THE ETHICS OF MEDICATION-ASSISTED RECOVERY:

STRENGTHENING THE MOTHER-INFANT BOND

April Mallory, MSW, LCSW, MAC & Cayce Watson, MSSW, LAPSW, MAC

USI Social Work Conference 2019

3:15-4:45 pm

AGENDA

• Identify the scope of opioid misuse

among women, pregnancy risks, and

ethical concerns with MAT.

• Discuss evidence-based non-

pharmacological interventions that

reduce NAS and support the

mother-infant dyad.

• Explore potential ethical conflicts

for social workers supporting a

harm reduction approach toward

this population.

OPIOID MISUSE IN WOMEN

• 8.4 million females (or 6.6 percent) ages 18 and older reported misuse of

prescription drugs in the previous year, according to the 2016 National Survey

on Drug Use and Health. (Center for Behavioral Health Statistics and Quality,

2017)

• The number of women with opioid use disorder at labor & delivery

quadrupled from 1999-2014. (1.5 to 6.5 per 1000 deliveries)

PREGNANCY RISKS

4 times as many infants were born with neonatal

abstinence syndrome (NAS) in 2014 than in 1999

(Haight, Ko, Tong, Bohm, & Callaghan, 2018).

Infograph: CDC

Neonatal Abstinence Syndrome (NAS)

• In 2012, among hospital related stays for substance

use, 60% were related to NAS with one-fourth

involving opioids (Fingar et al., 2015, & SAMHSA,

2016).

• A 2014 study revealed that 76,742 women, had been

prescribed an opioid during pregnancy (Bateman et

al., 2014).

• NAS is a result of fetal exposure to certain drugs,

primarily opioids, and manifests as clinical symptoms

in newborns with withdrawal. Symptoms may

include uncoordinated sucking reflexes leading to

poor feeding, neurological excitability, gastrointestinal

dysfunction, and a high-pitched cry (ASTHO, 2014).

THE RATIONALE FOR MAT DURING PREGNANCY

1. Prevent Opioid withdrawal or symptoms

2. Provide MAT for stabilization

3. Mitigate euphoria and desire/craving to use illicit opiates and other drugs, while

stabilizing the environment for the baby and limiting exposure to illicit drugs (Jones et.

al., 2008).

4. Shift focus to recovery process including building parenting skills, prenatal care,

nutritional support, and post-delivery planning; avoid high-risk behaviors associated

with drug use.

Neonatal abstinence syndrome is an expected and treatable condition that follows prenatal exposure to

opioid agonists and requires collaboration with the pediatric care team” (ACOG, 2017).

SAMHSA (2018) strongly recommends the use of MAT to treat OUD in pregnant women and suggests

“treatment without any pharmacotherapy is complicated by poor fetal health, high rates of return to

substance use, and the consequences such as risk of overdose” (p. 25).

NAS is treatable and anticipated in pregnant women using opioids, including those being treated on methadone (Terplan, Kennedy-Hendricks, & Chisolm, 2015).

NAS develops in “55-94% of substance-exposed infants” (University of Iowa Children’s Hospital, 2013).

NAS may pose less harm to a pregnant mother and her baby than non-medically supervised detoxification or the behaviors associated with high-risk drug use such as frequent physical withdrawal, exposure to infectious disease, tainted street drugs, criminal activity, or violence (ACOG, 2017; Watson & Mallory, 2017).

The current recommended approach for pregnant women with OUD is medication-assisted treatment (MAT). (SAMHSA, 2018)

NON-PHARMACOLOGIC STANDARDS

includes relieving infant symptoms and supporting maternal bonding and may include the following:

• Swaddling,

• rocking,

• reduced stimuli in environment (light & noise),

• breast feeding (if stable in medication-assisted recovery)

• bottle feed or pacifier in between to assist with sucking reflex, and

• rooming together

(SAMHSA, 2016 & University of Iowa Children’s Hospital, 2013).

primarily intended to relieve NAS symptoms and

its associated complications, such as fever, weight

loss, and seizures” (SAMHSA, 2016).

