Drugs and the pregnant patient: Perils, pitfalls and promising policy approaches
Studies indicate that 20 percent of pregnant women take a controlled substance during pregnancy, either under the care of a physician for a legitimate medical purpose or because of an addiction disorder for which they may or may not receive treatment by an addiction medicine specialist. Because virtually every drug a pregnant woman takes passes from her bloodstream through the placenta to the fetus, many infants born to these women will be diagnosed with neonatal abstinence syndrome (NAS). NAS is caused by the sudden discontinuation at the time of birth of one or more medications to which the infant had become physiologically dependent in utero. As troubling as this syndrome may be, these infants are not "born addicts," and most cases of NAS can be managed effectively without serious long-term consequences.
Women who become pregnant and wish to carry the pregnancy to term, but who require opioid analgesia for serious chronic pain problems or who are medically managed for an addiction disorder with methadone or similar medication, face a difficult dilemma. That’s particularly the case if they reside in a jurisdiction with a punitive approach to women who are found to be medicated while pregnant. Earlier this year the Supreme Court of Alabama emphatically reaffirmed its earlier position that the 2006 law cumbersomely titled "Chemical Endangerment of Exposing a Child to an Environment in Which Controlled Substances Are Produced or Distributed" applied not only to children born alive but also to fetuses at any stage of development. In an 8-to-1 ruling, the court summarily rejected the argument of an attorney defending a woman who had been convicted of a felony as a result of testing positive for cocaine when she gave birth to an otherwise healthy baby. The lawyer had unsuccessfully argued that the statute was intended to protect children exposed to methamphetamine labs, but that the scope of the law did not encompass a fetus.
Although Alabama may be at the punitive end of a public policy continuum, in many other jurisdictions diagnosis of NAS in a newborn must be reported and invariably will result in an investigation by the local child welfare agency, potentially leading to allegations of child abuse. Some agencies refuse to distinguish between women who take medications prescribed by a physician for a legitimate medical purpose and illicit street drugs or medications taken outside of a therapeutic relationship recreationally or because of addiction. According to the Guttmacher Institute, 17 states consider substance abuse during pregnancy to be child abuse under civil child welfare statutes (with three of these making it grounds for civil commitment), 15 require health-care professionals to report suspected prenatal substance abuse, and four require the provider to test for pre-natal drug exposure if they suspect abuse. Disturbingly, the sweeping definition of "substance abuse" by NIH Medline Plus is "any combination of drug, chemical, alcohol or smoking use during the pregnancy."
According to the Guttmacher Institute, 17 states consider substance abuse during pregnancy to be child abuse under civil child welfare statutes.
Medical professional organizations consistently assert that much mischief follows when legislatures and courts insinuate themselves into the physician-patient relationship. When a woman receiving substance abuse treatment or opioid analgesia becomes pregnant, the burdens and risks both to her and the fetus may be lower if the therapeutic regimen continues than if all such medications are withdrawn in an effort to avoid NAS.
In a rare collaboration among the medical profession, regulators and legislators, responding to an exponential increase in NAS, the state of Tennessee recently passed the "Safe Harbor Act," enacted with the support of the Tennessee Medical Association. The legislation prevents the Department of Children’s Services from seeking custody of a child whose mother took narcotics while pregnant, as long as the mother sought medical treatment by the 20th week of gestation and remained in prenatal care with a drug treatment program thereafter until delivery. Presumably the same "safe harbor" would apply to women taking controlled substances for legitimate medical purposes.
Ideally these challenging cases would involve consultation with the clinical specialties of pain and addiction medicine, obstetrics and neonatology. However, as a practical matter, many patients in rural settings may be unable to access this level of expertise without telehealth technologies. Enlightened public policy approaches to cases involving pregnant women with a legitimate medical need for medications that pose potential risks to the fetus can come about only through the inclusion of a multidisciplinary clinical perspective.
Columnist Ben A. Rich, J.D., Ph.D., holds the UC Davis School of Medicine Alumni Association Endowed Chair in Bioethics