Treatment of Substance Abuse During Pregnancy

Barry M Lester; Jean E Twomey

Disclosures

Women's Health. 2008;4(1):67-77. 

In This Article

Promising New Approaches

Motivational interviewing and computer-based motivational interventions are starting to be used as brief, accessible tools for substance using women.[45,46,47] Motivational interviewing attempts to increase the motivation for change through empathy, collaboration and setting goals for change. Women who were more compliant with motivational interviewing and behavioral incentives delivered infants with higher birth weights and had more negative drug-urine screens, although they were not drug abstinent.[48] In a study examining the effectiveness of motivational interviewing and behavioral incentives, pregnant substance users needed more intervention to keep appointments and had lower participation rates than a nonuser comparison group, and there was a positive association between the number of completed motivational interviewing sessions and clean urine screens.[8,49] However, no significant group differences were found between a group of perinatal substance users with CPS involvement who received motivational interviewing and a comparison group who were given an educational intervention.[45]

substance using postpartum women who used a computer-based motivational intervention program that gave them feedback regarding the negative consequences of drug use, potential benefits to not using, and a summary related to their motivation to change had higher levels of motivation.[47] A one-time computer-based motivational intervention contributed to decreased substance use among the group of postpartum women, who had reported illicit drug use in the month before pregnancy.[46]

Another new focus is interventions that address the emotional aspects of the mother-child relationship. These include working with mothers to help them understand child developmental and psychological needs by increasing their ability to identify and appreciate the impact that their own internal states have on the ways that they perceive and interact with their child.[50] This approach has been shown to reduce parenting stress and maternal depression[51] and to increase mothers' knowledge regarding caring for their infants.[52]

Although medications have been developed to treat addictive disorders, clinical trials typically exclude pregnant women for fear of ethical concerns and legal prosecution if there are negative birth outcomes. Methadone has been the traditional medication of choice for opioid-dependent pregnant women.[53] However, concerns regarding the severity of withdrawal in infants exposed to methadone have led to research on buprenorphine as an alternative. Early evidence has shown shorter hospitalization, less morphine needed to treat neonatal abstinence syndrome (NAS),[54] and less NAS in buprenorphine-exposed compared with methadone-exposed infants.[55] A multicenter clinical trial is underway to determine the safety and efficacy of buprenorphine for this population.

substance abusing parents involved with CPS have a low probability of successful reunification with their children, with the children spending extended periods of time in foster care.[56,57,58] The latest approach to this problem is represented by the almost 200 family treatment drug courts (FTDC) in the USA. These courts are based on a nonadversarial model and focus on treatment and reunification. Outcome data aresparse. One report found parents who participated in FTDC were more likely than a comparison group to engage in, stay in and complete treatment and achieve reunification with their children, and were less likely to become re-involved with CPS.[56]

Our own program, the Vulnerable Infants Program of Rhode Island (VIP-RI), connects with parents before the newborn infant leaves the hospital, develops a treatment plan based on identified needs and includes a FTDC. VIP-RI has resulted in a reduced length of stay beyond medical necessity for infants in the newborn nursery. The program has also shown earlier reunification in FTDC compared with traditional family courts.[59] Timely permanency represents a significant improvement in family stability, as well as cost savings to the child welfare system. Figure 1 & Figure 2 illustrates the final placement of the infant at the time of discharge from the VIP-RI program compared with the initial placement of the infant at discharge from the hospital (n = 123 cases).

Initial placement of children at hospital discharge.

Final placement of children at Vulnerable Infants Program of Rhode Island discharge.

As evident in Figure 1 & Figure 2, the number of children who were placed with their parent(s) increased from the point of hospital discharge to permanent placement: only 35% of these infants were initially placed with a parent or parents at hospital discharge; this increased to 56% of infants granted permanency with a biological parent. This represents a total of 69 children who achieved permanency with one or both of their biological parents (including five fathers granted sole custody of six children). Including the 21% of infants who were adopted by a relative, a total of 77% of these children remained with members of their birth families. (The term 'Other' refers to a specialized placement for a child with medical issues following termination of the parent's rights).

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