• This may be morphine as first line of treatment,

or methadone, followed by tapering off schedule

based on symptoms (University of Iowa

Children’s Hospital, 2013).

• In a 2010 study, infants with NAS required less

therapy and shorter hospital stays when roomed

with their mother on a postnatal unit than when

admitted to a traditional neonatal care unit

(Saiki, Lee, Hannam, & Greenough, 2010).

PHARMACOLOGIC INTERVENTIONS

NAS TREATMENT & FOSTERING SECURE BONDS

INTEGRATED TREATMENT

https://youtu.be/7IFLrd8zudo

6 minute video from:

Texas Department of State Health Services

ETHICAL CONFLICTS

• Values- Beliefs about right and wrong.

• Ethics- What should or should not be done.

• Ethical Dilemmas: Problematic situations whose possible solutions offer

imperfect answers on what ethically should be done.

• Ambiguity: View of different perspectives – solutions are unclear.

• Kirst-Ashman & Hull

DISCUSSION ACTIVITY

• Review the principles from the NASW Code of Ethics that follow each core value.

• As you discuss with your partner, what ethical conflicts can arise when working with pregnant women in MAT?

ETHICAL CONCERNS

• Safety concerns for infant at delivery and post-partum (rapid detox)

• Child abuse reporting policies & social policies that criminalize substance misuse

• Client Vulnerability & lack of infrastructure to support recovery (wrap around)

• Definitional debates about Non-Abstinence based therapies

• Stigmas that impact help-seeking, family connection, and public opinion (internalized stigma)

• Language used alters perceptions

• Trauma History, Promoting secure attachment during sensitive periods, toxic stress

• Promoting self-efficacy vs. Paternalism

• Checking self-awareness for our own biases

Move away from a moral model of understanding; view complex individual and social problems within the macro context:

• “Seeking obstetric-gynecologic care should not

expose a woman to criminal or civil penalties, such as

incarceration, involuntary commitment, loss of

custody of her children, or loss of housing. These

approaches treat addiction as a moral failing” (ACOG,

2011).

• Validating incremental change, redefining success,

and utilizing positive language such as Medication-

Assisted Recovery with clients is paramount (White,

2012).

• The assertion that recovery from opioid misuse begins

when medication management ends is discriminatory,

and “recovery from no other chronic health condition

rests on such a proposition” (White, 2012, p. 204).

MAT IS CONSISTENT WITH SOCIAL WORK VALUES

• Dignity and Relationships: When we advance the dignity of a mother, dignity extends to her baby ––and sustains a meaningful and healing connection.

• Self-Determination and Empowerment: Honoring self-determination allows autonomy to rest with the client; this creates an impetus for empowerment. It intentionally shifts the orientation away from pathology and honors client choice. We must also consider the ecological context in which her choice is made.

• Social Justice and Advocacy: Unworthy vs. worthy translates to the collective policy response (Collins and Garlington, 2017). Stigma limits accessibility and contributes to poorer health outcomes. Pregnant women of color are “least likely to be able to defend themselves and the least able to conform to the white middle-class standard of motherhood” (Van Wormer & Davis, 2018). Competent social workers must advocate for restorative policies that elevate dignity and strengthen the relationship between mothers and babies.

• Ethical practitioners act with Integrity and engage in critical examinations of personal beliefs alongside professional values within a strengths-based framework. Discernment of these concepts enables practitioners to weigh the benefits of a least harm perspective and creates the space to view a pregnant woman within the context of her strengths. Practicing in this space honors the dignity and worth of both a mother and her baby. This perspective is paramount to effectively engage clients, foster belonging, and sustain recovery.

(Watson, Mallory, & Crossland, in press)

PRESENTATION REFERENCES

American Congress of Obstetricians and Gynecologists. (2011). Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. Committee Opinion No. 473. 117:200–1.

American Congress of Obstetricians and Gynecologists. (2017). Opioid use and opioid use disorder in pregnancy.Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstetrics & Gynecology. 130, 81-94.

