In an age of pandemic, we’ve stopped talking much about another health crisis: opioid addition. Not only has it not gone away, it’s getting worse. Recent state data suggest there was a 30% increase in opioid overdoses in the first six months of 2020. One consequence is the growth in the number of babies with neonatal opioid withdrawal syndrome, or NOWS, a serious but treatable condition of newborns exposed to opioids before birth.
In order to give these newborns a chance at a stronger start in life, Minnesota should change a well-intentioned but counterproductive law requiring health care providers to notify the state immediately if a pregnant patient is suspected of using non-prescribed substances, including opioids. While this won’t singlehandedly solve the problem, it would be a step in the right direction. Another important part of the solution would be ensuring input from stakeholders throughout Minnesota, including individuals in recovery who already are a parent, or pregnant.
Health care professionals say such mandatory reporting often discourages pregnant people from seeking prenatal care. That constitutes a missed opportunity to get them into treatment that would help them and their babies.
The rate of NOWS cases reported in Minnesota doubled between 2018 and 2019, reaching 102.5 per 10,000 births. Infants with NOWS may have poor feeding, seizures, and/or increased risk of birth complications such as preterm delivery. It is an especially big problem in American Indian communities, where NOWS is eight times more common than the white population in Minnesota.
In 2018, the average hospital stay cost for each Minnesota infant affected by NOWS was $7,700, or a total of about $5 million. Nationally, about 80 percent of NOWS births are covered by Medicaid. Over a 10-year period, NOWS costs the United States about $2 billion more in Medicaid expenditures.
In Minnesota last year, 667 infants developed NOWS. Many of those infants were born to mothers not engaged in addiction treatment or prenatal care prior to delivery.
The stigma of addiction in pregnancy
Opioid use disorder is a chronic medical illness with known effective treatments. “The longstanding belief that a medical condition, opioid use disorder, is actually a moral failing has created barriers for seeking treatment, especially in pregnancy,” says Dr. Cresta Jones, a Minneapolis physician who specializes in the care of pregnant patients experiencing addiction.
In addition, a lack of culturally appropriate addiction treatment contributes to high rates of untreated opioid use and further reinforces racial inequities in addiction care. Structural racism is a root cause of racial inequities in maternal and infant health outcomes in Minnesota, increasing adverse outcomes for American Indian and Black patients.
Pregnant people who might otherwise want help with their addiction may be fearful of being reported and having their children removed from their care and therefore entirely avoid prenatal care. Statistics appear to bear this out: Women who give birth to infants who develop NOWS are 12 times as likely to not receive prenatal care. Infants of moms who do not receive prenatal care are five times more likely to die before their first birthday.
Dr. Jones adds, “When I am required to report a patient before I can get her into an appropriate addiction treatment program, it isn’t actually helping her get the resources and education that would help her start to heal and be able to parent. If I am allowed to gain her trust and assess the tools she has for parenting before deciding if she needs a referral to child welfare services, we will see better outcomes for Minnesota’s babies and families. “
We know that proper care can improve health outcomes. So what can we do about this?
Modify reporting requirements
One step Minnesota can take is to pass HF 1892, which modifies prenatal substance use reporting requirements (the file number may change in the next session). Specifically, health professionals or social service professionals would no longer be mandated to immediately report substance use. Rather, they can develop a trusting relationship with a woman, while helping create an environment in which patients feel more comfortable asking for help. This bill does not prevent a provider from reporting or referring patients for additional services if their safety is in question.
More than 20 health professional organizations have issued statements supporting non-punitive approaches for substance use in pregnancy. Currently, 70% of states do not have mandatory reporting laws.
State law in effect now was likely implemented to help pregnant people and protect the fetus. However, this and similar policies have actually had the opposite effect, deterring patients from seeking care and posing even greater health risks. Changing the statute will not prevent clinicians concerned about the mother and/or child’s health from notifying child welfare services. It will instead allow providers time to develop a partnership in care with patients while helping them access treatment for a chronic medical condition.
Alexandria Kristensen-Cabrera is an M.D.-P.hD. student at the University of Minnesota.
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