There are a lot of decisions that pregnant women addicted to opioids face.
They have to decide to get clean, for one. And they have to decide how to do it. But in Kentucky and across most of the country, the choice of treatment methods isn’t just about what’s best for the mother and her unborn baby.
It’s largely dictated by where that woman lives.
One treatment option is detox, or going cold turkey. But increasingly, the recommended method is medication-assisted treatment. In Kentucky, many may not have that choice; there are only approximately six health care providers per 100,000 residents who can prescribe treatment drugs like buprenorphine, according to a report out Thursday from the Institute for Medicaid Innovation.
At Volunteers of America’s Freedom House in Louisville, three women are using buprenorphine while they go through addiction treatment. Each either has an infant or is pregnant.
The program is specifically designed to help these women get clean, and a key element is the support system. At Freedom House, there are cribs, beds and childcare workers to care for the recovering women and their babies while they get treatment.
“The point of maintenance therapy is to quiet down the obsessions that tell you, ‘you should use right now,’ so they can learn coping skills,” said Erika Ruth, an addiction psychiatrist who works with each of the 11 women in the residential treatment program. “If they can’t learn these coping skills, we’re going to see a much higher rate of relapse.”
A tough choice
Treating these women for their addiction is difficult: There are two options, and neither one is great.
The first is going through detox and going into treatment immediately after. That often includes severe vomiting, seizures and swinging body temperatures, which Ruth said can pose a threat to the fetus.
“The body isn’t meant to be under that much stress, and they’re already under stress,” Ruth said.
That can result in miscarriage.
But the other option, medication-assisted treatment, is controversial, too. It relies on a prescription drug like naloxone or buprenorphine to help wean the patient off drugs, and some of the babies born to these mothers will go through neonatal abstinence syndrome.
“The baby will have seizures, high-pitched crying, have GI dysfunction, difficulty feeding, vomiting, poor weight gain, temp instability,” said Jennifer Moore, director of the Institute for Medicaid Innovation.
She’s also the author of the recent report that looked at the accessibility of treatment for pregnant opioid addicts on Medicaid.
Medication-assisted treatment is the path recommended by the American College of Obstetricians and Gynecologists based on current scientific evidence. Ruth said ideally a woman would get this medication for two years of regular doctor’s visits.
Because of the dearth of treatment options for women in Kentucky, for the women in Freedom House, often the decision comes down to where she’ll go after her six months in the treatment program is up.
“Another piece of that is, are these women all coming from Jefferson County or outlying counties that this is the only place they can get treatment at?” Freedom House nurse Laura George said.
Her organization runs into this access problem all the time in considering what women will do once they leave.
‘Follow-up care is difficult to find’
These women often face obstacles finding a provider that can see them and prescribe the medication. They also tend to struggle to afford it.
Even if there is a provider who can give the medication in a woman’s home county, they might not be accepting new patients. And driving once a week to Freedom House for treatment might not be an option for someone who lives an hour away with a baby.
Most of the women at Freedom House are covered by Medicaid, the state’s health insurance program for low-income and disabled people. Medicaid only pays for buprenorphine, naloxone and naltrexone. And there’s already a shortage of providers who take Medicaid.
“Not many providers take Medicaid, so follow-up care is difficult to find,” Ruth said.
But there are some clinics that only take cash, which can be an option for a woman who can’t find a Medicaid provider. But Ruth, the Freedom House psychiatrist, said the predicament of getting money to pay cash can also put women in danger.
“They’ll tell you, I don’t want to do the same things I had to do when I was in my addiction to be able to pay for recovery,” Ruth said. “Stealing, writing bad checks, selling their bodies, selling drugs: all the things we imagine they’d do that we don’t want to think about it.”
For the women at Freedom House, they’re fortunate they’ve found help.
“When they get in recovery, they talk about it, ‘I used to do that and now I can live a solid life to make a living and care for my children,’” Ruth said. “And that’s what I would want for all of them. But I worry it won’t be available to them.”