Women in the World

09.02.12

Medical Consensus or Child Abuse? Moms on Methadone Caught in the Middle

It can be a Catch-22 for new mothers addicted to opiates—doctors treat them with methadone while child-welfare caseworkers report them for continuing to use drugs. Rachel Blustain reports.

*The names of the mothers and children in this piece have been changed to protect their privacy.

Rebecca’s* obstetrician was off duty on the day she went into labor in 2010. That was a problem, because Rebecca was taking methadone on doctor’s orders.

She had been prescribed it eight months earlier, in an effort to help break her addiction to Vicodin. Doctors told her it was the best thing she could do for the fetus growing inside her. But that did not matter to the hospital staff, who seemed sure that Rebecca was abusing methadone.

Between contractions, Rebecca tried frantically to convince the staff that she was only doing what her doctor had ordered. Her son, Sam, was delivered via Caesarean section in good health: 8 pounds, 1 ounce. But instead of waking up to Sam’s face, the first she saw was the surgeon’s.

“Do you want an epidural or do you want painkillers?” Rebecca remembers the surgeon asking her. “You probably want painkillers, because you’re a drug addict.”

Soon after, investigators from child-protective services showed up and told Rebecca she wouldn’t be allowed to go home with her boyfriend, who was on methadone maintenance too. They said she could keep her baby only if a family member supervised her around the clock. She wouldn’t even be allowed to sit in the same room with Sam alone.

The investigators reassured Rebecca that the safety plan was a precautionary measure, and that they’d probably be closing the case soon. But through a series of tumultuous stays with relatives who resented having to oversee her every move, the case dragged on throughout the first year of Sam’s life. Meanwhile, doctors warned Rebecca that if she weaned herself from methadone too quickly, she might relapse.

Cases like Rebecca’s have become increasingly common in recent years, according to maternal-health and drug-treatment advocates, who say they are seeing more parents charged with child abuse for undergoing methadone maintenance, despite scientific evidence showing that it is the best way to wean addicts off opiates. The treatment may even save a fetus’s life, since going cold turkey can bring on premature birth or in some cases a miscarriage.

“We certainly know a lot more about the negative impact that tobacco exposure in utero can have on children than we do about opiates, but we don’t remove babies if mom smokes cigarettes.”
Video screenshot

Dr. Nora Volkow of the National Institute on Drug Abuse on the science of drug addictions.

But because methadone is an opiate, like the drugs it is prescribed to treat, there is confusion among some doctors, child welfare workers and judges that using it is just substituting one drug for another, said Jocelyn Woods of the National Alliance for Medication Assisted Recovery.

Mothers get caught in the middle. “Judges and caseworkers are practicing medicine without a license, even against medical advice,” said Emma Ketteringham of National Advocates for Pregnant Women, who worked on Rebecca’s case.

Add to that a fivefold increase in pregnant women using opiates between 2000 and 2009, a spike due primarily to growth in the abuse of prescription painkillers, according to a study in the April issue of the Journal of the American Medical Association. The study caught the attention of the Office of National Drug Control Policy, which convened a meeting in August to help set national policy for what has come to be seen as a growing crisis.

But critics of the study say the crisis may be overblown and fear it may become the basis for punitive measures against pregnant women—as did media reports in the 1980s and ’90s that exposure to crack cocaine in utero would devastate a whole generation of babies.

Critics also contend that separating mothers and children often harms the very people it’s meant to protect. “Even a brief mother-child separation early on sets people up for worse trouble later, and one of the things babies experiencing opiate withdrawal need, in particular, is to be held a lot,” said Deborah Frank, professor of pediatrics at Boston University School of Medicine. “If the mother is well enough, keeping the mother and baby together can help that process. It may also be very important to their relationship in the long run.”

Shortly before Sam’s first birthday, Rebecca’s relatives decided they could no longer manage the burden of supervising her, and a worker came and placed her son in a foster home.

“I was crying and screaming,” Rebecca recalled. “I kept thinking, ‘How’s he going to feel?’ Still, I had to put him in his car seat and watch them drive away.”

“Every time I visited him at the agency, I felt deeply ashamed of myself,” she said. “My son had begun to say words like ‘mama’ and ‘dada,’ but he completely stopped speaking. Every time my boyfriend and I said goodbye to him, our hearts would break.”

* * *

Methadone maintenance has been the gold-standard treatment for opiate-addicted pregnant women since the 1970s, because it treats the cravings of addiction without creating the hallmark roller coaster of highs and lows.

