Field applies knowledge around treating pregnant women to outpatient care

Congress passed the Comprehensive Addiction and Recovery Act (CARA), the first major federal addiction legislation in four decades, in July 2016. CARA authorizes national funding to combat the drug epidemic in our country, and focuses on six pillars. These include: expansion of prevention and education to promote recovery; increased availability of naloxone; expansion of disposal sites; expanded resources to treat incarcerated individuals suffering from addiction appropriately; development of treatment programs to fight opioid addiction, including medication-assisted treatment; and the reinforcement of statewide prescription drug monitoring programs (PDMPs).

CARA will change the way we provide treatment and assist pregnant and postpartum women, veterans, and youth. As a result, we need to ask ourselves these questions: What is it about our treatment programs that is working really well, and where do we have opportunities to improve? Are we effectively serving pregnant, postpartum and parenting women in their addiction treatment and recovery needs? Have we provided valuable and effective substance use prevention and health services for their children? These questions and more prompted my reflections on a recent Think Tank event in Washington, D.C.

Experts from around the country convened at this meeting of powerhouse women, who for three decades have done amazing work with pregnant, postpartum and parenting women suffering from substance use disorders and mental health diagnoses. Physicians, nurse practitioners, psychiatrists, therapists, researchers, clinicians and chief executives in all areas from the clinical, financial and evaluation sectors attended. The smartest of the smart were there. Many had started out in the trenches, and many continue to work in the trenches with this significantly challenged population.

Put on by the Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Substance Abuse Treatment (CSAT), this Think Tank was designed with the purpose of creating a pathway forward in the development of outpatient services for pregnant and postpartum women and their children. The goal was to reach a consensus in meeting the needs of the implementation of a family-centered approach to prevention, treatment and recovery for the women and their families, in various residential and outpatient settings. The federal government is getting ready to launch a new initiative for this population, which will now pertain to outpatient services.

Back in July, Health and Human Services (HHS) Secretary Sylvia M. Burwell said, “The opioid epidemic is one of the most pressing public health issues in the United States. More Americans now die from drug overdoses than car crashes.” With the current epidemic, and with so many pregnant and parenting women suffering through it, we in the industry are looking at applying the lessons we’ve learned to an outpatient setting. The focus will help determine how this level of care can wrap its arms around these women, so that they can not only get well, but thrive. And thrive not just in one area, but in all areas of their lives, from their trauma to their mental health, from their substance use to their parenting, from their work lives to their ability to be financially successful.

In looking back on the amazing programs created and progress made, we were able to see our many lessons learned in the history of each step we’ve taken. In the early 1990s, CSAT had funded 14 demonstration programs to create, design, demonstrate and implement residential services for pregnant, postpartum and parenting women. Extensive research and evaluation was done, documents were written, and foundational programs were created, from which almost all existing services for women and children have stemmed. These programs resulted in successful retention rates, reunification rates, back-to-work rates, housing rates, and other achieved outcomes. We learned a lot from the programs created 25 years ago, and those lessons have produced the look of gender-specific treatments for women in the substance use disorder field today.

We already know what works. We’ve demonstrated it. We know that we have to treat not just the substance use disorder, but also the concurrent mental health issues. We know we need to deal with housing, work, family reunification, and parenting skills. But beyond that, we choose to face the reality that many children are challenged children, affected by drug or alcohol use in utero. We never really talked about that. We have not talked openly about the effects of substance use on our children’s emotional, physical and mental development, and whether or not they’ve met developmental milestones. These aren’t the usual topics of discussion in the pediatrician’s office across this country—and once we’re well, we definitely brush those issues under the carpet, never to be brought up. Then we wonder why our children have as many difficulties as they do, why they’re not thriving. Because we’ve not been telling the truth about how they’ve been affected. We’re avoiding looking at the special needs our children have in overcoming the specific barriers they experience throughout various periods in their mental and physical development.

Participation in this Think Tank enabled us to focus on, collaborate on, and determine a wide umbrella of essential design elements and core services that are absolutely necessary for pregnant, postpartum and parenting women in treatment for substance use disorders. The umbrella included mental health services (evidence-based best practice therapies, proper assessments, and diagnoses), safety services (housing, transportation, and more), and children’s services (child care services, assessment, mental and developmental milestones, therapy). We discussed provision of trauma-informed and family-centered care, not only for pregnant women, but for their children and their families. We talked about creative ways of financing and fundraising, from private insurance to Medicaid and Medicare, from redirecting funds out of the child’s welfare system or the criminal justice system to the creation of mental health dollars. We included the Seeking Safety program, Eye Movement Desensitization and Reprocessing (EMDR), and family-centered care evaluations (types, research, and documentation).

We talked about the dynamics of the family. The family is not only the children, but the other parent to the children, the grandparents, and sometimes even a long-term therapist who has been engaged with the parent for many years. In conventional treatment programs, where only one person in a family unit is healed, without the entire family the healing has had limitations and risks. As stated in a paper on the SAMHSA website, “Although some programs served all families … in most programs, older children, fathers, domestic partners, and other family members received no services or limited services. These individuals were often not included in a healing process, frequently with the result of only partial family recovery and limited support for the women as they left treatment. For some families, the treatment caused divisions that actually created new problems and further rifts in family functioning.”

Infrastructure and workforce development was a priority in the umbrella of services. Workforce is such a challenging issue in the substance use treatment field, especially with the need for gender-separate and children's services to be culturally and linguistically relevant. Equally important to include were the array of factors that affect the way the workforce interacts with the women, and with the consumers, so that they are not retraumatized, shamed or blamed, but elevated and supported. When a woman in her third trimester comes in with track marks on her arm, and the nurse looks at her arm and then looks at her belly, just the way the woman is looked at suddenly produces shame, guilt and remorse, and it becomes very difficult for her to hear any healing words from the caregiver.

The point this all touches on for me, and what we believe here at New Directions for Women, is like that of the international Hunger Project: “promoting self reliance.” Research has shown that when women are well and empowered, families are healthier, more children go to school, incomes increase, and lives improve. And so with this opiate epidemic, I suggest we use that same approach. I challenge us really to invest in women getting well. Because when women start to get well, the fallout affects spouses and sons and daughters. And communities. This much I know. When women heal, generations heal.

It was wonderful for me to be in the presence of these passionate and powerful women, some of whom I hadn’t seen in a decade, and some whom I had never met. They challenged my thinking and directed my focus to key areas of our industry as a whole. I was re-energized and inspired to look at the “organization” of my own organization. My inner passion was reignited, and I was reminded once again why for 39 years I’ve done what I’ve done, and how grateful I am for our lessons learned.