Criminalizing Pregnant Women for Drug Abuse Is a Terrible Idea

By Dr. Lynn Webster, PNN Columnist

According to Guttmacher Institute, nearly half the states in the United States are willing to punish pregnant women in order to spare their babies the agony of being born with Neonatal Abstinence Syndrome (NAS). Ironically, their efforts are having the opposite effect.

Twenty-three states and the District of Columbia have passed legislation that criminalizes substance abuse during pregnancy. Additionally, 25 states and the District of Columbia require healthcare providers to report expectant mothers who may be illegally using substances. In 8 states, pregnant women who are suspected of substance abuse must also undergo drug testing.

The huge number of babies born to mothers dependent on opioids has driven policymakers to find ways to deter pregnant women from abusing opioids.

But new research points out there are unintended consequences to criminalization. And it provides lawmakers insight on how to create more effective policies that result in positive, not punitive, outcomes.

A study published recently in the journal JAMA Network Open examined 4.6 million births in the U.S. from 2000 to 2014. During this time, the diagnosis of NAS increased seven fold.

The study was conducted by the RAND Corporation, a nonprofit research institute that analyzed 8 states with punitive policies for drug-abusing pregnant women. The research was funded by the National Institute of Drug Abuse.

According to a RAND press release, Arkansas, Arizona, Colorado, Kentucky, Massachusetts, Maryland, Nevada and Utah adopted either punitive penalties for drug use during pregnancy or policies that required health care providers to report pregnant women with suspected illegal substance use.

RAND researchers found that the annual rate of NAS increased in the 8 states, from 46 cases per 10,000 live births to 60 cases per 10,000 after punitive policies were enacted. That is an alarming 30% increase in NAS cases.

This is not the first study that has shown political efforts to curb opioid addiction and overdoses have not had a positive impact. We have seen the harm associated with forced tapers and dose limits adversely affecting millions of pain patients.

It is hard to understand why these destructive policies are put in place, but it may be because policymakers are misinformed or biased. Regardless, it reflects a systemic flaw for governments to fail to evaluate the efficacy and outcomes of the very policies they create.

Addiction Is a Disease, Not a Crime

How best to address addiction has long been the subject of debate. For example, a state hospital in South Carolina illegally obtained the diagnostic tests of pregnant women in an effort “to obtain evidence of a patient's criminal conduct for law enforcement purposes” (this was the case of Ferguson v. Charleston).

Unfortunately, some people still believe that addiction is a volitional or character flaw that should be recognized as criminal behavior rather than a disease.

Indisputably, addiction is a complicated, life-threatening disease. Treating people with the disease as criminals is the worst possible approach. Most experts in the substance abuse treatment community have known this for years. Fortunately, the RAND Corporation has now provided evidence of how this applies to babies born to women who abuse opioids. 

Typically, lawmakers do not evaluate the impact of the policies they pass. There have been many policies over the past few years that were implemented by state legislatures, healthcare organizations and insurance companies that were intended to reduce harm from opioids. Almost no one has attempted to measure their effectiveness or unintended consequences.

Fortunately, in this case, we have an exception. We have a unique opportunity as a result. The RAND study should provide policymakers with insights on how to more effectively address the problem of substance abuse during pregnancy.

Threatening to punish a pregnant women does not decrease the number of women who abuse drugs. However, it does scare many of them away from seeking the treatment they need and can deter pregnant mothers from seeking prenatal care.

Pregnant women who are opioid-dependent frequently use other illegal substances that risk the health of their babies. There should not be more barriers for pregnant women to receive prenatal care. Infants born after exposure to opioids often require prolonged hospitalizations to manage their needs, with those cumulative costs totaling more than $500 million, according to the RAND study. More importantly, babies with NAS suffer needlessly.

It should go without saying that every policymaker wants to solve problems and not create additional harm for new mothers or to babies born to them. Hopefully, this study will be used as it is intended: to help create policies that actually reduce harm from opioids. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is the author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.”