Association of State and Territorial Health Officials. (2014). Neonatal Abstinence Syndrome: How States Can Help Advance the Knowledge Base for Primary Prevention and Best Practices of Care. [PDF Document]. Retrieved from: http://www.astho.org/prevention/nas-neonatal-abstinence-report/

Bateman, B., Hernandez-Diaz, S., Rathmell, J., Seeger, J., Doherty, M., Fischer, M., & Huybrechts, L. (2014). Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States. Anesthesiology, 120(5):1216–24. doi: 10.1097/ALN0000000000000172

Centers for Disease Control and Prevention. (2015). Press Release: Opioid Painkillers Widely Prescribed Among Reproductive Age Women. Retrieved from: http://www.cdc.gov/media/releases/2015/p0122-pregnancy-opioids.html

Collins, M., & Garlington, S. (2017). Compassionate response: Intersection of religious faith and public policy. Journal of Religion & Spirituality in Social Work: Social Thought, 36(4), 392-408. doi: 10.1080/15426432.2017.1358127

Debelak, K, Morrone, WR, O’Grady, KE, and Jones, HE. Buprenorphine + naloxone in the treatment of opioid dependence during pregnancy-initial patient care and outcome data. American Journal of Addiction, 2013 May-June; 22(3):252-4. doi: 10.1111/j.1521-0391.2012.12005.x.

Fingar, K.R., Stocks, C., Weiss, A.J., & Owens, P.L. (2015). Neonatal and maternal hospital stays related to substance use, 2006–2012. HCUP Statistical Brief #193. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://hcup-us.ahrq.gov/reports/statbriefs/sb193-Neonatal-Maternal-Hospitalizations-Substance-Use.pdf

• Center for Behavioral Health Statistics and Quality. Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2017. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf.

• Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2018;67:845–849. DOI: http://dx.doi.org/10.15585/mmwr.mm6731a1

• Identifying Neonatal Abstinence Syndrome (NAS) and Treatment Guidelines, 2013 PDF University of Iowa Children’s Hospital Retrieved from https://www.uichildrens.org/uploadedFiles/UIChildrens/Health_Professionals/Iowa_Neonatology_Handbook/Pharmacology/Neonatal%20Abstinence%20Syndrome%20Treatment%20Guidelines%20Feb2013%20revision.pdf

• Jones, H., Martin, P., Heil, S., Kaltenbach, K., et al. (2008). Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues. Journal of Substance Abuse Treatment (35), 245-259.

• Kirst-Ashman, K., & Hull, G. (2016). Understanding generalist practice (8th ed.). Boston, MA: Cengage

• Saiki, T., Lee, S., Hannam, S., & Greenough, A. (2010) Neonatal abstinence syndrome –postnatal ward vs neonatal management European Journal of Pediatrics 169:95–98

• Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. (2008). Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214

• Substance Abuse and Mental Health Services Administration, Advancing the Care of Pregnant and Parenting Women With Opioid Use Disorder and Their Infants: A Foundation for Clinical Guidance, Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.

• Substance Abuse and Mental Health Services Administration. (2018). Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants (HHS Publication No. (SMA) 18-5054). Rockville, MD: Substance Abuse and Mental Health Services Administration.

• Terplan, M., Kennedy-Hendricks, A., & Chisolm, M. (2015). Prenatal Substance Use: Exploring Assumptions of Maternal Unfitness. Substance Abuse: Research and Treatment 9 (S2) 1-4.

• Watson, C. & Mallory, A. (2017, January). The criminalization of addiction in pregnancy: Is this what justice looks like?The New

Social Worker Magazine 24(1), 14-16.

• Watson, C., Mallory, A., & Crossland, A. (in press). The spiritual and ethical implications of medication-assisted recovery in

pregnancy: Preserving the dignity and worth of mother and baby. The Journal of Social Work & Christianity

• White, W. (2012). Medication-assisted recovery from opioid addiction: Historical and contemporary perspectives. Journal of

Addictive Diseases. 31(3), 199-206. doi: 10.1080/10550887.2012.694597