doesn't prevent illicit drug use, and it doesn't help the women get help. What is more likely to happen is that these women simply don't get prenatal care," Dr Weiss said.

Catch 22

"I was very impressed by this poster," Karol Kaltenbach, MD, professor emeritus of pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, told Medscape Medical News.

Dr Karol Kaltenbach

"The findings are very important because the authors were able to highlight the fact that the states that have punitive approaches don't provide resources for the women, so they are really caught in a 'catch 22' deadlock," Dr Kaltenbach said.

Such punitive laws are often justified by the rationalization that they are for the good of the unborn child, which is just plain wrong, Dr Kaltenbach said.

"Everybody says they want the best outcome for the baby, but they don't stop to think that if a woman is not getting treatment, she's probably going to have a premature baby, with all the problems concomitant to prematurity," she said.

"Women who are abusing opioids, short-acting opioids, go through withdrawal a lot, and when they do, so does the fetus. That's one of the reasons why medication-assisted treatment, or MAT, is so important for the pregnant woman. It stabilizes the intrauterine environment so that the fetus is not exposed to repeated episodes of withdrawal. MAT is a prescribed treatment. The woman is under a doctor's care. And yet you have judges and prosecutors telling women they cannot receive it. They are so focused on NAS [neonatal abstinence syndrome], which in fact is treatable and has no harmful long-term sequelae for the infant," Dr Kaltenbach said.

"We have women who have severe diabetes who may be putting their infants at risk because they are not managing their diabetes appropriately, but we would never think of charging them with child abuse or denigrating them in any way. We still have a long way to go for the American public and politicians to understand that addiction is a disease and that this is not something that women are 'choosing' to do. Such laws are extremely punitive to the woman, extremely counterproductive to the infant, and put the infant at further risk. They highlight that lawmakers are quick to judge, but then do not provide options to help."

Dr Weiss, Dr Angelotta, and Dr Kaltenbach report no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting. Abstract 1. Presented December 4, 2015.


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