Treatment of Substance Abuse During Pregnancy

Barry M Lester; Jean E Twomey

Disclosures

Women's Health. 2008;4(1):67-77. 

In This Article

Background

Drug abuse tears at the fabric of our society and the effects on children can be tragic. The most recent National Household Survey on Drug Use and Health estimated that in 2004-2005, 3.9% of pregnant mothers had used illicit drugs, including cocaine, in the past month.[101] Even more alarming, the prevalence rate of illegal drug use was higher for pregnant women in the 15-18-year age range (12.3%) than for women aged 18-25 years (7%). Moreover, the women who abuse illicit drugs often use licit drugs. An estimated 32% of those using one illicit drug during pregnancy also use both alcohol and cigarettes, revealing disturbing estimates of 800,000 to 1 million fetuses exposed to the effects of legal (including alcohol) or illegal substances every year.[1,2] These children are at increased risk of placement in out-of-home care.[3] In addition, substance abuse is a contributing factor in child abuse and neglect cases for 40% or more of the 1.2 million annual confirmed cases of child maltreatment[101] and in 40-80% of families involved with the child welfare system.[4] The presence of substance use disorders in parents increases the risk of child maltreatment by threefold or more.[5,6] In total, 11% of children (8.3 million) live with at least one parent who is either alcoholic or in need of treatment for the abuse of illicit drugs.[7] Young adolescents with parents who abuse substances are two- to three-times more likely to try substances.[8,9] Furthermore, these children are 2.4- to 4-times more likely to have a substance use disorder during adolescence.[10] Even these estimates, conservative as they are based on self report, indicate that gestational exposure to licit drugs of abuse, such as alcohol and cigarettes, and illicit drugs of abuse, such as marijuana, cocaine, methamphetamine and opiates, is the single largest preventable cause of in utero developmental compromise of infants in the USA today.

In the 1980s, the 'war on drugs' associated with the crack cocaine epidemic focused national attention on the relationship between drug use and social and economic problems in society. Early reports on prenatal cocaine effects created a public frenzy regarding so-called 'unfit to parent' women and their damaged 'crack babies'. This impacted public perception and state-policy decisions affecting women who used illegal drugs during pregnancy. Treatment for these women is complicated because of the involvement of the child welfare and legal systems, by wide-ranging state statutes, some of which are treatment oriented and some of which are punishment oriented. Treatment programs that target mothers with children face additional issues such as should children be allowed to remain with their parent(s) during substance abuse treatment and differences in professional perspectives and policies between child welfare workers and substance abuse treatment providers. These women are a heterogeneous group and often face, in addition to substance abuse problems, other psychiatric disorders, trauma, domestic violence, poor health, unstable work histories and compromised parenting abilities. Thus, substance abuse cannot be treated as a discrete diagnosis. Recent advances in drug-abuse research have shown that drug addiction is a chronic brain disease[11] and that treatment can result in recovery of damaged brain regions.[2,4,12] This new understanding helps to reduce the stigma of drug abuse by viewing drug abuse as a biologically determined mental health problem rather than as a lifestyle choice.

In this article, we define treatment of substance use during pregnancy broadly to include treatment during pregnancy and/or the postnatal period. We focus on illegal drugs (e.g., cocaine) with the full recognition that most women who use cocaine also use alcohol and tobacco and that the problem is really one of polydrug use.[13] We describe barriers to treatment and evidence-based approaches to treatment, with a focus on those that have been developed over the past 5 years (since 2002). We also discuss issues that need to be addressed in the study of treatment outcomes research in this field and some promising newer initiatives.

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