In the first of a virtual series on maternal health, U.S. Health Resources and Services Administration (HRSA) Office of Regional Operations (Regions 5, 6, and 7) presented on substance use disorder (SUD) and pregnancy. According to the webinar, fetal exposure to substances can affect both the mother and child during pregnancy and after birth. The webinar provided an overview of HRSA’s Rural Community Opioid Response Program (RCORP), the effects of substance use during pregnancy, and treatment options.

Though treatment is available, it is crucial to understand the effects of various substances and which treatments are best suited for each specific individual. Speakers included Dr. Monica Rousseau, public health analyst for the Federal Office of Rural Health Policy at HRSA, and Dr. Michael Weaver, psychiatry professor and medical director of the Center for Neurobehavioral Research on Addiction (CNRA) at UTHealth.

RCORP aims to combat the opioid epidemic in vulnerable and underserved populations. The multi-year HRSA initiative addresses barriers to health care access in rural communities related to SUD and opioid use disorder (OUD). To date, HRSA has dispersed $298 million across 1,420 counties since the 2018 fiscal year.

According to Dr. Rousseau, project officer for the RCORP Neonatal Abstinence Syndrome (RCORP-NAS) program, rural areas are often left behind in policy. “Evidence-based practices and research are designed, created, and thought up in urban areas. That means not all evidence-based practices are best suited for a rural community. Our job is to be at the forefront of policy change and ensure that HHS knows how it will affect rural areas.”

RCORP’s success to date is credited to its cooperative agreements and branch programs. Cooperative agreements include publicly available technical assistance support for grantees and their work, development of evaluation tools for data collection and analysis, and the program’s centers of excellence. “The goal of the centers of excellence is to identify the best evidence-based practices to improve SUD in rural communities,” said Dr. Rousseau.

Branch programs of RCORP include planning, implementation, medication addiction treatment (MAT), and Neonatal Abstinence Syndrome (NAS). Together, the goal of the branches is to address opioid use disorder prevention, treatment, and recovery. HRSA is currently funding a new cycle of RCORP which will award $1 million over three years. Recipients will be announced later this fiscal year. HRSA will also add a new RCORP branch to address psychostimulants, expanding the opioid crisis to include the meth crisis as well.

RCORP-NAS: Addressing Substance Use in Rural Pregnancies

As defined by the CDC, the leading causes of pregnancy-associated deaths are homicide, suicide, and drug overdose. “When a new mother has delivered, you see a decrease in risk for fatal and nonfatal overdoses immediately after birth,” Dr. Rousseau said. “But you see that spike again 7-12 months after birth.”

In rural areas, the rate of SUD-related deliveries was higher for patients from rural than from urban areas (37.7 vs 22.5 per 1,000 stays). “There is a lot of need in rural communities, and there are some very special contributing factors that need to be addressed to improve these rates,” said Dr. Rousseau. Contributing factors to overdoses include having a newborn with a diagnosis of Neonatal Abstinence Syndrome (NAS), insurance loss, or termination of pregnancy-related SUD treatment after delivery, among others.

To address the impact of NAS on pregnant and childbearing-able women, RCORP introduced RCORP-NAS. The program will award up to $500,000 via 30 awards over a three-year period. The goal of the program is to reduce the incidence and impact of NAS in rural communities by improving systems of care, family supports, and social determinants of health.

The target population includes individuals who are pregnant or likely to become pregnant, those at risk of SUD and OUD, and their children, family, and caregivers. “SUD and OUD do not operate in isolation,” said Dr. Rousseau. “We know that family ecosystems can contribute to SUD and OUD, so we really want to make sure to include children, family, and caregivers.” The program also treats those in recovery or currently struggling with SUD and OUD.

Award recipients work on two strategies each for prevention, treatment, and recovery strategies. Grantees choose their efforts to focus in one or two areas of the following: criminal justice, family support services, integrated care and care coordination, provider workforce, recovery capital, transportation, and telehealth.

Effects of Substance Use During Pregnancy

Dr. Weaver sees patients in the Innovations Addiction Treatment Clinic at the Texas Medical Center in Houston, observing the effects of various substances during and after pregnancy. Exposure to alcohol during pregnancy can cause Fetal Alcohol Syndrome (FAS) leading to heart and facial defects and developmental delays. FAS is the leading preventable cause of developmental delay.

Because the amount of alcohol or duration of drinking needed to cause FAS is unknown, abstinence is encouraged as soon as pregnancy is suspected. “The safest amount of alcohol during pregnancy is none,” said Dr. Weaver. “Because we don’t know exactly when is the most critical time, we consider all of pregnancy to be critical in terms of exposure to alcohol causing FAS or FA effects (symptoms).”

Smoking tobacco is the most common form of fetal exposure, leading to intrauterine growth complications that cause low birth weight and other problems before and during delivery. Other challenges include higher rates of spontaneous abortion, placenta previa, and increased risk of sudden infant death syndrome (SIDS). The risk of SIDS is four times greater in smoking households than in non-smoking households, and this risk continues for as long as smoking continues after pregnancy.

Quitting smoking can be challenging. Though quitting without replacements or medications is ideal, replacement with gum, lozenges, or a nicotine patch is still helpful and effective. “Even though it’s exposing a fetus to nicotine, it’s still safer in terms of harm reduction, in terms of all the other chemicals we see in tobacco smoke,” said Dr. Weaver. “The same goes for electronic cigarettes – it’s still exposure to nicotine, and there are other chemicals in the electronic cigarettes. It’s not a safe exposure during pregnancy.”

