Treatment of Substance Abuse During Pregnancy

Barry M Lester; Jean E Twomey

Disclosures

Women's Health. 2008;4(1):67-77. 

In This Article

Discussion

Research on treatment of substance abuse during pregnancy continues to expand. Evidence-based programs suggest that a variety of approaches are effective, including traditional programs, which focus on the pregnancy period, length of treatment, comprehensive treatment and home visitation, and newer approaches, which include motivational interviewing and contingency management, a focus on the mother-infant relationship, collaboration among social service systems, including CPS and FTDC, and pharmacotherapy.

It is difficult to compare approaches or individual programs for several reasons. First, these studies are difficult to evaluate because they are complex and are complicated by methodological issues, including small sample size, many confounding variables, inability to randomize patients to different conditions, and unblinded observers. Second, programs are developed for different purposes. Although it could be argued that abstinence from drug use is (or should be?) the sine qua non of all of these studies, for some studies, abstinence may be the ultimate goal but not the focus of a particular approach, such as a study with the goal of getting women into treatment during pregnancy. Alternatively, a study designed to improve the mother-child relationship might see this objective embedded in the context of a larger abstinence program. A third reason is that studies use a wide array of outcome measures, which are difficult to compare. In addition, there are no long-term follow-up studies. Fourth, studies are developed for different populations. For example, studies that address families involved with the child welfare system have a unique set of issues to address. In a similar vein, there are local population issues. State statues, regional practices, existing services and infrastructure often play a role in how programs are developed. Thus, even when positive generic practices are identified, such as 'comprehensive services', they still need to be adapted to the local environment. Finally, most treatment programs are multifaceted. In most cases, it will not be possible to tease out the effects of individual components. In addition, because many programs are based on the needs of the individual, not all participants receive the same treatment. There is no 'one size fits all' model, but there are clearly strategies that can be drawn from different models that can be adapted to a specific population. It is also worth noting that, in most cases, programs are not drug specific. In part, this is owing to the polydrug nature of the population, but also because these strategies do seem to be effective across drug groups.

Notwithstanding these limitations, this field has made great strides in the past few years and we have many reasons to be optimistic regarding treatment programs for drug-using mothers. As society moves towards the acceptance of drug use as a mental health disorder, we should see a reduction in many of the barriers to treatment, including the stigma and marginalization of these women, and a shift from punitive, criminalization to treatment based on scientifically informed policies and laws. This will enable drug-using women to take advantage of the kinds of programs described in this article and contribute to the development of improved treatment approaches as we continue to increase our understanding of their needs. For example, more women in treatment during pregnancy will reduce the number of drug-affected babies, the number of families involved with the child welfare system and the number of children in foster care.

The past few years have seen the development of innovative programs that, although not evidenced-based, are promising. The Zero Exposure Project developed a public awareness education campaign regarding substance use during pregnancy by using a website, radio announcements, a toll-free information and referral line, and providing outreach to female inmates.[60] In the Milagro Program,[16] screening for substance use, education, prevention and referrals at a prenatal clinic were effective in increasing women's willingness to engage in comprehensive services.

Treatment programs are showing an increased sophistication regarding psychological aspects of the mother-infant relationship. A Finnish residential program for pregnant and postpartum women helps mothers with infant mental health issues.[32] The mother-infant relationship is also a primary focus of a Toronto-based program that provides the mother with a therapeutic relationship to foster the development of a nurturing relationship with her infant.[49]

Partners are increasingly recognized as influencing women's recovery efforts and affecting family functioning, including the roles of substance using men as fathers.[61,62,63,64] It has been suggested that families affected by drug use during pregnancy can be best served when the needs and strengths of the partners can be identified, creating opportunities for intervention in the service of promoting more adaptive family functioning whether or not the couple remains together.[65]

We know that outcomes for substance using pregnant women depend not only on their individual life experiences and characteristics but also on factors related to social service systems, societal institutions, and conditions beyond their direct control.[66,67] When does the need for treatment end? Our preliminary data suggest that parents continue to need support for substance use, mental health and parenting after their involvement with FTDC.[66]

The cost-benefit of treatment for this population is complex because the impact that pregnant and parenting women have on society is especially pronounced, as women are typically the primary caregivers in a family. The high cost of comprehensive, long-term residential programs for pregnant and parenting women may make them targets of cost-saving measures, raising questions as to whether the costs can be justified and if there may be alternative, more economical ways to provide services.[19,38] There is evidence that a specialty residential treatment program has a more favorable net benefit (US$17,144) than a standard residential treatment program (US$8090).[68] A quality-of-life index also showed treatment and cost-benefit effects.[69] When the cost of providing special education services for these children when they get to school is considered, there is no doubt regarding the cost-effectiveness of programs for pregnant women and mothers with young infants.[70] An earlier study provided further evidence of the cost-effectiveness of the five different treatment modalities (detoxification, methadone, residential, outpatient, and a combination of residential and outpatient treatment) for pregnant substance using women.[71] Findings showed that involvement in treatment led to a noticeable reduction in the costs of crime-related activities, with the two types of residential programs showing the greatest cost-benefits.

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