(This is cross-posted at the Century Foundation’s Taking Note site)
This morning’s Times has a nice story by Abby Goodnough and Katie Zezima about the problem of opiate-dependent newborns. Painkiller abuse and dependence is a serious and widespread problem. Any substance abuse issue that makes inroads among reproductive-age women sooner or later shows up in the newborn nursery. So it was with alcohol, tobacco, crack, and methamphetamine. So it is with OxyContin and the rest.
I’ve done a fair amount of research on substance use among pregnant and parenting women. Eleven years ago, at Mark Kleiman’s behest, I wrote a piece for the Drug Policy Analysis Bulletin, was called “when pregnant women use crack.” I argued then that the “crack baby” problem was often a pediatric problem masquerading as an obstetric one. I’d stand by this basic perspective.
People are often most disturbed by the direct biological impacts of a specific substance, especially because these impacts are often poorly-understood at the period when prenatal substance use first attracts public attention. Most of the time, the chief threats to maternal and infant well-being do not arise from the immediate teratogenic properties of a drug on the developing fetus. With the ironic and crucial exception of alcohol, the direct biological impacts of intoxicating substances are readily overstated.
Most pregnant women who use illicit drugs will have basically healthy babies. When they don’t, the underlying biological mechanism is often something other than the illicit drug, but something that becomes much more difficult to properly address when illicit drug use is in the mix. They may have infections that affect birth outcomes. They are likely to be smoking and drinking. They may have depression or other mental health concerns. They may have poor nutrition and poor general health. Some of these women will be exposed to domestic violence or various challenges that come with being pregnant and not having much money. They may delay prenatal care because they are ambivalent about the pregnancy. They may be afraid or ashamed to access medical resources when they have a drug problem.
Women will need help having healthy pregnancies. Many will also need help taking proper care of their baby after it is born, especially if their baby is more difficult to care for as it experiences the difficult but temporary symptoms of opiate withdrawal.
The right clinical and policy response is not to panic or to assume that these babies will be damaged in the womb, but to find ways of engaging these women more effectively, providing the proper care, and staying with them to help after their babies are born.
I think we’ll pursue more sensible policies towards prescription opiate abuse than we managed in earlier drug epidemics. For one thing, we have the chastening example of bad public policies followed during the crack epidemic of two decades ago. It’s also pertinent that Goodnough and Zezima’s article concerns white people in rural Maine. As with alcohol, tobacco, and methamphetamine, prenatal opiate dependence is not a problem of the inner city or one that pings every racial, economic, and lifestyle receptor in the culture wars. (With luck, it will turn out that physicians and policymakers have learned that just putting someone in an opiate detox facility has little value by itself.)
As always, the right response is to stay calm, to use engagement rather than compulsion as our first line of intervention and help. As always, the real challenge is to develop and field good interventions to help pregnant women with drug problems both before and after their children are born. As always, we would be wise to maintain high tobacco and (especially) alcohol taxes to address the two most widely-used substances that affect infant health.
Oh yeah. One simple thing is to provide proper insurance coverage for evidence-based addiction therapies. The military’s huge TriCare insurance program won’t cover methadone and buprenorphine maintenance therapies for opiate addiction. So women in the military and women who are military dependents have constrained access medications that could really help them. We’ll have more to say about this topic soon.