Cannabis, whether smoked or ingested through tinctures or edibles, can cause abnormal startle reflex in newborns, leading to hyperactivity. As they get older, reduced memory and verbal skills can begin to show around age four.

Though opioids don’t cause the same fetal anomalies that alcohol and smoking do, continuous exposure can cause NAS. If a woman recognizes dependence and stops use prior to delivery, she may not develop opioid withdrawal symptoms and can prevent NAS in her newborn.

Stimulants, such as cocaine, crack, ecstasy, and bath salts, have high rate of fetal complications including spontaneous abortion, fetal defects, low birth weight, and placental abruption, which can be catastrophic if it occurs before delivery. A since-disproven theory named “Crack Baby Syndrome” attempted to link children with learning disabilities to increased likelihood of drug use. However, their home environments often accounted for many of the same features as exposure to cocaine during pregnancy. The environments were not syndromes, but contributed to a higher risk of substance use later in life, though these factors can be addressed. “If we can provide appropriate treatment for mom, that can help assist the future achievements of the child,” said Dr. Weaver.

Screening for Substance Use

According to Dr. Weaver, all pregnant people should be screened for substance use at their first prenatal visit. “The purpose of screening is to allow for treatment of SUD, not to punish or prosecute,” he said. “The purpose is not to be punitive or get child protective services or the justice system involved initially, unless there is another cause for concern related to that.”

In addition to substance use, pregnant people should also be screened for possible mental health issues, HIV, hepatitis B and C (which can cooccur with substance use through shared needles), and domestic violence. A hospital survey found that although 97% do a universal screening of pregnant women, only 6% use a specific validated screening tool. Dr. Weaver recommends the following instruments for identifying women at risk and making recommendations and diagnoses to initiate treatment:

While it may be prudent to test the mother and/or newborn for drug use or SUD, it’s important to note that drug tests do not indicate the details of what substance she has been using, the amount, the frequency of use, or the route administered. Dr. Weaver said positive drug tests are not indicative of an SUD diagnosis. “There may be other reasons why mom may have various substances on board that are prescribed for her appropriately or because she’s in treatment.”

“A positive test result does not provide a result of parenting ability and should not be used to determine that in any way. It is simply a data point used together with the big picture to determine an appropriate course of action to help a pregnant woman and identify the conditions she may need testing for.”

Testing should never be done without the woman’s knowledge and requires informed consent for bodily fluid tests. Providers should discuss the importance of gathering this information to best determine a course of action to improve her total health while respecting her autonomy.

Treatments for Substance Use During and After Pregnancy

When approaching treatment options for pregnant or childbearing-able people, it’s important to explain the complex nature of addiction and validate that the person is not totally responsible for acquiring it. “We recognize that addiction is a brain disease, and there are a lot of factors involved,” said Dr. Weaver. “No one wants to develop SUD, but through a series of choices, they find themselves in a situation that is very difficult to get out of.”

While the patient is not responsible for their addiction, they are responsible for their own recovery and continuing to make healthy choices. Addiction is treatable; it’s critical to remain optimistic about the ability to overcome the disease and stressful outcomes. Providers should remind their patient of the effects substances can have on them and their unborn child. It’s also helpful to point out how improving their overall health can improve the social factors affecting their life as well.

Unfortunately, women may be wary of acknowledging that they have a substance use problem out of fear of legal consequences such as loss of custody. Reporting requirements can be very confusing and may put women in a difficult position at times. Providers should inform patients of their legal obligation in terms of reporting positive drug tests and deciding whether to enter treatment.

Medication for Addiction Treatment (MAT) is the standard of care for pregnant women with OUD. Withdrawal of MAT during pregnancy is not recommended as it can lead to high relapse rates and health risks to the fetus. MAT is recommended through and after delivery, and once the woman is more stable, she can decide if she wants to continue or end treatment.

Initial treatment for NAS includes supportive swaddling, frequent feeding, and IV fluids. Supportive approaches are needed to treat hyperactivity, irritability, and difficulty latching during breastfeeding. “When a baby is born with NAS, they experience a withdrawal symptom that is a little bit different from an adult, as well as the fact that a newborn can’t tell us what they’re going through,” said Dr. Weaver. High-pitched cries and other symptoms of distress are often treated with pharmacotherapy, including sedative-hypnotic opioids or a tincture. Breastfeeding is encouraged as it promotes bonding, optimal nutrition, and passive immunity.

Improving maternal health is a high priority, so entry into programs such as these are often more rapid than traditional health appointments. Maternal and fetal health stabilization is the ultimate goal, according to Dr. Weaver. “This allows her to fully participate in her substance use treatment and her mental health care, obstetrical plan of care, and other social services she needs.”

“If we intervene effectively on pregnant women or women of child-bearing potential, we can have a significant impact on this cause and definitely make an improvement from a public health standpoint.”

Learn more about HRSA’s RCORP and NAS programs by watching the recorded webinar.

Resources for people with substance use concerns include:

  • SAMHSA treatment locator website: findtreatment.gov
  • American Society of Addiction Medicine: asam.org
  • American Academy of Addiction Psychiatry: aaap.org
  • National Association for Alcohol and Drug Abuse Counselors: naadac.org