The federal government’s Substance Abuse and Mental Health Services Administration also counsels addicted women that the treatment is safe for the fetus and that the risks of going cold turkey are much greater. Studies have consistently found that outcomes for babies exposed to methadone maintenance in utero are far better than for babies exposed to street drugs and to the risky lifestyle that often comes along with addiction.

“Mothers on methadone maintenance stop getting high, they tend to lead more stable lives, get better prenatal care, and are rarely born premature,” says Barry Lester, the director of the Center for the Study of Children at Risk at Brown Alpert Medical School's Women and Infants Hospital.

But, Lester explains, there is little research on the long-term risks to children exposed to methadone in utero, and methadone has never been approved by the Federal Drug Administration. 

And babies exposed to methadone in utero often experience symptoms of withdrawal for hours, days, and sometimes weeks after birth—which is one of the reasons child-protective workers give when removing infants from their mothers.

Linda Gabriel, who directs a methadone clinic in Mobile, Ala., said that all 20 methadone clinics in the state have reported some disagreements with child-protective services.

“We’ll have workers and judges say, ‘How long have you been on methadone? Well it’s time to get off,’ even though the research shows that some people may never be able to get off. Very often, when we try to educate people, we hit a brick wall.”

The judge assigned to Rebecca’s case said he wouldn’t close her case until she got off methadone. When she introduced letters from experts testifying that the federal government recommends methadone maintenance for opiate-addicted women, she said the judge told her, “I can make a paper airplane out of these papers and glide it across the courtroom.”

* * *

The child-welfare system has come a long way since the crack epidemic of the 1980s. Today, greater efforts are made to keep parents and children together, and mothers get help not only with physical addiction, but with the social and emotional problems that often go with it. But the arbitrary nature of the cases—in which caseworkers and judges appear to overrule doctors’ orders and even official child-welfare policies—may help explain why parents struggling with addiction sometimes choose to hide drug problems rather than reach out for help, said Ketteringham.

That fear can continue even after mothers are in treatment. Debra Schnall, a psychotherapist in New York who works with addicted mothers, recalls one woman on methadone maintenance who had had child-welfare cases in the past. When Schnall encouraged her to speak with her child’s pediatrician about a feeding disagreement she’d had with program staff, the mother refused, saying: “‘You know, then he’s going to call the social worker, and the doctor and social worker will say, ‘Why aren’t you able to look after your baby?’ She was so afraid of getting a case on this baby and losing her other children that she wouldn’t even talk to her baby’s pediatrician.”

There’s also a double standard at work when it comes to determining how a mother’s behavior affects the health of her fetus, say some maternal-health advocates.

“We certainly know a lot more about the negative impact that tobacco exposure in utero can have on children than we do about opiates,” said Deborah Frank, director of the Boston Medical Center’s Grow Clinic for Children, “but we don’t remove babies if mom smokes cigarettes.”

Advocates acknowledge that there are situations when a mother is unable to raise her own children, but they say scaring mothers away from treatment is not the answer.

“There are definitely situations where reporting is appropriate in order to keep children safe,” said Maureen Phipps, immediate past chair of American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women. “But whenever possible, that ought to be done after doctors have been able to establish a relationship with their patients. When women are too afraid of the consequences of being honest with their doctors, that can be a very risky situation for the mother and for the fetus.”

In methadone-maintenance cases, advocates say, parents are being punished precisely because they sought treatment.

“These are not pregnant women using methadone,” said Robert Newman, a doctor who established some of the first methadone-maintenance clinics in the country. “These are pregnant women receiving medical treatment from licensed trained physicians, approved by the federal government and by state governments. To penalize them because they are compliant with a medical regimen is hard to understand.”

* * *

After a year of her own efforts to seek help for her addiction, Rebecca thought she had nothing left to hide. But with a 1-year-old son living in a foster home, she decided to switch to taking Suboxone, a drug that works like methadone, though with higher rates of relapse. The main benefit of Suboxone is that it isn’t detected in most drug tests. Three months later, Sam came home to stay.

That day, Rebecca said, a caseworker who visited her home told her: “‘Y’all did good. Y’all are reformed. We actually changed you.’ What they did was terrify us, traumatize my son, ruin my relationship with my family, leave us in so much debt that we lost our house. I felt like they’d destroyed my life, even though everything I’d done since I’d found out I was pregnant was absolutely legal.”