You can find Lynn on Twitter: @LynnRWebsterMD.

Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences or Pain News Network. 

Misuse of Pain Meds by Teens Continues Decline

By Pat Anson, Editor

Two new studies this week paint a somewhat conflicting picture about the abuse of opioids by teens and pregnant women.

A survey of over 45,000 teens by the University of Michigan and the National Institutes of Health found that teenage drug abuse continues to decline, with a significant drop in the misuse of the painkiller Vicodin. A second study at the university found the number of babies born with opioid withdrawal symptoms has grown substantially, especially in rural areas.

The annual Monitoring the Future survey found that 4.8% of high school seniors had misused an opioid pain reliever in the past year, down from a peak of 9.5% in 2004. In the past five years alone, misuse of opioid pain medication by 12th graders has declined by 45 percent.

Only 2.9% of high school seniors reported the misuse of Vicodin in 2016, compared to nearly 10 percent a decade ago. Vicodin and other hydrocodone products were reclassified as Schedule II controlled substances in 2015, making them harder to obtain.

"Clearly our public health prevention efforts, as well as policy changes to reduce availability, are working to reduce teen drug use,”  said Nora Volkow, MD, director of National Institute of Drug Abuse.

The survey found a continued long-term decline in teenage use of many illicit substances, as well as alcohol and tobacco. The use of any illicit drug was the lowest in the survey’s history for eighth graders. One negative sign was an increase in the misuse of over-the-counter cough medicine by eighth graders.

Marijuana use in the past month by eighth graders fell to 5.4%, down from 6.5% in 2015. However, among high school seniors, nearly one in four reported marijuana use in the past month. There also continues to be a higher rate of marijuana use in the past year (38%) among 12th graders in states with medical marijuana laws.

"It is encouraging to see more young people making healthy choices not to use illicit substances," said National Drug Control Policy Director Michael Botticelli. "We must continue to do all we can to support young people through evidence-based prevention efforts as well as treatment for those who may develop substance use disorders.”

The majority of teens continue to say they get most of their opioid pain relievers from friends or relatives, either stolen, bought or given. The only prescription drugs seen as easier to get in 2016 than last year are tranquilizers, with 11.4 percent of eighth graders reporting they would be “fairly easy” or “very easy” to get.

More Babies Suffering from Opioid Withdrawal

The number of babies born with drug withdrawal symptoms from opioids grew substantially faster in rural communities than in cities, according to the University of Michigan study. The study did not distinguish between opioid pain medication and illegal opioids such as heroin.

Newborns exposed to opioids in the womb and who experience withdrawal symptoms after birth (neonatal abstinence syndrome) are more likely to have seizures, low birthweight, breathing, sleeping and feeding problems.

Researchers found that in rural areas, the rate of newborns diagnosed with neonatal abstinence syndrome increased from nearly one case per 1,000 births from 2003-2004 to 7.5 cases from 2012-2013. That's a surge nearly 80% higher than the growth rate of such cases in urban communities.

"The opioid epidemic has hit rural communities especially hard and we found that these geographical disparities also affect pregnant women and infants," says lead author and pediatrician Nicole Villapiano, MD, whose study was published in JAMA Pediatrics.

Using national data, researchers found that rural infants accounted for over 21 percent of all infants born with neonatal abstinence syndrome. In 2003, rural infants made up only 13 percent of the neonatal abstinence syndrome cases in the U.S.  

Maternal use of opioids in rural counties was nearly 70 percent higher than in urban counties. Rural infants and mothers with opioid-related diagnoses were more likely to be from lower-income families, have public insurance and be transferred to another hospital following delivery.

Villapiano says families in urban areas typically have better access to addiction treatment programs.

"We need to consider what kind of support moms with opioid disorders have in rural communities," she said.

Villapiano suggests that increasing the number of rural doctors authorized to prescribe the addiction treatment drug buprenorphine (Suboxone), as well as expanding rural mental health and substance abuse services, would be good first steps in reversing the trend in neonatal abstinence syndrome.